Death of Shi-Anne Downer, an 18 month-old-girl from a white British and black African background in September 2015. The post mortem revealed over 150 internal and external injuries that had been caused over a number of months; Shi-Anne's guardian was subsequently convicted of murder. Shi-Anne's mother had a history of drug abuse, mental health issues, reluctance to engage with services and time in prison; her father was in prison at the time of her birth; and her five older siblings had previously been taken into care. Shi-Anne was made the subject of a child protection plan before her birth and was placed in foster care after birth. In January 2015, Shi-Anne became the subject of a special guardianship order (SGO). Her guardian was not related to Shi-Anne but had previously been married to Shi-Anne's father's cousin, and her name was put forward by a family friend. Issues identified include: the pre-birth decisions made about Shi-Anne's care followed the same approach as decisions made for her older sibling, without considering whether this was also appropriate for Shi-Anne five years later; the assessments for the SGO were flawed and incomplete; professionals had little or no contact with Shi-Anne after the SGO; risk factors for the guardian's reduced parental capacity, such as becoming pregnant and the breakdown of her relationship, were not recognised and acted upon. Uses a blended methodology to establish lessons that can be learned, including: ensure all relevant checks are carried out and consider the need for a period of monitoring before a SGO is finalised.
      
 Title:  Serious case review: Shi-Anne Downer (birth name): AKA Keegan Downer: born on 9th March 2014: died on 5th September 2015 aged 18 months: case identifier: BSCB 2015-16/2. LSCB: Birmingham Safeguarding Children Board Author: Russell Wate Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Publication Date:  22nd February 2017 1 | P a g e                                 Serious Case Review Shi-Anne Downer (Birth Name)   AKA Keegan Downer Born on 9th March 2014 Died on 5th September 2015  aged 18 months  Case Identifier: BSCB 2015-16/2   Independent Author:  Dr Russell Wate QPM Publication Date:  22nd February 2017 2 | P a g e   Contents   1: Introduction          Page 3  2: Terms of Reference, Contributions and Methodology    Page 4     3: Summary of the case        Page 6  4: Analysis of significant safeguarding events     Page 14  5: Family perspective         Page 25  6: Conclusion          Page 28  7: Acronyms          Page 33             Publication Date:  22nd February 2017 3 | P a g e   1.0 Introduction       1.1 This review involves a young girl (toddler) who is referred to as Shi-Anne Downer she lived with her guardian Kandyce Downer at her home address on a Special Guardianship Order (SGO). Shi-Anne lived there along with Kandyce Downer’s four other older children. Shi-Anne was born on 9th March 2014 and is the sixth child of her mother and her partner. Their other five children had all also been taken into care.   1.2 Shi-Anne was a child with a White British and Black African background. Her mother had a long history of drug abuse and mental health issues and had spent time in prison. Shi-Anne was exposed to her mother’s drug taking during the pregnancy and as a result developed withdrawal symptoms after her birth. As mentioned above the other five children had been removed due to parental alcohol and drug abuse. Both these adults also have a history of not engaging with Children’s Social Care (CSC).   1.3 CSC was notified of the mother’s pregnancy in January 2014 and an assessment established that there had been little change in the lifestyle of them both since their fifth child had been removed from them in 2009. A pre-birth Child Protection Conference was held on 7th March 2014 and the unborn baby, Shi-Anne, was made the subject of a Child Protection Plan. After parental non-engagement, plans were made to initiate care proceedings as soon as Shi-Anne was born. An Interim Care Order was put in place immediately after Shi-Anne’s birth and she was placed with a Foster Carer whilst a decision about her future was made.  1.4 A number of months later an SGO was granted on 27th January 2015 to Kandyce Downer and Shi-Anne went to live with her and her four children three days later.  1.5 On Saturday the 5th September 2015, Kandyce Downer was at home with Shi-Anne and one of her own children.  An older child was at a wedding that day so Kandyce Downer left her home address at about 08:30 am to drop this child off. She left Shi-Anne (18 months) at home alone. When she returned home at 09:55 am she has stated that Shi-Anne was well, however shortly afterwards she telephoned for an ambulance claiming that Shi-Anne was not breathing. This call was made at 09:55 am the same time as she returned home. Paramedics attended at 09:59 am and discovered that Shi-Anne had no pulse and after initial treatment was rushed to the Children’s Hospital arriving at 10:15 am. On arrival Shi-Anne was not breathing and still had no pulse. Resuscitation was ceased at 10.21 am and rigor mortis was evident. Medical staff also noticed a number of serious injuries which in their view was indicative of abuse.   1.6 A Consultant Paediatrician examined Shi-Anne shortly after her death and noted a large number of significant injuries to her body which they considered to be non-accidental.   1.7 A police investigation commenced and Kandyce Downer was arrested at the hospital that day and when interviewed she provided a prepared statement. In this statement she accepted she was the sole carer for Shi-Anne and responsible for her, but denied any neglect, assault or causing her death. During the interview she made no comment throughout.  1.8 Shi-Anne’s post mortem revealed over 150 injuries both internal and external that had been caused over a number of months. These included blunt force trauma to her head Publication Date:  22nd February 2017 4 | P a g e   and face, as well as multiple bi-lateral rib fractures and fractures to both her femurs and pelvis. The pathologists believed that the injuries were non-accidental.  1.9 Kandyce Downer was charged with both murder and causing or allowing the death of Shi-Anne. Kandyce Downer has now been convicted of the murder of Shi-Anne.  1.10 This review has sought to identify what, if any, factors inhibited or caused practitioners and their agencies, to fail to act effectively, to ensure Shi-Anne’s safety. The review has found lessons to be learned for some of these agencies.  1.11 Observations have been made for better safeguarding and they are underpinned by key learning, which the Birmingham Safeguarding Children Board (BSCB) and its partners are invited to accept.  1.12 When a child dies and abuse or neglect is either known or suspected the Local Safeguarding Children Board (LSCB) should always undertake a Serious Case Review (SCR). Following consideration of the SCR Sub-Group’s recommendation, the Independent Chair ratified the decision to commission a SCR in relation to Shi-Anne on 4th October 2015.  1.13 This case has been subject to criminal proceedings, and the SCR might not be published until the conclusion of any appeal, and any new or relevant information from the proceedings considered. This is a decision for the Board and their Independent Chair. However, this does not stop the LSCB immediately and properly identifying what can be learnt and applying it to bring improvements in practice. The BSCB is ensuring that any emerging findings are acted upon by agencies and monitor whether any early lessons are fully implemented and improvements made.                   1.14 Detective Superintendent Tim Bacon who is independent and has played no part in the police investigation, chaired the SCR Panel and the Panel agreed the scope of the review and identified key lines of enquiry, timescales and identified the agencies who would be required to provide a chronology of their involvement and an Individual Agency Summary Report. The Panel then supervised the process and the completion of the agreed overview report.  1.15 The timescale for the review was agreed to focus solely from Shi-Anne’s pre-birth assessment which was undertaken from January 2014 to the date of her death on 5th September 2015.  Other information outside of the defined period was to be considered and included if identified as relevant.  1.16 The review centres on Shi-Anne, her biological mother, father and Kandyce Downer who was appointed Special Guardian of Shi-Anne.  2.0 Terms of Reference  2.1 The focus and key issues that this review sought to address were as follows:  • To establish what lessons are learned to safeguard and promote the welfare of children and by doing so act upon these lessons swiftly identifying change where appropriate. Publication Date:  22nd February 2017 5 | P a g e   • To review the circumstances leading to the death of Shi-Anne and establish what lessons are to be learned from the case about the way in which local professionals and organisations worked individually and together.  • To determine what happened and why to safeguard and promote Shi-Anne’s welfare, about the context within which local professionals and organisations were working and the support they were provided with to do their jobs effectively.            2.2 The Panel’s membership included professional experts with no direct case responsibility or     management links to the case drawn from:  • Birmingham City Council People Directorate Children’s Social Care (now known as Children’s Services). • CAFCASS • West Midlands Police   • Sandwell and West Birmingham Clinical Commissioning Group (CCG)  Issues to be addressed within the Review  2.3 The SCR Sub-Group members requested that the SCR should take into account the following:  • What key events had taken place since Kandyce Downer found out she was pregnant in June 2015 and what input from other agencies had there been since this event? • Was Shi-Anne attending nursery or in contact with any universal service? • Was the care of Shi-Anne different from that of Kandyce Downer’s own children?  In addition, the reviewers involved in the SCR have considered:  • The quality of practice, supervision and management oversight and support of those multi-agency professionals involved with the case during that period. • The quality and robustness of assessments, reports to court, care planning and court decision making processes. • The degree to which information about the individual making an application for an SGO was evaluated, assessed, challenged and analysed during the proceedings. • The quality of the post court decision making, support and oversight processes put in place to support and monitor the SGO placement. • The degree to which universal services were engaged in providing ongoing monitoring of the placement, and whether they demonstrated appropriate rigour and professional curiosity about the nature of the household. • Whether any concerns or indicators of concern were raised, identified or, with hindsight, missed in relation to Kandyce Downer’s care of Shi-Anne following the placement, up to and including her death by any agency, universal or specialist in contact with the family in which she was living. • The operational, organisational, and strategic context within which multi-agency children’s safeguarding activity (including in the court service) was taking place at the time of the court case and the degree to which this context affected front line practice and decision making. Publication Date:  22nd February 2017 6 | P a g e   • Whether there are any key national, regional or local policy issues arising from the use of an SGO in the circumstances that need to be addressed.    Contributors to the review  2.4 A number of agencies have contributed to this review as follows:  • Birmingham Community Healthcare (BCHC) NHS Trust  • West Midlands Police  • Birmingham City Council People Directorate Children’s Social Care (now known as Children’s Services) • Birmingham City Council Legal Services • Birmingham City Council Education advisors • Children and Family Court Advisory and Support Service (CAFCASS)  • Sandwell and West Birmingham CCG                 Independent Author and Chair  2.5 Birmingham LSCB made a decision to appoint D/Supt Tim Bacon as the Independent Chair of the Panel and the SCR process, and as stated above he has had no involvement in the case. They also appointed an Independent Author to carry out the review. The review is supplied by RJW Associates and the Lead Reviewer is Dr Russell Wate QPM. He is independent of any agency within the Birmingham area. He is a retired Senior Police Detective, who is very experienced in the completion of a large number of SCR’s as well as investigation of homicide and in particular child death and child neglect issues. He has contributed to a number of national reviews, inspections and inquiries, as well as being nationally experienced in all aspects of safeguarding children and public protection. He is also an Independent Chair of an LSCB.                        Methodology   2.6  The review took the format of the BSCB inviting all appropriate agencies to submit an Individual Agency Summary Report and a chronology of significant events. Analysis then took place of the findings and after requests for further information from certain agencies; a report was completed for sharing and presenting to firstly the SCR Panel and then the SCR Sub-Group for comment, prior to submission to the Safeguarding Board.  2.7  The methodology applied has been a “blended methodology” utilising the rigour of this key events chronology and Individual Agency Summary Report’s from each agency, with the review author’s analysis. The review was then supplemented by a thorough and well attended practitioner workshop. It is good practice for an Overview Report to have input from professionals who have been involved in the case so as to test out the material gathered and to try and answer the ‘why’ question. In this review it was particularly helpful.   3 Summary of the case  3.1  The following section aims to provide a picture of the life of child Shi-Anne both pre and post birth with the adults involved in her care as seen through their interactions with professionals from various agencies.  Publication Date:  22nd February 2017 7 | P a g e   Pre Birth period  3.2   On 28th January 2014 Children’s Social Care (CSC) were made aware that the mother was pregnant with Shi-Anne her baby being due on 28th February 2014. This referral made by the Community Midwife outlined the history of drug abuse, mental health issues, time spent in prison and the previous children were in foster care. It also stated that the mother had no family support and her partner was in prison. As a result of this a pre-birth assessment would take place.  3.3   On 12th February 2014 CSC was informed by a Community Midwife that the mother had visited her General Practitioner (GP) some 3 weeks previously having not received any ante-natal care which she had avoided due to her previous children being taken into care. The mother had also told her Midwife that she was receiving treatment for drug abuse and was using heroin and crack cocaine. A Support Worker was allocated from the Pregnancy Outreach Team.  3.4   Home visits were tried over the next few days by a Social Worker and it was felt that the mother was at home, but not answering the door. Telephone contact was made and an appointment made for the 17th February 2014 which the mother cancelled despite being told she had to be seen that day. A home visit is then not recorded as occurring until 6th March 2014. The mother told her Social Worker that she dismissed the prospect of a Section 20 arrangement saying her baby should stay with her and the Local Authority should leave her alone.   3.5   A Section 47 assessment was commenced on the 17th February 2014 the same day as the Strategy Discussion. It was wrongly believed that the mother had only made contact with Health Services about her pregnancy in January 2014 and this was seen as an aspect of her neglect. She had in fact told her GP on 18th September 2013 that she was pregnant and after a pregnancy test she returned to her GP on 8th October 2013 saying she wanted a termination. She was referred to the British Pregnancy Advisory Service (BPAS) but changed her mind and saw her GP on 3rd December 2013 stating that she wanted to keep her child. She was examined and referred (this fitted in with local procedures to refer after 20 weeks gestation), but the GP did not submit this referral for another month until 2nd January 2014. It is noted by the review author that the Section 47 assessment is well written and reaches the proper conclusion that an Initial Child Protection Conference and Legal Planning Meeting should be convened.   3.6  On 20th February 2014 CSC held a Legal Planning Meeting. It was agreed that the threshold for care proceedings was met and an application for a Care Order would be submitted upon the birth of Shi-Anne with a plan of immediate removal of her from her mother’s care. On the same day it was confirmed by West Midlands Police that the father had been sentenced to 96 months imprisonment on 5th February 2014.  3.7  An Initial Child Protection Conference was held on 7th March 2014 and a unanimous decision was made that Shi-Anne would be made the subject of a Child Protection Plan under the category of neglect.  3.8   On 9th March 2014 Shi-Anne was born by emergency caesarean section.            Publication Date:  22nd February 2017 8 | P a g e   Post birth and early care planning  3.9 On the day Shi-Anne was born, 9th March 2014, a student Midwife contacted CSC Emergency Duty Team (EDT) to notify them of Shi-Anne’s birth stating the mother had delivered a healthy baby girl. This was a result of a flagging marker recorded by the Hospital. EDT made contact later that day advising hospital staff that Shi-Anne should not be discharged home with mother.   3.10 A test of Shi-Anne’s urine after her birth showed positive for heroin, methadone and cocaine. Shi-Anne was observed for 2 days in Special Care and then for 4 days on the High Dependency Unit before being discharged to a foster mother.  3.11 On 12th March 2014 the Social Worker visited the mother in hospital and informed her by letter of the immediate issuing of care proceedings for Shi-Anne. The mother was still unwilling to provide details of any family members and stated she wished to care for Shi-Anne herself.  3.12 On 13th March 2014 the mother was again seen by the Social Worker in hospital and served papers for a Family Court Hearing the following day. It is unclear whether Shi-Anne was seen by the Social Worker on these occasions, although an update is recorded that Shi-Anne had been affected by the exposure to drugs pre-birth but not on a serious level.  3.13 On 14th March 2014 Shi-Anne was made subject of an Interim Care Order at the Family Court and placed into the care of the Local Authority, although the CSC notes do not provide detail of the court hearing or directions. (CSC has now issued new instructions to all staff that expect a separate case record for every appearance in Court).  3.14 On 17th March 2014 Shi-Anne was taken into foster care and on 19th March 2014 a Statutory Visit and Placement Meeting took place at the foster home.  3.15 Shi-Anne was registered with a GP on 24th March 2014. On the same day the father was seen in prison by CSC as he was sent a follow up letter regarding his need to take legal advice.    3.16 On 26th March 2014 Shi-Anne was seen by a Health Visitor with her Foster Carer in a New Birth Visit. Shi-Anne’s health and progress was recorded as good and it is stated that Shi-Anne was being seen by her mother 3 times a week.   3.17 On 31st March 2014 a further case management hearing was held at the Family Court.  Neither birth parents had put forward any alternative family carer and the timetable for proceedings was set for 26 weeks.  3.18 On 2nd April 2014 a planned home visit took place by a Nurse and again Shi-Anne is reported as progressing well. This was an appropriate follow up and good practice is noted as the Nurse identified some missing results and set about obtaining them and then correctly sharing them.  3.19 On 4th April 2014 CSC records record a Court Hearing. There is no further information in the records to elaborate on what happened. It is known the mother did not attend as she had stated she had no means of getting there. Publication Date:  22nd February 2017 9 | P a g e    3.20 On 28th April 2014 Shi-Anne had a permanency medical examination, as part of the dual plan for either adoption or an SGO.  This was carried out by a Community Paediatrician where she was found to be healthy and developing normally. It was reported that her Foster Carer had been vigilant and all health appointments had been met.  3.21 The mother had made contact with CSC requesting contact with Shi-Anne and a meeting was set up for 28th May 2014. On the morning of that day the mother sent a text message to the Social Worker saying she would not be attending as she was going out for the day instead.   3.22 CSC records state on 3rd July 2014 that 5 attempts had been made in the previous weeks to contact the mother by telephone to update her on the plans for Shi-Anne. A home visit was made with no success in contacting her and letters were left for her.  3.23 A Looked After Child Review meeting was held on 7th July 2014 and no concerns were raised regarding Shi-Anne, she had now settled into her placement. The mother had not had any contact with her since March.   3.24 The allocated Social Worker completed a statutory visit on Shi-Anne on 12th August 2014 and she was found to be settled and content. The Foster Carer had heard nothing about the prospective care plan for Shi-Anne or when it would happen.  3.25 On 11th December 2014 a planned home visit was made by the Health Visitor and Shi-Anne was seen with no concerns.  3.26 A development review was undertaken on 26th January 2015 by the Health Visitor and Shi-Anne was observed happy, smiling and sociable. She was clean, healthy and her growth was satisfactory. The Foster Carer stated that Shi-Anne was leaving her care to live with Kandyce Downer on 30th January 2015.  SGO Assessment Process  3.27 Court Orders were made on 15th April 2014 for the assessment of alternative family members who had been identified by the Social Worker based on the previous proceedings for an older sibling. Kandyce Downer was not mentioned in this Order.  3.28 On 16th April 2014 the Local Authority Legal Representative was advised that 3 people had put themselves forward as potential carers for Shi-Anne on the basis of who the father was. These were a friend of the father, a cousin of the father and the daughter of the cousin. As is now known Kandyce Downer was subsequently put forward by a friend and not any family member as a carer for Shi-Anne. Kandyce Downer was happy to be put forward, as her name with her then husband had been put forward in the past for an older sibling of Shi-Anne.  3.29 The mother was visited by a Social Worker on 12th May 2014 where she was unwilling to engage in constructive discussion. She was however insistent that Shi-Anne was not cared for by any relative or associate of the father. This information was forwarded to Legal Services.  Publication Date:  22nd February 2017 10 | P a g e   3.30 A Schedule 4 Assessment (all assessments at this time were completed by the Local Authority Social Worker) of the father’s cousin’s daughter was completed on 21st May 2014.  It was concluded that she was likely to meet the standards for approval as a Foster Carer if put forward for full assessment.  A full assessment was recommended but this was not agreed by the Head of Service who concluded that her accommodation was probably insufficient to meet fostering standards and also that there were concerns about the demands on her as a single carer of 2 very young children.  3.31 A Schedule 4 Assessment of the friend was completed on a date in May 2014 and before 2nd June 2014. She was recommended for a full Special Guardianship Assessment and this was agreed by the Head of Service and completed.  It did not however lead to a positive recommendation. The initial decision making has been considered as flawed and lacking an in-depth analysis of the needs of a young child and the potential of the applicant to provide care for Shi-Anne.  3.32 On 27th May 2014 it was confirmed by DNA tests who was the paternal father of Shi-Anne as this was contingent to family assessments being confirmed.      3.33 A Schedule 4 Assessment of Kandyce Downer was completed on 28th May 2014 which was positive, her name having been put forward by a family friend. Kandyce Downer is not related to Shi-Anne, but her previous husband is a cousin of the father.  3.34 A Schedule 4 Assessment of the father’s cousin was not seen, but on 5th June 2014 a letter was sent to her informing her that it had been decided that a full Special Guardianship Assessment of her would not be undertaken. It appears that the difficulties which had disrupted the placement of Shi-Anne’s sibling with her over 4 years previously still remained.  3.35 On 5th June 2014 CSC commissioned a Special Guardianship Assessment of Kandyce Downer via an independent agency, Minster Social Work Ltd with a completion date of 22nd July 2014.  3.36 The allocated Social Worker was absent from work from 10th July 2014 until 1st September 2014, and it is unclear what, if any, arrangements were made for the reviewing of important messages sent via email that were not read. One such message received was the advising that Kandyce Downer’s records were available for viewing and this message was overlooked for about 7 weeks before the Social Worker returned to work. During the allocated Social Worker’s absence, the case was reallocated to 3 different Social Workers who do not appear to have done any work on the case and have stated in messages that they knew nothing about the case.   3.37 A positive Special Guardianship Assessment of Kandyce Downer was completed by Minister Social Work on 22nd July 2014.  3.38 On 16th September 2014 the Social Worker completed a statutory visit to see Shi-Anne and observed her settled and content. It is recorded that Kandyce Downer had attended the foster home to facilitate an introductory meeting and set up a structured introductions schedule for the purpose of progressing the SGO plan. There is no record on case recordings of a Social Worker being present at this meeting of Kandyce Downer and Shi-Anne, but on interview with the Individual Agency Summary Report Author for CSC the Publication Date:  22nd February 2017 11 | P a g e   Social Worker and Team Manager both say the Social Worker was present. There is an anomaly as SGOs do not have introduction plans. This suggests a decision had already been made that Kandyce Downer would be the Special Guardian.   3.39 On 18th September 2014 Kandyce Downer sent the Social Worker a text message stating that she wished to put her contact with Shi-Anne on hold until the financial support to be provided to her by the Local Authority, including assistance to purchase another car was confirmed. She was advised that a decision had not been made.   3.40 Despite this, CSC outlined on the same day as the above the position of a successful SGO assessment of Kandyce Downer, a structured contact plan as agreed in Court and also that, “the Court Hearing identified that Kandyce Downer would require basic baby items before Shi-Anne is placed with her”.  3.41 On 8th October 2014 the Foster Carer was told that Kandyce Downer would be the new carer for Shi-Anne and the appointment of a different Social Worker.  3.42  A statutory home visit took place on 9th October 2014 by a Senior Social Worker and Shi-Anne was seen to be happy with no concerns raised. The Foster Carer said that Kandyce Downer had cancelled contact with Shi-Anne due to outstanding financial issues in respect of the car. The Foster Carer was clearly concerned about this and the impact on the SGO application.  3.43 On 21st October 2014 Kandyce Downer notified the Local Authority that she was withdrawing her application for the Special Guardianship of Shi-Anne without giving any reasons.   3.44 The following day, 22nd October, Kandyce Downer contacted the Local Authority and retracted her decision which she said was made in frustration over the need for a larger vehicle to care for Shi-Anne.   3.45 A Position Statement was set out on 31st October 2014 by CSC regarding the assessments of Kandyce Downer. It is stated that Kandyce Downer had been seen by the Local Authority Medical Advisor who had no concerns for her health. This was incorrect though as she had not been seen. It also stated that the father did not contest the SGO in respect of Kandyce Downer. There is no recorded contact with him since April 2014, so it is not known how his views were understood. It further stated that the views of the mother were not known due to her disengagement with the Local Authority but again as there is no recorded contact with her since early July 2014.  3.46 Kandyce Downer made contact with CSC by email on 4th November 2014 stating how she would like contact with Shi-Anne and to include overnight visits. There is no record of a response to this and the proposed introductions as suggested by Kandyce Downer are noted to be too drawn out and take no account of Shi-Anne’s routine. There is also no mention of any supervision or assessment of the proposed introductions.  3.47 After some contact with Legal Services and the solicitor for Shi-Anne a report was asked for to investigate the motivation and commitment of Kandyce Downer and to ask why she had withdrawn from the assessment. This was on 26th November 2014. A letter of instruction that had apparently been sent was requested as it had not been seen by Publication Date:  22nd February 2017 12 | P a g e   Birmingham City Council Legal Services. No evidence of the letter has been seen by this review as well.  3.48 On 9th December 2014 information was received that the DBS check for Kandyce Downer “contained information” and that the Social Worker needed to ask Kandyce Downer what this referred to. There is no record of this being acted upon.  3.49 On 23rd December 2014 the final evidence was filed and served. Kandyce Downer was informed by CSC that she had been successful in her application for Special Guardianship of Shi-Anne. Financial support was agreed and a loan agreed to cover the difference between her selling her old car and purchasing a new larger car, and was against the SGO payments she would have been receiving on a regular basis following her means test.  3.50 On 12th January 2015 an amended final statement, care plan and SGO support plan was filed at Court. The care plan and final statement both stated that after placement of Shi-Anne on 30th January there would be a settling in visit on 2nd February 2015 and then visits every 2 weeks until 9th March 2015.  3.51 A letter was sent from Kandyce Downer’s solicitor to Legal Services on 26th January 2015 that mentioned the name change of Shi-Anne by Kandyce Downer. It was because “all of the female children in her care have a first name starting with K which gives all the children a sense of identity and connection with each other”. This letter was forwarded to the Social Worker who responded that as the name was part of Shi-Anne’s identity, permission should be sought from her birth parents.  3.52 On 27th January 2015 a final Court Hearing recorded that Kandyce Downer was appointed the Special Guardian for Shi-Anne and permission was given for a name change.  The decision was made by Lay Justices / the Magistrates who may be less likely to challenge the recommendation of the Local Authority supported by the Children’s Guardian than a Judge, would have been.  Post placement  3.53 On 28th January 2015 Kandyce Downer visited a Nurse at the GP practice for a contraception matter and was found to have very high blood pressure and was referred to a GP. She was diagnosed with severe hypertension requiring medical follow up. She stated that she was adopting Shi-Anne that week and referred to her as her niece.  3.54 On 30th January 2015 Shi-Anne went to live with Kandyce Downer and CSC closed the case with the outstanding commitment to the 3 visits before 9th March 2015. Kandyce Downer was paid over £3000 and sent Shi-Anne’s birth certificate. There are no records of the support visits ever taking place.   3.55  On 17th February 2015 Shi-Anne was registered at a GP surgery under her new name.  3.56 On 20th February 2015 Legal Services were contacted by Kandyce Downer’s solicitor chasing up payments and Shi-Anne’s birth certificate. It appeared that Kandyce Downer was now finding a lack of co-operation from the Local Authority. She was also dealing with the recent death of her 27 year old brother.  It appears no extra support was considered for this event. Publication Date:  22nd February 2017 13 | P a g e    3.57  On 9th March 2015 a formal handover took place between the Health Visitors.  3.58 On 1st April 2015 the new Health Visitor made a ‘New to the Area’ home visit at Kandyce Downer’s home. It is documented that Shi-Anne (although now known by her new name) was on a Special Guardianship Order. Kandyce Downer stated that she had had contact with Shi-Anne since she was a few months old and she had been living with her for a number of weeks on a full time basis. Shi-Anne was seen with Kandyce Downer and there were no concerns in relation to her health or welfare. Shi-Anne was not weighed on this occasion. Shi-Anne was reported to be attending a Pre-School and Nursery whilst Kandyce Downer attends College. There were no further health visits made and this was the last time any health professional saw Shi-Anne before she died. The review author accepts that this practice was correct, but suggests that in the future a further follow up visit should take place for children on SGO’s.  3.59 On the 1st July 2015 Kandyce Downer attended her GP’s surgery and gave a positive pregnancy test. As a result Kandyce Downer was prescribed iron, folic acid and blood pressure medication. There were no concerns of any description noted on her records.   3.60 Following the confirmation of her pregnancy, Kandyce Downer attended her initial Midwife’s appointment on the 16th July 2015. There were no concerns noted on her pregnancy notes at this time other than her hypertension, which was being managed through medication. Kandyce Downer did mention to the midwife that she had suffered from depression in 2013. She also stated that she had support from her family and friends.   3.61 On 27th July 2015 Kandyce Downer, Shi-Anne and the other four children all went on holiday to Spain, flying from Birmingham International Airport and returning on 3rd August 2015.   3.62 On 8th August 2015 Kandyce Downer hosted a barbeque to celebrate her birthday. There is photographic evidence taken on this date that clearly shows marks to the neck of Shi-Anne. Apparently Kandyce Downer had told people that this mark was Shi-Anne scratching herself as she had eczema. Shi-Anne was also seen on this occasion sat on the grass and not moving and staring at the fence, whilst Kandyce Downer ignored her. It is also observed that Shi-Anne was not seen crawling as she had been seen to before and was carried everywhere.  3.63 On Saturday 5th September 2015, Kandyce Downer was at home with Shi-Anne and one of her own older children. Kandyce Downer’s older child was at a wedding that day so Kandyce Downer left her home address at about 08:30 am to drop this child off. She left Shi-Anne at home alone. When she returned home at 09:55 am she has stated that Shi-Anne was well however shortly afterwards she telephoned for an ambulance claiming that Shi-Anne was not breathing. This call was made at 09:55 am the same time as she returned home. Paramedics attended at 09:59 am and discovered that Shi-Anne had no pulse and after initial treatment was rushed to the Children’s Hospital arriving at 10:15 am. On arrival Shi-Anne was not breathing and still had no pulse. Resuscitation was ceased at 10.21 am and rigor mortis was evident. Medical staff also noticed a number of serious injuries indicative of abuse.  Publication Date:  22nd February 2017 14 | P a g e   3.64 A police investigation commenced and after arrest and interview, Kandyce Downer was charged with both murder and causing or allowing the death of Shi-Anne. Kandyce Downer has now been convicted of the murder of Shi-Anne.  4 Analysis of significant safeguarding events  Pre – Birth period  4.1 Shi-Anne was the sixth child of her parents, who had been known to CSC since 2002. Their other five children had been removed from their care because of drug and alcohol abuse. They had a history of non-engagement with CSC and there was no contact between the parents and any of their other children when CSC became aware of her pregnancy with Shi-Anne in January 2014. An assessment established that there had been little change in the parents’ lifestyle since the removal of their fifth child in 2009.  4.2  It was wrongly believed that the mother had only made contact with Health Services about her pregnancy in January 2014 and this was seen as an aspect of her neglect. She had in fact told her GP on 18th September 2013 that she was pregnant and after a pregnancy test she returned to her GP on 8th October 2013 saying she wanted a termination. She was referred to the British Pregnancy Advisory Service (BPAS) but changed her mind and saw her GP on 3rd December 2013 stating that she wanted to keep her child. She was examined and referred but the GP did not submit this referral for another month until 2nd January 2014, which is regarded by the review author as practice which needs to be improved. In particular when you take into account the mothers historical risky behaviour. At the practitioner workshop the opinion of the group and the GP present was that it should have happened within a week at the most, especially when you consider the mothers vulnerabilities.  4.3   A pre-birth Child Protection Conference was held on 7th March 2014, with the unborn baby being made the subject of a Child Protection Plan. The parents were not prepared to agree to Section 20 accommodation, so plans were made to initiate care proceedings as soon as the baby was born. In view of the previous history in this family, it was agreed that there would be no new assessment of the parents’ ability to care for the baby and that a permanent placement was the likely care plan. Neither parent would suggest any members of their family who might be able to care for their baby. The mother specifically stated that she did not want her child to be cared for by any of her extended family.  4.4 CSC had reasonable planning time regarding this pregnancy and the review recognises that this time was used appropriately to reach a decision about Shi-Anne’s immediate future post her birth. Legal advice was sought and there was both a Legal Planning meeting and a Case Conference prior to her birth. The parents were appropriately involved and a Child Protection Plan was in place on the day of Shi-Anne’s birth. This good practice is noted.   4.5  The priority for Legal Services at this time was to identify any possible extended family members or connected persons. There was however in place on examination of the Looked After Child (LAC) minutes a twin track approach or dual plan for either adoption or an SGO. There was though no apparent discussion for Shi-Anne about the respective merits of adoption versus special guardianship, for her. The analysis and decision making which had taken place for her sibling appears to have been replicated for Shi-Anne with Publication Date:  22nd February 2017 15 | P a g e   little or no consideration about whether, some 5 years later, this was also the appropriate care plan for Shi-Anne. It appears that the thought process was that if an SGO was right for her sibling in 2009, then it must be right for Shi-Anne now, even though the early circumstances of their lives were not similar. Shi-Anne was not being treated as an individual with her own specific needs.           Post Birth and early care planning  4.6   An interim care plan was drawn up the day after Shi-Anne’s birth on 10th March 2014. The permanence plan stated that, “Shi-Anne Downer is to be placed with a Foster Carer while family members and connected persons are identified and assessed. The primary plan for permanence is therefore placement with connected persons on the basis that a potential carer is identified and assessed to be suitable to care for Shi-Anne Downer. Should this plan prove successful, permanency and security can be achieved under the auspices of an SGO.” This was then followed by the granting of an Interim Care Order on 14th March 2014. There was still no willingness from either birth parent to identify any member of their family who might be appropriate to care for Shi-Anne on a permanent basis and the mother still continued to state she did not want this to happen.  Despite this, a Social Worker was advised to see if there were any extended family members or connected persons who had been identified as possible carers for her sibling when she was the subject of care proceedings in 2009.  4.7   A LAC Review took place on 9th April 2014 and endorsed the leading plan to place Shi-Anne with relatives or other connected person or seek adoption.  4.8   It must be noted by the review that the time that Shi-Anne had in foster care appeared to be a happy one. This is reported by all professionals who came into contact with her in foster care. The Foster Carer in particular describes Shi-Anne as a very happy child.  SGO Assessment Process  4.9 A Schedule 4 Assessment enables the Local Authority to determine whether a potential care arrangement is likely to meet the needs of the child as set out in their care plan and therefore determine who should be the subject of a full SGO assessment. The Social Worker undertook 3 such Schedule 4 Assessments, all on applicants who had previously been identified for her sibling five years previously.  4.10 Kandyce Downer and her ex-husband had been assessed as potential Special Guardians at that time with a report being completed in January 2010. This assessment was very positive and the applicants were reported to have the support of the birth father for that earlier assessment. The ex-husband was Shi-Anne’s third cousin (he and the father are first cousins once removed.) There is no reference in the SGO assessment to Kandyce Downer’s time in care as a teenager (or how she came to be in care), it is reported that the medical reports were awaited and the outcome of Disclosure and Barring Service (DBS) checks were not referred to. Kandyce Downer and  her ex-husband were contacted to see if they might be interested in caring for Shi-Anne.  4.11 A second applicant who was 57yrs old, also from previous care proceedings, wished to be considered. She was not a relative and had an older partner who did not live with her although planned to do so when he retired. A third applicant was single and a very distant Publication Date:  22nd February 2017 16 | P a g e   relative.  She had given birth since the first assessment and was therefore already caring for a very young child.  4.12 The Schedule 4 Assessments were completed during May 2014 and with the agreement of the Team Manager and Area Manager two applicants were put forward for full Special Guardianship Assessments. On 2nd June 2014, the Team Manager advised Minster Social Work Ltd, the organisation undertaking the SGO assessments that, “out of the 3 assessments, the carer that stands out is Kandyce Downer”.   4.13 The planning for Shi-Anne continued to be timely after her birth, with the initiation of care proceedings and a LAC review shortly after her placement in foster care, together with the completion by the allocated Social Worker of a number of Schedule 4 Assessments. This again is recognised as fitting effective practice. Identification of a placement with a relative or a connected person as being the preferred permanence plan was considered to be the only real option. Although there was still in place the twin track approach of adoption and SGO, there was no reflection for Shi-Anne of the potential merits of adoption versus special guardianship for her.   4.14 National good practice guidance has been issued by the Coram Children’s Legal Centre (CLC) offers the following advice about whether adoption or Special Guardianship is the most appropriate permanence option. It states Special Guardianship may be more suitable than adoption if:  • An older child would struggle to deal with the status of being adopted. • The child has a good relationship with the parent(s) or members of the family, and/or the special guardian and parent(s) have a good relationship because it doesn’t distort the family relationship like adoption can. • There is a close relationship between the special guardian and the parent such as grandparents. • More than ‘occasional’ contact is planned between the child and the birth parents. • The child stands to inherit money. • There is a need to maintain cultural links and the need is greater than the ability of the adopters to provide this link. • Potential Special Guardians from minority ethnic groups may wish to offer a child a permanent family, but have religious or cultural difficulties with adoption.  4.15  The Local Authority’s procedures on SGOs state that:  ‘If a child’s parents are unable to care for him/her for an extended period, the most suitable arrangement is usually for the child to live with a relative or another person already known to him/her.  It is generally preferable for such arrangements to be made outside the care system – one option to achieve this is through special guardianship.’  The review author has not been made aware of any other departmental guidance which offers advice on the merits or otherwise of Special Guardianship as opposed to adoption (It is accepted that more detailed guidance is now available at http://birminghamcs.proceduresonline.com/chapters/g_perm_plan.html)  4.16  The following issues in the review author’s opinion were not taken into account:  Publication Date:  22nd February 2017 17 | P a g e   • Shi-Anne had been removed at birth and therefore had no pre-existing relationship with any member of her extended family. • None of Shi-Anne’s older siblings had contact with their birth parents, so what would be the reason for Shi-Anne to have it? • None of Shi-Anne’s older siblings wanted contact with her and none appeared to be planned for the future. • If Shi-Anne was to be brought up within the extended family, how would her relationship to her birth parents and siblings be explained to her, especially given the above? • The birth mother’s wish was that Shi-Anne was not cared for within the extended family. Why was this not apparently considered?  4.17 The review author suggests that at this point the Local Authority had adopted the stance that placement with a relative or connected person was the preferred permanence option for this child in any circumstances.  It is not really the case that Shi-Anne fitted any of the above criteria from either Coram’s advice or their own Local Authority Guidance with the current applicants to be placed under a SGO.       4.18 After the Schedule 4 Assessments, full SGO assessments were commissioned from an independent agency, Minster Social Work Ltd, on Kandyce Downer and the friend. The filing for the SGOs was time-tabled for 31st July 2014.  4.19 Both applicants were single women, Kandyce Downer was now separated and neither applicant was a biological relative, although Kandyce Downer’s children had a very distant relationship through their father’s side of the family. Neither applicant had ever met Shi-Anne. This in the review author’s opinion means that Kandyce Downer did not meet the criteria of the ‘spirit’ of who should have been awarded an SGO for Shi-Anne.  4.20 DBS checks had been undertaken in June 2014 but the outcome was not known at the time the completed assessment was filed with the Court. Health assessments were also arranged and Kandyce Downer refused permission to share information about her sexual health and other related matters stating that she would discuss it with an Independent Assessor, if required. The review author feels that this refusal should have triggered some concern to look deeper at Kandyce Downer. This health assessment also disclosed that she had suffered from a period of depression following the breakup of her marriage. Information was also sought on Kandyce Downer’s time in care.  4.21 From 10th July 2014 to 1st September 2014, the allocated Social Worker was not at work and the case was reallocated but remained in the same team under the same Team Manager.   4.22 The SGO Assessor arranged for Kandyce Downer to meet Shi-Anne for the first time on 16th July 2014. The report to the Court included the following statement: ‘I observed Kandyce Downer interacting with Shi-Anne Downer; the sparkle in her wet eyes and the love and affection she displayed were beyond compare. Kandyce Downer has seen Shi-Anne Downer only once and has immediately bonded with her’. The review author finds this account based on one visit does not carry enough assessment or to be fully evidence based. This meeting doesn’t normally take place until after an assessment is completed as it would not be helpful to the child if the final assessment is negative. So this was a missed opportunity in this case. Publication Date:  22nd February 2017 18 | P a g e    4.23 The SGO assessment stated that there was likely to be no contact with Shi-Anne’s siblings but made no reference to how Kandyce Downer might cope with that during Shi-Anne’s childhood, especially during her adolescence. Kandyce Downer was reported to be agreeable to whatever was decided by the Court regarding contact with the birth parents, but as there was no specific plan this was an abstract reflection. There appeared to be no consideration of what any sort of contact might mean in practice for Shi-Anne, for Kandyce Downer or for her other children. Similarly, it is not clear what Kandyce Downer had decided to tell Shi-Anne about her birth family. There is no reference at all to changing Shi-Anne’s name, which was subsequently requested by Kandyce Downer at the final hearing and agreed by the Court.  4.24 Kandyce Downer already had 4 children at home aged between 3 and 16 years. There was no assessment of how Kandyce Downer would manage a fifth child as a single mother, with no planned support from that child’s birth family. Similarly, the Independent Assessor recorded that on completing her business degree, Kandyce Downer planned to be self-employed and to work from home so child care would not be a problem. There is no reference to what exactly Kandyce Downer was planning to do or any acknowledgement that living in a small house as a single carer with 5 children might make this difficult. The medical assessments remained outstanding and Kandyce Downer made no reference to her period of depression in her meetings with the SGO Assessor. Similarly, the break-up of her marriage is barely referred to, with no mention of why it had happened or what the impact had been for Kandyce Downer and the children. In fact, the DBS check would reference longstanding domestic violence, but it is not clear if the independent assessor ever saw this.   4.25 The Assessor completed the report on 22nd July 2014, apparently without seeing either the DBS checks or the medical assessment. The recommendation was that the Local Authority should provide financial help to Kandyce Downer and that there should not be a Contact Order despite no conversation taking place with either the Social Worker (there was some contact between the Assessor and the first Social Worker but unclear if they had in depth discussion re contact) or the birth parents.  4.26 Whilst Kandyce Downer referred to her time in care and the Social Worker requested relevant information, it is not clear who, if anyone received that information. The references in the SGO assessment are superficial and appear to be Kandyce Downer’s interpretation of events. The Assessor makes no reference to having seen Kandyce Downer’s Social Care records. As the Sandwell records are on microfiche it can probably be assumed that the Assessor did not view them.  4.27 The Social Care record states Kandyce Downer had significant contact with Social Services again in 1999-2001, but this was not referred to in the report.  Kandyce Downer’s attitude to the reasons for this contact, together with how her oldest child coped with having no contact with his birth father would have provided a valuable insight into how she might parent Shi-Anne as she grew up.  4.28 The final care plan for the Care Proceedings is dated 1st September 2014.  As well as recommending an SGO to Kandyce Downer, it states that ‘the Local Authority proposes no contact arrangements directly or indirectly between Shi-Anne Downer’s birth father or mother at this time. However, if in future, Kandyce Downer believes that contact will be in Publication Date:  22nd February 2017 19 | P a g e   Shi-Anne Downer’s interest these should be supervised and monitored according to Shi-Anne Downer’s needs, wishes and feelings’. There had been no contact with either birth parent in coming to this decision.  4.29 In October 2014, Shi-Anne’s case was allocated to another Social Worker. In a statement to the Court dated 31st October 2014 requesting further time, the Social Worker stated that the DBS checks on Kandyce Downer and her ex-husband had still not been received. The Court was also advised that on 21st October 2014, Kandyce Downer had withdrawn her application and then changed her mind the following day. The reason for this withdrawal seemed to have been financial, as in addition to a weekly allowance, Kandyce Downer had requested a one-off payment of £3500 to help her buy a car large enough for all the family. This request at this time had been refused. The review author feels that at this point the Social Worker and Team Manager should have been very concerned about Kandyce Downer’s motivation for the SGO.  4.30 An addendum to the SGO assessment was completed by a second Independent Assessor, from the same agency in order to pursue further Kandyce Downer’s commitment to Shi-Anne. This addendum was completed following a single telephone conversation on 21st November 2014.  4.31 Kandyce Downer was reported to have been upset by the implication that her motivation to care for Shi-Anne was financial. She had been advised that she would be entitled to a £500 settling in grant and £135 weekly allowance until Shi-Anne reached her 18th birthday. Kandyce Downer still also wanted a 7 seater car in order that all 5 of her children which now included Shi-Anne could travel together.   4.32 It is recorded in the addendum report of 24th November 2014 that Kandyce Downer was ‘confident to be able to manage contact arrangements with birth parents’ despite the fact that none was being proposed and regarding her medical assessment, ‘I have had sight of Kandyce Downer’s medical report and this has not raised any issues or concerns’. Kandyce Downer had still refused to disclose some information around sexual health and this is overlooked or perhaps ignored. There is no reference to the fact that the DBS checks had still not been seen.    4.33 On 9th December 2014, the original Social Worker was advised of a positive DBS result on Kandyce Downer. This was shared with the current Social Worker who was not aware of the contents of this positive DBS result. It is not known what action, if any, followed from the receipt of this information which included statements from Kandyce Downer that she had been the subject of domestic violence from her husband since 2004, with the last reported incident being in August 2010.  4.34 The SGO was granted on 27th January 2015 and the Hearing was uncontested with the care plan being fully supported by both the Local Authority and the Children’s Guardian. The decision was made by Lay Justices / the Magistrates who may be less likely to challenge the recommendation of the Local Authority supported by the Children’s Guardian than a Judge, would have been.  At this Hearing, Kandyce Downer requested that Shi-Anne’s first name be changed and this was agreed, despite there being no prior knowledge of this request at the assessment and no consideration that the SGO report stated that Kandyce Downer understood that she could not change Shi-Anne’s name. The Local Authority’s solicitor at the hearing ‘took a neutral position’ on the basis that the birth Publication Date:  22nd February 2017 20 | P a g e   mother did not oppose or consent to the change of name and the Children’s Guardian supported the name change. Neither the allocated Social Worker nor the Team Manager had any concerns about the name change, which they should have as the father had not been properly consulted.  4.35 There was no further contact by CSC with Kandyce Downer or Shi-Anne after she was placed with Kandyce Downer on the 30th January and the case closure notes were written on the 30th January itself, and the case was closed on the 7th February 2015 as Kandyce Downer stated that she did not want any further support and there was no requirement in the procedures to keep the case open.  4.36 The decision about where Shi-Anne would spend her childhood was equally important whether the plan was for an SGO or adoption, but the quality of the SGO assessment is striking in its superficiality compared to those provided for adoption placements. The quality of the assessment should have been challenged by the Social Worker and their Manager. The Children’s Guardian did query it but both they and the child’s solicitor after this initial challenge did accept it.  4.37 The Assessor’s description of Kandyce Downer’s first meeting with Shi-Anne demonstrates a level of optimism which is very concerning. Similarly, to sign off an assessment without knowledge of the DBS checks and without following up queries from the health assessment is a fundamental and improper lapse.  4.38 The Assessor does not appear to have challenged any of Kandyce Downer’s responses regarding her time in care, her divorce, how she was going to earn a living or how she was going to help Shi-Anne cope with the very difficult questions which were likely to arise regarding her birth family. Contact was considered only in the abstract and it seems to have been assumed that somehow Kandyce Downer would know what was best for Shi-Anne as she grew up which is in contrast to the time spent preparing adoptive parents.  4.39 The Children’s Guardian had concerns in relation to Kandyce Downer’s commitment and motivation they raised these concerns with Shi-Anne’s solicitor and asked that an addendum to the SGO report to cover this should be included.   4.40 Similarly, the Local Authority recommended no contact at all with the birth parents, which is more restrictive than the majority of adoption placements, where annual letters and photos may be appropriate. No thought was ever given to Shi-Anne’s future contact with her siblings, a matter which would be a routine consideration in an adoption placement.   4.41 Minster Social Work Ltd was a company which had been commissioned by CSC and were due to complete an assessment with a timescale of less than seven weeks. There have been no reports or records available to this review and they have not been shared with CSC either. The Local Authority ceased commissioning independent companies in June 2015 and there is currently an audit and review of these services used at the time. The Local Authority state that they now provide these services in-house and do allocate enough time and resources to complete them in the depth and detail required.  4.42 The review author finds the request of a change of name at the final Hearing to be concerning. The importance of birth names is very important for adopted children and it has been the practice for many years for adopted children to keep their birth names unless Publication Date:  22nd February 2017 21 | P a g e   it is too risky for them to do so. The Children’s Guardian did address this issue in her final analysis taking the view that the change of name (so that it began with the same letter as the Kandyce Downer’s younger female children) might help her feel part of the family and provided the court with her advice.  4.43 Shi-Anne’s case was written up for closure on the day the SGO was granted.  Although this was not in breach of departmental procedures and reflected Kandyce Downer’s wishes to have no ongoing support from the Local Authority. This practice demonstrates the difference between long-term foster placements, adoptive placements and SGOs.  4.44 When the medical assessment which forms part of Kandyce Downer’s SGO assessment was completed, there were some omissions which should have been followed up by the Agency Medical Advisor with the medical practitioner, who had written the assessment to establish if they were significant or not.  If they were significant the Agency Medical Advisor should have identified these as concerns, which would then have been considered as part of the assessment.   There was also an opportunity for the Social Worker or Team Manager to have followed up the gaps in the medical assessment.  There are no records of requests from CSC about Kandyce Downer’s health or mental health or requests for reports from the GP about these issues. In this case the GP was not asked for any information about Kandyce Downer or any of her children.  4.45 There is no evidence within the GP notes that the implications of Kandyce Downer having a child on a SGO had been considered, with no liaison between her GP and the Health Visitor. There was no inquiry regarding her most recent partner and whether he gave or would give any support to her. There was no recent inquiry into Kandyce Downer’s mental state either. She had previously been of low mood in early 2013, and on another occasion a few years earlier. This was described as a “stress-related problem” incorporating both her marital split and issues at work and she was signed off work for 4 months in 2013. She was offered antidepressants but only took them for 1 month (therefore no clinical benefits). At this time a history of domestic violence is noted, but no further details are provided. It is not clear whether the abuse was historical or current at that time.   4.46 It is of note that on two occasions younger children within the family were brought to the GP by other siblings who were therefore helping Kandyce Downer with the demands of her family, although it is not clear why.   4.47 There is no indication within the primary care notes that Kandyce Downer had ever neglected or mistreated any of her existing children. Her children were immunised, although their immunisations were delayed by variable periods. She brought them up for reviews of their medical illnesses and when an appointment was missed she attended soon after. Kandyce Downer’s children had not been subject to Child Protection Plans or Child in Need Plans.  4.48 The changes and absence of Social Worker’s to the case, impacted on the consistency of the whole SGO process. Although Legal Services did analyse the work completed or on occasions not completed, their depth of analysis, challenge and escalation could and should have been more effective.    Publication Date:  22nd February 2017 22 | P a g e   Post placement  4.49 It is very clear what life was like for Shi-Anne whilst she was in foster care and that all her health visiting services were appropriate. Shi-Anne was up to date with her development checks and immunisations prior to her move to live with Kandyce Downer.  4.50 Kandyce Downer did register Shi-Anne with a new GP, within 24 days of her coming to live with her under the SGO and notification was received by the new Health Visiting Team from the GP surgery on 23rd February 2015, enabling Health Visitor records for Shi-Anne to be requested from the previous Health Visiting Team.   4.51 The first time that Primary Care (a GP would have filled in the SGO assessment though) is aware of the Special Guardianship Order is when Kandyce Downer mentions that she is about to adopt her niece in January 2015. This is when it was revealed that she had severe hypertension, which medically may have distracted the nurse and the GP from picking up on the aspects of this information. Ideally this statement should have been explored and her mood and level of support required could have been followed up by the Health Visiting Team.  4.52 Shi-Anne did not have a flag or red code on her medical notes which would alert staff that she was effectively an adopted child. She was not seen by the GP or Nurse after her placement in any case. A flag is not placed on Kandyce Downer’s notes either to indicate that she is an adoptive parent. Both these are possible and could have assisted in safeguarding of Shi-Anne.  4.53 During the New to Area contact visit on 1st April 2015 where Shi-Anne (now known by her new name – Keegan Downer) was seen with Kandyce Downer the Health Visitor did not see Shi-Anne initially as Kandyce Downer reported that she was asleep. When she was brought downstairs by Kandyce Downer the Health Visitor observed Shi-Anne sitting very close to Kandyce Downer throughout the visit and an apparent good bond between them was reported. The Health Visitor took routine details which were recorded on the Reference Card for Shi-Anne, including that she was subject to a SGO from January 2015 and that Kandyce Downer was attending college. Details of Kandyce Downer’s other children’s schools were noted. There was no information recorded regarding any partner of Kandyce Downer and the Health Visitor recorded that Shi-Anne’s ethnicity was “Black other”, her religion was Christian and that her language was English. She assessed Shi-Anne’s level of need as Universal Plus, in accordance with the Right Service, Right Time Guidance for Practitioners (BSCB March 2015), indicating that Shi-Anne and her family required support and interventions above and beyond universal services. There is no record of what analysis led to Shi-Anne being assessed as Universal Plus or in fact that any activity then took place to support this assessment. It has been confirmed at the practitioner’s workshop that this assessment of Universal Plus was only because the Heath Visitor was waiting for Shi-Anne’s records to be transferred across, not because of any assessed need.  4.54 Kandyce Downer’s birth children were in receipt of universal services, indicating that there were no additional needs identified by either the Health Visiting or School Health service to that point. The same Health Visitor had previously attended the home address of Kandyce Downer on 19th February 2013 to visit her youngest child as a New to Area contact and her assessment was recorded as Level 1, indicating that no additional needs were Publication Date:  22nd February 2017 23 | P a g e   identified. This is comparable with Universal Needs using the Right Service, Right Time Guidance.   4.55 In the Health Visiting Care Plan for Shi-Anne the Health Visitor documents that she needed to be brought for her further immunisations and to be weighed at the clinic. Shi-Anne was also to continue attending her pre-school with Kandyce Downer’s youngest child.   4.56 It is unclear from the records why there was no further contact with Shi-Anne and no further visits by Children’s Social Care. The final care plan suggests three visits in six weeks and then closure but Kandyce Downer could request if she wanted further support. The Social Worker has stated that the case was reallocated and that had Kandyce Downer requested support it would have been provided. The review author feels that these visits as promised should have taken place.  4.57 Shi-Anne was not brought for her further immunisations or weight check as agreed. A further visit may have established why she wasn’t taken for her immunisations or revealed any other issues.  It is noted that a visit was scheduled but on a date after Shi-Anne had died.   4.58 The Family Court had an understanding that support would be available to Kandyce Downer and her family for 6 weeks after the final Hearing, and then at her request. There is only one example of any contact by the Social Worker taking place and no record of the outcome of it.   4.59 There was a cause for concern as far as the educational welfare of one of Kandyce Downer’s children. The other schools that they have attended all provided positive comments in that the children appeared to be well looked after and their physical appearance was good. This one school reference however, stated about the behaviour problems they were having with one of the older children.  Shi-Anne herself attended a Pre-School on a full time basis and her interaction with Kandyce Downer’s youngest child was observed as a caring relationship with Shi-Anne being “mothered”. There was no issue highlighted by them with parental engagement. The school reference as mentioned above should though have triggered an exploration on Kandyce Downer’s ability to cope with five children.  4.60 When Shi-Anne was placed with the foster mother she was registered with a Children’s Centre in that area. When she moved to be placed with Kandyce Downer no handover or transition to a new Children Centre took place. The local one to Kandyce Downer’s address only found out about it when they saw the under 5 health list and saw another under 5 registered there. They were then proactive and made a home visit but unfortunately no one was at home. It would have been really beneficial in terms of help, support and monitoring for Shi-Anne if this notification had taken place soon after the decision for the award of the SGO, had taken place, so proper handover and transition could have taken place.  4.61 Within 4 months of the SGO, Kandyce Downer was pregnant again, apparently having missed or stopped her contraception injection. There is no exploration of how she was coping with 5 children, let alone a sixth, and no mention of her mood, well-being, her work situation, home life or who the father of the latest pregnancy is or whether he was living in the family home or supporting Kandyce Downer. It would have been appropriate for the Publication Date:  22nd February 2017 24 | P a g e   GP to communicate with the Health Visitor given her large family including Shi-Anne despite there being no immediate safeguarding concerns.  4.62 The Children’s Guardian did not actively liaise with the Independent Reviewing Officer (IRO) during the case which meant limited contact. Such liaison is important in the interests of the child. Although the relevant protocol was only issued earlier in 2014, there had been previous guidance on this, but limited training had taken place. The Children’s Guardian has since attended training and now liaises with the IRO from the outset of a case. Good liaison can have significant impact on the management of cases and avoid significant delays.   4.63 Special Guardianship Orders were introduced in 2005 as a legal pathway to permanence for children, often within the extended family network.  It was introduced to meet the needs of a significant group of children, including mainly older children who had become separated from their birth family, children already living with a relative or Foster Carer, and groups such as unaccompanied asylum-seeking children. Statutory guidance on Special Guardianship states that its purpose is to:   • give the carer clear responsibility for caring for the child and for making decisions to do with their upbringing  • provide a foundation on which to build a lifelong permanent relationship between the child and their carer  • be legally secure  • preserve the link between the child and their birth family  • be accompanied by access to a range of support services, including, where appropriate, financial support (Department for Education and Skills, 2005).   Special Guardianship is a private law order.  The Court may make a Special Guardianship Order (SGO) with respect to any child on the application of an individual who is entitled to make such an application or who has obtained permission of the Court (S.14A (3) Children Act 1989). The Act defines those who are entitled individuals, including:    • a Local Authority foster parent with whom the child has lived for a period of at least one year immediately preceding the application  • a relative with whom the child has lived for a period of at least one year immediately preceding the application  • any person with whom the child has lived for a period of at least three years  • where the child is in the care of the Local Authority the person has the consent of that Authority  • any person who has the consent of each of those who have parental responsibility for the child  • a guardian of the child  • any individual who is named in a Child Arrangement Order as a person with whom the child is to live.1   4.64 Thus, SGOs can be made in respect of children in a range of very different circumstances. For example, SGOs are made in respect of children subject to care proceedings, or for whom the alternative may be to enter care proceedings, and in these cases the order often                                                            1 Department of Education (2015) Special Guardianship Qualitative Case File Analysis research report  Publication Date:  22nd February 2017 25 | P a g e   leads to a change in where children live and who cares for them. SGOs are also made for children where the Local Authority has not been previously involved, or who have been settled in a kinship or foster care placement for a period of time. This may involve no change in a child’s home or primary carers, but will involve a change in legal status.    4.65 A Court may make a Care or Supervision Order if it is satisfied that the ‘threshold criteria’ as defined by S.31 (2) Children Act 1989 is fulfilled (i.e. that the child is suffering or is likely to suffer significant harm). A Supervision Order does not confer parental responsibility on the local authority. While a Supervision Order is in force it is the duty of the supervisor (usually the LA Social Worker) to:   • advise, assist and befriend the supervised child  • take steps that are reasonably necessary to give effect to the order   • where the order is not wholly complied with or the supervisor considers that the order is no longer necessary, to consider whether or not to apply to the court to vary or discharge the order.   4.66 A variety of directions and requirements can be attached to a Supervision Order. There are no specific consequences for breach of these directions and requirements other than returning the matter to court for a review.   4.67 The primary purpose of course is to enable the Local Authority to monitor and support the placement in the best interest of the child2.  4.68 The review author is firmly of the opinion that if an SGO was going to be awarded in this case (which he doesn’t believe it should have been, as it neither met the original purpose or even the spirit of why SGO’s were introduced) that a supervision order should have been attached to it.  5 Family Perspective  5.1  The review author has met with mother and foster mother; they were supported by an advocate from Advocacy After Fatal Domestic Abuse (AAFDA). The review author has also spoken to the father. It is essential that overview reports where possible obtain the views of family members. This report has benefited from hearing their perspective.  Mother  5.2  Mother really didn't want anybody to know that she was pregnant and thought about running away because she knew with all of the other children being taken away, that this child would be removed when she gave birth.  5.3 The mother felt she was just labelled as someone who took drugs; she was on methadone at the time and doing quite well.  5.4 When she first got pregnant she went to the GP who then of course referred her along with all of her background.  Social Care took Shi-Anne, the mother said she had no choice they                                                            2 Department of Education (2015) Special Guardianship Qualitative Case File Analysis research report Publication Date:  22nd February 2017 26 | P a g e   didn't want her to have the child and because it was always going to happen. It wasn’t worth her fighting it.  5.5 Mother and Shi-Anne spent five days in hospital, and the court on the Friday removed her and she went to the Foster Carer. She did have some supervised contact three times a week. She went for couple of months, then they moved the location and she didn't know the place that they went to, it was filthy dirty and she didn't like it like that at all, and stopped going.  5.6 The mother knew little about the court case but she was spoken to, and she said to them quite clearly that she did not want Shi-Anne to go to Kandyce Downer at any time. This was because of how she is with her own children. She feels that her wishes should've been heard but they weren't. She would rather have had her go to a stranger than to Kandyce Downer, who in fact really was a stranger to Shi-Anne. The mother didn't know her at all and had only met her on a couple of occasions.  5.7   The court reports that she saw were copied word for word from the previous time when her last daughter was taken her into care. That was five years earlier with very little different wording. They didn't treat Shi-Anne as an individual, they just followed exactly what they done before. They had no thoughts on whether she could care for her herself, that she had changed, and in fact nobody did an assessment they just labelled her as she had been before. She tried to contact the second Social Worker a number of times in the case and that never got any reply.  5.8   She knew there was nothing that she could do and didn’t have the heart or strength to fight it. She did object to the name change and told her solicitor this, but it happened anyway. Nothing was organised for contact for her and she kept ringing the Social Worker but got no reply.   5.9 They (CSC) should have taken the time to visit Shi-Anne which they should have done to make sure she was okay. The Health Visitor only visited once. When she misses an appointment they come down on her like a ton of bricks, why wasn’t this in place for her? If there's ever anything like an SGO, adoption or fostering there must be constant checking and supervision, just to make sure that person is safe and okay. This ensures contact on a regular basis and should last for a year. They could have prevented her death if they had monitored Kandyce Downer’s care.  5.10 When Shi-Anne was taken into foster care, the mother sent her Redbook and a letter saying ‘please take care of my baby’ she feels that this wasn't done and no body cared for her baby, after she moved to Kandyce Downer.  Father  5.11 He feels that the mother should have been given a chance to care for Shi-Anne, with someone working with her. When you take someone’s child away it rips them apart. Just because the other ones have been taken doesn’t mean that this should have happened this time.  The mother needs support to make sure she can bounce back from this. He has had no bereavement counselling and he wants and needs this.  Publication Date:  22nd February 2017 27 | P a g e   5.12 A Social Worker did come and visit him, and he did say he didn’t have a problem with Kandyce Downer having Shi-Anne, but he knew that the mother was against this. The reports that were used though were all the same and used again and again and no new assessments had been used.  5.13 When the SGO was ordered why was there no contact for him. He should have had at least three times a year and be able to write to her.  Kandyce Downer should not been able to have her own way. He feels that they must and should have been supervision in place, enough to report on what they saw. As it turned out she could just do what she wanted to do, unchecked by anyone. Once SGO was made the Social Workers never ever went and checked her and they should supervise, they need to do that.  5.14 In relation to the change of name, they never once contacted him.  He would never ever have allowed it to happen, so he is shocked that it did happen. He felt that keeping her name Shi-Anne, at least was to keep her part of the family.  5.15 He just wants Kandyce Downer to say why she did it.  Even to this day he has never got an explanation and he knows the Judge said that we need to do something positive, as a result of Shi-Anne’s death and make changes in order to stop this happening ever again in the future.  Foster Mother  5.16 Foster carer has been a Foster Carer for nine years and had been for seven years at the time, that she had Shi-Anne placed with her. She is registered to have 0-7 years. She often specialises in babies, in particular if they've got some drug issue in their background.  5.17 Foster Carer had Shi-Anne from five days old and she kept and took care of her for 10 months. The Foster Carer had not met the birth mother until after Shi-Anne had died.  5.18 The Foster Carer had lots of contact with the Health Visitor who was good. Foster Carer wonders how and when SGO’s are determined as it is a lot less than adoption or fostering. When it came to assessments for Shi-Anne, there was an initial plan, and this initial plan was really involved, and thorough. and it was a plan that she would say was good. There was three Social Workers involved throughout the time that she had Shi-Anne and it was the second Social Worker that developed the plan, to help with transition. However, this was put on hold when Kandyce Downer said that she didn't want to commit, and she was coming out because she wanted confirmation that there would be some finance for her in order to get a larger car. That initial plan was then stopped.  5.19 The Foster Carer felt throughout that there were lots of things that didn't add up about Kandyce Downer and she mentioned it to the Social Worker, (the second one) about her concerns that Kandyce Downer and her motivation and how she was going to care for Shi-Anne didn't add up. The Foster Carer went to all of the LAC reviews and at the first review when SGO was mentioned that the only applicant going forward was Kandyce Downer. The Social Worker was asked what was her connection with Shi-Anne, when told that the connection between them was that Kandyce Downer was once married to a cousin of the father, everybody asked how wide a connection can go, but this was ignored.   Publication Date:  22nd February 2017 28 | P a g e   5.20 The Foster Carer didn’t think it was the right thing when Kandyce Downer decided that she would get back involved but another plan was made. This plan was very rushed, an example of this was that there was a full day home visit one day and then after that no contact the following week and then three overnights and when Shi-Anne came back she was very clingy to her and she seemed to be very quiet.  5.21 The Foster Carer was shocked by the name change and never knew about it until the SGO was awarded. This is because when it comes to adoption one of the things you must do is keep their identity and keep their name. The Foster Carer feels that there needs to be a definite recommendation that there must be a Supervision Order put in place with an SGO. This must last for 12 months and then they would be totally supporting and making sure that everything is going well. The Foster Carer feels that it just seemed a rush to SGO; if it was an adoption it takes a lot longer. SGO’s should be closer to adoption. Kandyce Downer was doing everything on her own terms. With the SGO’s there needs to be strict guidelines, not changes depending on who they are dealing with. There is no way if this had been an adoption or even for fostering that Kandyce Downer would ever have got Shi-Anne.  5.22 The Foster Carer describes Shi-Anne as a lovely baby; she was wonderful from the day she was placed with her. She could only be described as a beautiful baby, and all of her friends and neighbours all agree, and also Foster Carer’s own family agreed that she was a lovely baby.  5.23 The Foster Carer feels that there needs to be some formal welfare support for Foster Carers.  The Foster Carer has really felt that she is grieving; nobody contacted her when Shi-Anne was murdered.  One of the people she knows that works in adoption told her about it.  The Foster Carer really feels that where a foster child in particular one that had such a long relationship and something dramatic happens there must be welfare and support given to Foster Carers that should be her recommendation from this review.  6.0   Conclusion            6.1   The above commentary and analysis shows what happened during the period leading to the death of Shi-Anne. The commentary also shows answers to the questions posed for the review.  6.2  The review has recognised a number of themes for learning that have arisen from the analysis. These Themes are:  • Lived Experience of Shi-Anne  • Information sharing • Assessments in general • Supervision and Management Oversight • Special Guardianship Order Process  6.3  Very little is known of what life was like for Shi-Anne after she was placed with Kandyce Downer. There is only a little bit of information from a single visit by the Health Visitor and then a short mention by education on her time in pre-school. This means that after the SGO was granted Shi-Anne was almost invisible to professionals.  Publication Date:  22nd February 2017 29 | P a g e   6.4 It is felt that at times there was too much focus on the carer of Shi-Anne and not the effect they were ultimately to have on Shi-Anne. The voice of Shi-Anne was regularly missed.     6.5  The Health Visitors’ provided good care up until 1st April 2015 and their documentation of events and attention to Shi-Anne is recognised by the review.       6.6  It has also been noted that improvements are still needed in relation to information sharing and that barriers to this must be overcome. Agencies must adequately share routine information and work together with it and this is a key issue.   6.7  The change in status for the child becoming subject of a Special Guardianship Order was not information shared between key professionals, such as GP and Health Visitor.  There were also examples of where information when known was not considered for meaning and impact on the safe and appropriate care placement for the child.    6.8 The triennial analysis of Serious Case Reviews 2011-20143, highlights the need for a ‘culture of communication’ that supports information being shared, verified and actively used to inform decision making.  Whilst there continues to be Serious Case Reviews where information sharing is an issue, there has not been one case in the ten years of analysing Serious Case Reviews, where too much information sharing has caused harm to a child.  Assessments  6.9 The Designated Judge for the Family Court has reviewed the file for the case and has met with both the City Council and CAFCASS and stressed to them the importance of more in depth reports and to scrutinise assessments and proposals in more detail. This is now in place. However, it wasn’t at the time and more scrutiny of the City Council assessments should have taken place by both CAFCASS, and the Family Court in this case. It is fully accepted that the hearing was uncontested with the care plan being fully supported by both the Local Authority, and the child’s solicitor, but the review author does feel that more scrutiny could have taken place by the Family Court in this case, as clearly gaps in the assessments were evident to all.  The fact that the decision was made by Lay Justices (the Magistrates) may suggest that they are less likely to challenge the recommendation of the Local Authority supported by the Children’s Guardian than a Judge would have been and that this level of scrutiny needs to take place.  6.10 While there are no firm indications in any of the agencies notes that Kandyce Downer’s parenting was compromised, there are a number of risk factors such as being a single mother with 4 children. Also the two historical episodes of domestic abuse, a previous history of stress leading to time off work, a new partner and a pregnancy that didn’t appear to be planned. This represents risk factors for her reduced parental capacity. Recognising this might have led to an assessment and an offer of support, once all the factors were put together. For example without clear flags on the notes, the GP would not have had time to read the whole family’s background to the level of detail required to come to this conclusion. An indicator that Kandyce Downer was an “adoptive” mother as well as having 4 of her own children and then becoming pregnant might have prompted the GP. This                                                            3 Sidebotham P et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 DfE Publication Date:  22nd February 2017 30 | P a g e   could have resulted in a referral to the Health Visitor being made as it is not clear from the GP records whether the Health Visitor was already involved or not.   Supervision and Management Oversight  6.11 The review author considers that close supervision and proper management oversight were not always evident in this case.  Staff need support and reassurance and the case management across the agencies requires closer supervision.  It is felt that for professionals that the voice of the child was not the priority.  The review author suggests that training should help learn this lesson.  6.12 It could be said that if interventions had been made earlier through the home visits that should have in the review author’s view happened, but never occurred, or picked up by supervisors, in particular action taken after Kandyce Downer informed her GP she was pregnant; concerns should have been recognised and then acted on.  6.13 The children’s workforce, including Foster Carers, plays a critical role in provision of safe and stable care.  In this case the Foster Carer had care of the child from 5 days old to 10 months old.  Management need to understand and support the required emotional investement needed from those who work with children, it is important that the support they receive extends to the rare but tragic instances where a child they have recently worked or cared for, dies.  Special Guardianship Order Process.  6.14 From the outset adoption was considered as an option for Shi-Anne. There was a twin track approach in relation to both adoption and an SGO. Adoption and its much tighter processes, was though, on balance, not seen as the priority option by the Local Authority, this was the SGO. This arose for two reasons. Firstly, the Local Authority policy around adoption and SGOs was unclear and secondly, because extended family members/connected persons had been identified for an older sibling some 5 years earlier and when contacted, they expressed a similar interest in caring for Shi-Anne.  6.15 It seems to have become the practice for Birmingham City Council to regard a placement with an extended family member or a ‘connected person’ as being preferable to adoption, irrespective of the circumstances of the child. It is fully accepted by the review author why this was happening through the impact of two cases4 . These judgements require Family Court Judges and therefore Children Social Care and their Legal Advisors to ensure that they fully consider and balance the benefits to the welfare of a child remaining in their family group to being adopted by a stranger.   6.16 However, the practice in Birmingham on SGO’s, would seem to be contradictory to the stated purpose of SGOs, particularly in a case like this where a child was removed at birth and where no contact with any birth relative was planned. However, these decisions also reflected practice elsewhere and did not just happen in Birmingham, and the national concerns about the misuse of SGOs have led to a review of SGO guidance and practice                                                            4 Re B (A Child) [2013] UKSC 33 and Re B-S (Children) [2013] EWCA Civ 1146  Publication Date:  22nd February 2017 31 | P a g e   by the Department for Education. This new guidance was issued in February 2016 and amended in January 2017.   6.17 There is a stark difference between the assessment and preparation process for a prospective adopter and that for an SGO applicant. Whilst this might be appropriate for some circumstances, it is not acceptable for babies and very young children who have no pre-existing relationships with their birth family. Such placements require the same attention to detail irrespective of what type of final legal order.  6.18 Whilst it is known that the Children’s Guardian supported the SGO, it is not known if there would have been support for an adoption plan. They were however involved in the previous two children’s Care Orders, and would have been involved in the dual plan thoughts for them. On analysis it is possible however in Shi-Anne’s case that Local Authority practice at the time may have dictated that a dual plan was not considered in this case.  6.19 There are some learning points in relation to the Children’s Guardian which include the need to ensure that all relevant checks are carried out and the need for considering whether a period of monitoring is needed, before a final order is made. There is also a need for them as the challenging voice of the child to ensure all checks have been carried out.  In this case a key point is the addendum assessment which is where there should have been further challenge as it was clearly of inadequate quality. The Team Manager did have regular oversight of the case and reviewed the final report but a Supervision Order in the review author’s opinion should have been considered. It is accepted that the issue was raised earlier in the proceedings by the Children’s Guardian, but by the final hearing after seeing the SGO assessment felt no longer required.  6.20 When passing sentence at the conclusion of the criminal trial, during which all circumstances in relation to this case were examined in detail, Mrs Justice Frances Patterson (the trial Judge) said: “it is a horrific tale of callous conduct. It can only be described as vicious. You have shown no remorse. Why you changed from a loving mother to a brutal attacker of a defenceless child is a mystery.  I sentence you to life and you must serve a minimum period of 18 years.”  6.21 The review author is firmly of the opinion (albeit based on hindsight) that Shi-Anne should never have been placed with Kandyce Downer, due to a) Kandyce Downer not really fitting the criteria to be awarded an SGO, b) the flawed and incomplete assessments. As Mrs Justice Patterson says above, there is no evidence why Kandyce Downer changed from that loving mother into the brutal attacker. As a result of this the author feels that Shi-Anne’s death couldn’t have been predicted. It is felt though, that if there was a Supervision Order in place (as long as implemented effectively) or in particular, what the review author sees as a significant event when Kandyce Downer became pregnant again (including the breakdown of her relationship) an assessment of the risks posed by this additional stress to the household, that the opportunity for Kandyce Downer to carry out these assaults could have been prevented by the involvement of professional action and curiosity into the life of Kandyce Downer and the children, in particular Shi-Anne.  6.22 Birmingham City Council after the death of Shi-Anne reviewed their procedures and incorporated them into their Individual Agency Summary Report presented to this review.  They also provided assurance to the review that they are making the necessary Publication Date:  22nd February 2017 32 | P a g e   improvements through the provision of position statements against each key area of work they had identified.  The key areas they identified are including now completing all SGO assessments in house; the SGO procedures have been updated and guidance produced about ensuring the assessments are thorough and include all relevant points, also identifying the most appropriate permanence option for children.  They now keep cases where an SGO has been awarded open and notify relevant agencies that an SGO has been granted, so they can be flagged on their systems, and also ensure support and supervision is provided for a number of months.   6.23 They need to ensure the involvement of the IRO and also improvements in management and supervision of SGO cases through clear guidance and tasks that must be completed by Managers.  6.24 Birmingham LSCB now need to ensure that they incorporate the lessons highlighted from this review into an action plan.  This action plan should be focused on making a difference in the performance of the partnership to the issues highlighted in this review.      Publication Date:  22nd February 2017 33 | P a g e   ACRONYMS  AAFDA  Advocacy After Fatal Domestic Abuse  SGO   Special Guardianship Order  CSC  Children’s Social Care  BCHC  Birmingham Community Healthcare  BPAS  British Pregnancy Advisory Service  BSCB  Birmingham Safeguarding Children Board  CAFCASS Children and Family Court Advisory and Support Service  CCG  Clinical Commissioning Group  CLC  Children’s Legal Centre  DBS   Disclosure and Barring Service  D/Supt  Detective Superintendent  EDT  Emergency Duty Team  GP  General Practitioner  IRO  Independent Reviewing Officer  LAC  Looked After Child  LSCB  Local Safeguarding Children Board  SCR  Serious Case Review   