Dying for a change?

After yesterday’s eventual departure of Sharon Shoesmith, Haringay’s Director of Children’s Services, in the wake of the traumatic levels of bureaucratic failure surrounding the death of ‘Baby P’, James Barlow has been taking a look at Bristol’s Safeguarding Children Board (BSCB) and in particular their statutory Serious Case Review (pdf) into the death of local child ‘Baby Z’ after the ingestion of opiates and methadone in the family home.

This is rather timely, because yesterday Ofsted, under pressure, from Children’s Minister Ed Balls, published ‘Learning lessons, taking action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008‘.

This is a thorough assessment of every statutory review undertaken by local authorities in cases where a child has died or has been seriously injured or harmed and abuse is known or suspected to have been a factor.

The purpose of these Serious Case Reviews should be to independently, honestly and openly investigate these cases, look at what might have gone wrong and learn the lessons that need to be learnt in order to prevent such tragedies happening in the future.

Ofsted’s report covers all 50 cases from across the UK for the year and rather worryingly two are from Bristol and they won’t look at ‘Baby Z’s’ case review until next year.

But of even more concern is the fact that the most recent Serious Case Review from Bristol that Ofsted looked at was one finally published in January 2008 and it has been evaluated as ‘inadequate’. Concerning ‘Family W‘ (pdf), it too involved infants and the apparent ingestion of opiates in the family home and reviews events that actually occurred in 2004.

By Ofsted’s own definition ‘Inadequate’ means:

The review does not fully address the terms of reference or meet the requirements of chapter 8 of Working together. A lack of rigour in the management of the review impacts adversely on its capacity to ensure that lessons are identified and learned.

This means the report has failed in some of these areas:

– The scope of the review is unclear and supported by imprecise terms of reference which fail to ensure that the relevant information can be obtained and analysed.

– The contributions of some relevant agencies are not secured.

– Insufficient independence is built into the process.

– The involvement of relevant family members has not been agreed.

– Some parallel investigations including criminal investigations and coroner’s enquiries have not been considered within the scope of the review and processes for communication are unclear.

– There are substantial and avoidable or unexplained delays in the completion of the review which impede timely dissemination of lessons to be learned.

– Not all relevant agencies produced a management review of their involvement with the child(ren) and family.

– Reviews do not take into account the individual needs of the child(ren) and family including their racial, cultural, linguistic and religious identity.

– The extent to which practice at individual and organisational levels is analysed openly and critically against national and local statutory requirements, professional standards and current procedural guidance is inconsistent across agencies.

– There are gaps in information which are not fully explained.

– Some areas for changes in practice are identified but are not always supported with measurable and relevant recommendations for improvement.

– Reference is not always made to what information was known to the agencies and professionals concerned about the parents, carers and perpetrators, the family history and home circumstances of the child(ren).

– The report lacks rigour in its examination of the facts and explanations on how and why events occurred and actions or decisions by agencies were or were not taken.

– The use of the benefit of hindsight by reviewers to judge whether different actions or decisions by agencies may have led to an alternative course of events is not convincing.

– The use of the benefit of hindsight by reviewers to judge whether different actions or decisions by agencies may have led to an alternative course of events is not convincing.

– An executive summary is completed but there are gaps in information about the review process, key issues arising from the case and recommendations which have been made.

There’s a whiff of cover-up here isn’t there? And is this good enough? Not only have we collectively failed to protect our vulnerable children but those we employ and remunerate to objectively find out the reasons why this might have happened, and so, perhaps, prevent it happening again in the future have manifestly failed us.

The case of ‘Family W’ dates from 2004 and involves the ingestion of opiates by children in the family home. An inadequate Serious Case Review and its findings and recommendations were finally published in January 2008. ‘Baby Z’ died from the ingestion of methadone and opiates in the family home in July 2007, a full three years after ‘Family W’s’ case.

Draw your own conclusions.

The officer who has the ultimate responsibility for this is Heather Tomlinson.

Currently wafting around the Council House on an income in excess of £120k and now sporting the grandiose title Strategic Director Children, Young People and Skills, tonight Tory John Goulandris will ask Labour education boss, Peter Hammond at a Full Council Meeting: “Can he confirm that the Strategic Director for Children, Young People & Skills still retains his and the Cabinet’s confidence or does he believe that it is time for a change?”

In the light of this Ofsted report and the events it highlights, Mr Hammond should be considering his answer very carefully indeed.

Update: Looks like Ed Balls has some concerns about this too:

Balls urged investigations into 38 other abuse cases to be reopened after Ofsted criticised the quality of previous reviews. They include three cases in Cornwall, three in Northamptonshire and deaths and serious injuries to children in Bristol, Derbyshire and Hampshire.

The Guardian, 2 December 2008