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Friday, July 30, 2010

Another death reviewed

In Britain the case of Khyra Ishaq has not received the attention that the more famous child deaths have recived. Baby Peter and Victoria Climbie became household names there as the media laid bare mistake after mistake by child protection workers leading up to the deaths of these children. It was almost numbing to read the litany of errors - something that I have become quite interested in and will be writing a great deal about on this blog. There are many systemic reasons why these deaths occur but it is distressingly obvious that case workers are making the same errors again and again - in country after country.

We should be asking less why the workers are making the mistakes and more why the work environment, political system and community standards keep a system functioning in a way that these mistakes almost become inevitable.

Two years after Khyra's death, the Birmingahm Safeguarding Children Board has released their report on the death of Khyra. It was preventable.

What is different with this report is that the whole review has been released as opposed to the practice of the last few years where the serious case reviews only had the executive summary made publically available. This change represents a shift in direction in Britain, although it is unclear if that will be broadly done. Here in Canada, many reports are published in their entirety if they are made public - although that is not always the practice. There is a real debate about the value of showing the public all the facts as it risks making workers public targets as was seen in the case of Baby Peter where one of the workers has been publically vilified.

The 18 recommendations made in the Ishaq case are all too familiar - better assessment, better communication between agencies, better investigation, better monitoring, better training - recommednations that come out of the vast majority of these reviews.

The full report can be read at
Here is a summary that was published in the Herald Scotalnd newspaper:

Social workers could have saved starving Khyra, 7, report claims

• Khyra Ishaq: Died after suffering months of cruelty

heraldscotland staff accessed 2010 07 30

28 Jul 2010

A seven-year-old girl starved to death after a catalogue of missed opportunities by social services and other professionals, a review has found.

The report, by the Birmingham Safeguarding Children Board (BSCB), comes more than two years after Khyra Ishaq died at her home in the city.

Following months of starvation and cruelty at the hands of her mother and stepfather, Khyra died in May 2008 after contracting an infection.

But the report – published in full – found that her death could have been prevented, and occurred after the authorities simply lost sight of her.

Hilary Thompson, chairwoman of the BSCB, said: “The serious case review concludes that although the scale of the abuse inflicted would have been hard to predict, Khyra’s death was preventable.

“The report identifies missed opportunities, highlighting that better assessment and information-sharing by key organisations could have resulted in a different outcome.”

The 180-page document found that, despite concerns being raised by members of the public and school staff about Khyra’s welfare as far back as March 2006, information was not acted upon and safeguarding procedures were not properly followed.

It said: “There were a number of early missed opportunities for intervention by professionals.

“Three incidents during March 2006 were not progressed, either by failures of paperwork to reach the correct departments; failure to follow safeguarding procedures, or [failure] to conduct thorough checks.”

This resulted in any knowledge and intervention remaining purely single-agency at that stage.

The review, which began in May 2008, concluded: “Had there been better assessments and effective inter-agency communication over a period of time, Khyra’s death could have been prevented.”

A complaint of harrassment by Khyra’s mother, Angela Gordon, against a social worker who visited their Handsworth home in February 2008, generated a reluctance to complete an assessment, it was found.

The report said: “The complaint by the mother ... appeared to impact upon the Children’s Social Care manager and practitioner.

“This action generated a reluctance to follow through on plans with a partner agency to effectively pursue assessment procedures, for fear of repercussions.”

In March, Mr Justice Roderick Evans sentenced Khyra’s 35-year-old mother Angela Gordon, 35, to 15 years and jailed her former partner, Junaid Abuhamza, 31, indefinitely for the public’s protection, for a minimum of seven-and-a-half years. The pair were cleared of murder at Birmingham Crown Court but convicted of manslaughter.

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