Kaenu Williams and Marchella Pierce - some common territory in their tragic deaths

By chance, the Serious Case Review (SCR) into the death of Keanu Williams in Birmingham, UK and the grand jury deliberations regarding the death of Marchella Pierce in Brooklyn, NY were published in the same week. Also by chance, are some common themes. For any of us connected to the world of child protection, both reports are disturbing not only in their details but also in the familiarity of the concerns that they raise.

Injuries to Keanu Williams

The injuries to Keanu were extensive as the above illustration shows. The mother had prior history with child welfare as a child in need as well as with her other children. Prior history is something that is seen in many cases, although certainly not all. But the all too familiar aspects of the case were, as the SCR notes "...various agencies involved had collectively failed to prevent Keanu's death as they missed a significant number of opportunities to intervene and take action" (p.6).  The SCR concludes that the death could not have been predicted.  This is a point that many media have noted. But, also on p. 6, the SCR goes on to state,

However, in view of the background history of Rebecca Shuttleworth and the older Siblings including the lifestyle and parenting capacity of Rebecca Shuttleworth and the vulnerability of Keanu in Rebecca Shuttleworth’s care; it could have been predicted that Keanu was likely to suffer significant harm and should have been subject of a Child Protection Plan on at least two occasions to address issues of neglect and physical harm.

In other words, had the various agencies and authorities been paying attention, communicating with each other and giving priority to the child, the outcome may well have been different. As the SCR notes on p. 8, there had been a lack of focus on the children of this mother. The SCR found themes that have been repeated often in these kinds of reviews:

A number of the issues which have arisen in this Review are also familiar themes in Serious Case Reviews nationally, such as: poor communications between and within agencies, a lack of analysis of information as well as a lack of professional curiosity in questioning the information, a lack of confidence among professionals in challenging parents and other professionals, short comings in recording systems and practice, professional over optimism rather than to ‘respectfully disbelieve’ and dealing with events as one off episodes often referred to as the ‘start again syndrome’.

The start again syndrome is dangerous. There is no other way to put it. It is a way to ignore history. Something that a child protection agency does at its peril. In Canada, we are experiencing the brutal inquest into the death of Jeffery Baldwin where the child protection authorities failed to read their own files to see that the grandmother who starved Jeffery to death had been previously convicted of child abuse.

As the Keanu Williams SCR notes, it is the business of child protection to stay focused on the child's journey. But to do so requires the time to be so focused. This brings us to the Marchella Pierce case where the former case worker and the case work supervisor are both facing charges in her death.

Amongst other things, the Brooklyn Grand Jury notes that the workers faced a system that had failed before. But, case loads are high. Problems have been identified and not corrected. Now, rather than the system being held accountable, there is a risk that the people working in the system will be the scapegoats. We have seen that before as well with the Baby Peter case in the UK where Sharon Shoesmith was vilified in the media.

Marchella Pierce

Workers faced with high caseloads will make mistakes and the clients, children and their families will suffer as a result. Should we hold the caseworkers liable or should we be having a discussion about whether or not society should be held accountable by failing to fund child protection at a rate needed? Or by not funding the kind of prevention services needed?

There is also the ugly truth that, no matter what we do, some parents will kill their children.

In my research, I have catalogued about 900 cases where children have died when child protection was involved. I have missed many cases I am sure, Each week, I add to the list. But each week I see a repetition of the systemic issues such as these.There is no easy solution. We need to continue to highlight these cases putting pressure on governments to properly fund both prevention and reaction services.