Child Death Reviews - An American imperative?

Youth Today is reporting on a recommendation from a US Federal Commission that:

wants the states to examine all child abuse and neglect fatalities from the past five years as part of a national strategy to end such deaths.

The notion is interesting. Trying to understand what has gone wrong in the past is often seen as a way to help prevent further deaths. Looking into deaths has become common in many countries. For example:

• Serious Case Reviews in the UK are used as a way to find leanings from deaths that might help the child protection system do a better job protecting children
• Large scale formal public reviews are used by politicians to look into high profile cases. In Canada, there has been the Phoenix Sinclair review which published its report in 2015 after months of public hearings. Another example is the Victoria Climbe case in the UK.
• The Jeffrey Baldwin case saw a high profile Coroner's Inquiry which received national media attention.
• There are inquiries by agencies that represent children and youth such as the Child and Youth Advocate in Alberta which this week issued a report on the death of Lily. These reviews offer an independent lens on what might have gone wrong.

There are other methods as well such as aggregate reviews by third parties along with internal reviews. The latter are not typically made public. The advantage of many review processes is that they are public allowing citizens to feel that there is a sense of accountability.

There are downsides however. There is somehow a feeling that all deaths can be prevented. That is not the case as it is not possible to predict with any certainity who will or will not kill a child. There is also the negative impact that these stories have in child protection practice. In particular is the impact on worker's decision making - they tend towards bringing more children into care in order to not be the worker with the next case on the front page. That may not serve children well.

The recommendation in the United States may not be the best use of resources. There are literally hundreds of inquiries in the western world that show oft repeating patterns of practice errors that contribute to poor outcomes for children. A better use of resources might have been to analyze and learn from those inquires. A next step might be to set up a way to use that knowledge while also setting up methodologies to learn from new cases. Going back over a 5 year period will use a lot of resources and be unlikely to yield information that is different from the existing knowledge base.

By using existing data, there has been an opportunity to reframe how child protection is delivered. This is an opportunity missed. Doing it differently has more promise than spending time looking backward especially when a large database of such learning already exists.

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.

Oxford child sexual abuse scandal

Child protection again finds itself under scrutiny as a result of the failure to protect girls caught up in a sexual abuse ring.

Oxford gang members: (top left to right) Akhtar Dogar, Anjum Dogar, Kamar Jamil, Assad Hussain, (bottom left to right) Mohammed Karrar, Bassam Karrar and Zeeshan Ahmed who were found guilty of child sexual exploitation. Photograph: PA

Some of the girls who have come forward tell stories of classical grooming behaviours that led to them be enslaved within the power of the men who ran the ring. One of the girls gave the British newspaper, The Guardian, an exclusive interview. In it, she states:

She described how the gang began to abuse her when she was 13, plied her with crack cocaine and threatened to cut off the head of the baby she had by one of her abusers if she ever tried to escape them.

What perhaps is most disturbing about this case is that it did not occur without the knowledge of the social service and police agencies. The Guardian goes on to state:

A litany of failings by police and social services had allowed the men between 2004 and 2012 to groom young, vulnerable girls they met on the streets, outside schools and in cafes, entice them with the promise of alcohol and trinkets, and subject them over years to sexual atrocities and torture....

Girl C said her adoptive mother went to social services in 2004 to beg for help. She said: "Mum wrote to all the key people in social services, called her own case conferences, invited agencies and got them sitting around the table, but they just passed the parcel between them – and all the while, I was getting increasingly under the power and influence of the gang."

It is astonishing on one level that this could go on. There will be a Serious Case Review which may help us to better understand why. But there are some common themes arising in this matter. Perhaps the one that stands out for me is the failure of organizations to  collectively gather what was happening and build a coordinated response. Agencies are prone to see problems such as this belonging to the jurisdiction of another. There may well be shared responsibility. Silos in child protection work run directly contrary to the needs of children whose problems and situations often cross mandates of various agencies. Silos are simply dangerous for the well being of children. To illustrate this point, the Chief Constable in Oxford stated:

She said the cases were originally looked at individually. "I don't think we understood the extent that the abuse was systematic and it was organised," she said. "It was only when we sat down, pooled our information with that of the social workers, that we began to piece together the picture which explained what was happening in terms of this criminal network in Oxford."

This raises another area of concern which is looking only at cases in isolation as opposed to looking for the trends.

A fundamental principle of social work is to see the person within an environmental context. That means looking at not only the facts of the particular case but also the context in which the person is operating. In this case, a troubled girl (as she would be in prostitution and drug addiction) but those behaviours do not exist in isolation.

One hopes that the various authorities did not just see a troubled girl and a mother who wasn't an effective parent. Hopefully, the inquiry will also look beyond such possibly narrow views and see why the systems failed these girls.

Finally, one has to ask about leadership. Uncoordinated work such as appears to exist in these cases, will too often be the result of weak leadership both locally and beyond. This includes managers who are not giving the strength of supervision needed for cases like this but also funding and policy issues that make co-ordinating this work challenging. Limited resources tend to narrow the focus of workers to what can and must be done immediately. This is not an excuse but should encourage those that will do the SCR to look beyond the local issues. That too requires leadership.

 

 

Social Worker Sanctions

CommunityCare in the UK has reported that two social workers have been sanctioned as a result of their work in a case known as Child F.

Barry Smith was suspended from the social care register for two months and Marilyn Tweedale received a three-year admonishment, following two conduct hearings held last week.

The serious case review found that there were practice errors. The East Riding Safeguarding Children's Board notes that the "Agencies did not coordinate and manage the risk that Adam Hewitt was known to pose to children and information passed to the police  from Children's Social Care should have led to the police reopening the case against Hewitt following earlier allegations." The social workers were sanctioned were noted to have failed to properly assess the risk associated with the case.

As we have seen in many cases, there was a lack of coordination of information between agencies that hampered effective decision making. The Serious Case Review states: “No agency thought to take stock and initiate a process that would have brought all the information about Male 1 into a single arena from which a plan should have merged, to assess and manage the risk he presented to children. “

The SCR also notes a flawed initial assessment that meant that Mr. Hewitt was able to continue access to the child. This raises one of the fundamental issues in case management. What we initially see in a case tends to lead to the unfolding of a case plan. If the social worker becomes attached to that case plan, then the case direction does not get the ongoing re-assessment that is often needed. We never know everything in a case and often lack quite substantive information. This means that we should be open to reconsidering case plans on an ongoing basis.

Very telling about the environment in which the case occurs, are these comments from the SCR: the social worker involved felt overwhelmed by complex cases and had little opportunity for reflection and planning. This goes some way towards explaining how on one hand the social worker understood the risk factors as evidenced in the case closure letter sent to Ms A, but also failed to consider successfully the risk factors in a comprehensive recorded account. The social worker clearly required direction and support which managers failed to make available. It is also noteworthy that the social worker felt “too junior” to challenge the direction offered by managers.  Lord Laming in his 2009 recommendations identifies the need for “respectful challenge” for childcare professionals.”

If a social worker is not in a position to challenge issues within a case, not able to ensure that case consultations are occurring, and have time to consider what is going on in a case, then poor case management occurs. In addition, cases are often very complex and it is unwise to expect that one case worker is going to be able to determine the best course of action. Supervision is crucial.

In what might be a self serving view, the SCR notes comments from the mother. “The mother of Child F states that the message from the assessing Social Worker did not convey the clarity that was necessary regarding the level of risk posed by Male 1.  Her view is that she was told he possibly posed a risk but other men were also named as possible perpetrators in the earlier allegations.  The mother considers that had she been given clear information that he was believed to be the perpetrator of the injuries, she would have terminated the relationship.” However, these comments do raise an important issue that social workers need to attend to – being very clear with clients. When there are risk factors that a client must attend to, the social worker should not be couching language in ways that can lead to an ambiguous understanding.

Social workers also need to be ready to state that risk exists and to take the steps needed to protect a child. That may anger people which makes them harder to work with. Such is the nature of our work.