It's everyone's job to make sure "I'm alright" Literature Review
Messages from reviews and inquiries
At least one to two children in the UK die every week from abuse and neglect. In spite of many inquiries and changes to child protection practice over the last 30 years, child deaths from abuse and neglect have not decreased (NSPCC 2001). Of the 70 reports identified by Corby et al (1998) 13 were statutory, 34 were carried out by authorities using an independent inquiry panel and 19 were carried out largely on an internal basis. 51 of the 70 inquiries were concerned with physical abuse of individual children living in their own homes or in foster families, three were concerned with gross neglect and one with sexual abuse. Three of the inquiries - Cleveland, Orkney and Newcastle Upon Tyne dealt with the response of public agencies to multiple cases of alleged sexual abuse in the family home and in day care and the remaining 13 were concerned with the physical and sexual abuse of children in residential care. The aim of public inquiries into child abuse is to find out about causes, to establish responsibility where possible and to arrive at recommendations to avoid the recurrence of similar events in the future. The findings of child abuse inquiries continually stress the fact that many fatal child abuse deaths are preventable. Inquiries and reviews tend to repeat the conclusions of previous inquiries and reviews which would seem to suggest that lessons are not being learned (Reder et al 1993; Longlade 1999; Brandon et al 1999). Inquiries into child deaths have repeatedly identified problems in the management of the cases involved (Department of Health 1991; Munro 1998; 1999; Fitzgerald, 1998; 1996; Corby et al 1998; Ibbetson 1996; Greenland 1986). This chapter considers the findings of reviews and inquiries into child protection practice.
(i) Professional standards
Many inquiries have highlighted unacceptably low professional standards. The reports make constant reference to the clouding of professional judgement and lack of professional experience and expertise. Inquiries often have difficulty ascertaining what judgements and decisions social workers have made and the reasoning behind them (Munro 1998; Department of Health 1991). The Hammond report concludes that no single person was responsible for Kennedy's death and that the staff did their best in difficult circumstances. The report states, however, that there were numerous opportunities when the extent of the risks to Kennedy could have been identified and effective intervention implemented. The report points to the fact that health colleagues could have challenged the decision to discharge Kennedy during or after the meeting and to the fact that the team manager should have felt that there was enough concern/evidence of harm to justify a case conference (Hammond, 2001). Some inquiries have pointed to breaches of departmental policy (Department of Health 1991). For example, the Kennedy McFarlane report concluded that Dumfries and Galloway had in place practice and procedures in keeping with current guidelines which if fully invoked would have led to her protection, but the procedures which should have led to full multi-agency investigation, risk assessment and a child protection plan were never fully instituted (Hammond, 2001). Brandon et al (1999) also found many instances of non-procedural adherence in their analysis for the Welsh office of serious child abuse cases in Wales.
The process of assessment is consistently criticised in inquiries, particularly in relation to professionals' understanding of risk factors (Department of Health 1991; Brandon et al 1999). In assessing risk and family functioning there is sometimes a tendency to overlook the mother's male partner, the father's past is not always examined or his role in the current circumstances assessed. Domestic violence is sometimes ignored, particularly its significance in assessing risk to children, for example, the reports in relation to Sukina and Rikki Neave highlighted the impact of domestic violence and showed that there was a lack of any systematic assessment of the male carer's capacity to parent and of their dangerousness to the children in their care (Munro 1998; Fitzgerald 1998; O'Hara 1993; Cleaver et al 1998; Brandon et al 1999; Hill 1990). The McFarlane report highlighted the lack of methodical investigation and analysis throughout the case, particularly at team manager level. Lack of effective documentation and presentation of the medical evidence resulted in a failure to give an implicit account of the inherent risks to Kennedy's safety. Subsequent investigation produced a lot of information about the problems of the family, the mother's health, etc. which would have been very relevant to the risk assessment and planning for Kennedy. This was available to be gathered at the time had a full investigation in line with child protection procedures been triggered (Hammond, 2001).
Inquiries also highlight inadequate social work training and an inadequate grasp of the theoretical knowledge needed to make sense of the information which is gathered. Reports continually recommend more training. They suggest that social workers need a working knowledge of research on factors which are predictive of child abuse eg domestic violence, and some reports comment on the need for greater knowledge of the relevant procedures and legislation (Munro 1998; Greenland 1986; Department of Health 1991; Brandon et al 1999). There was uncertainty over the legal procedures in the McFarlane case. The professionals interviewed shared a lack of clarity about procedures and decision making. At the early stages they were unsure whether the case was a child care or child protection referral. Health and social workers were unclear whether the planning meeting was an informal preliminary case conference, a pre-referral sharing of professional concerns or a meeting of professionals to plan ongoing child protection investigations. As a result they were confused about its status and whether or not parents could be excluded (Hammond, 2001).
Lack of supervision and incidence of poor line management has been a further theme of inquiry reports (Greenland 1986; Department of Health 1991; Brandon et al 1999). The McFarlane report highlights the need for regular and meaningful supervision. The report states that there was inappropriate reliance on the opinions and advice of others and over confidence in the decision making by/of team managers and a failure to recognise the need to introduce checks and balances by testing out theories and plans with experienced colleagues. The team manager never mentioned the case to her line manager in monthly supervision sessions although a number of these were cancelled due to pressure of work. The tendency for professionals who perceived themselves to be at a lower level in the hierarchy to defer to those at a higher level was another feature of the case (Hammond, 2001).
Poor recording has also been highlighted by a number of inquiries and there are numerous examples of information not being recorded or being recorded incorrectly. Many reports have concluded that the low standard of record keeping adversely affected the way a case was handled. It has been recommended that the quality of record keeping should be monitored and referral information properly recorded (Munro 1998; Department of Health 1991; Brandon et al 1999). The failure of social work staff to complete the forms required in child care and child protection was a repeated finding of the McFarlane inquiry (Hammond, 2001).
A second finding from inquiries is the failure of professionals and agencies to communicate appropriately or share information. Almost every review or inquiry report has catalogued the failure of communication and stated that professionals need to bring accurate information together at an earlier stage, accurately analyse the context of the information and think qualitatively as well as quantitatively about the information. There is a particular problem of inter-disciplinary communication and co-operation with relevant information not being passed between agencies, for example, a failure to communicate admission to, or discharge from, hospital to social services departments (Greenland 1986; Department of Health 1991; Ibbetson 1996; Munro 1999; Brandon et al 1999; Hill 1990). Professionals sometimes base assessments of risk on a narrow range of evidence which is biased towards the information readily available to them and they overlook significant data known to other professionals. For example, in the inquiry into the death of 'Paul' it was found that a number of agencies had contact with Paul's family but one of the problems identified was of information being buried in large numbers of files across different agencies (Fitzgerald 1996; 1998).
The Kennedy McFarlane inquiry report highlights a failure to work in partnership with other agencies. Lack of effective communication and joint decision making was a recurrent issue through the inquiry. The team manager took the decision not to request joint investigation although local guidance makes it clear that information from the relevant agencies including police, health and education services should be sought even in referrals not deemed to require an immediate response. Police involvement was not sought until the death despite the fact that accepted good practice in inter-agency practices should have led at least to a discussion with senior police colleagues experienced in child abuse work at each point of referral. The difficulties experienced by professionals in effectively sharing their concerns at case conferences particularly when they conflicted with others' views or where parents were present was a common theme of the case. The inquiry along with many others (Department of Health 1991) highlighted the need for effective sharing of information and stressed the need for team building and training between agencies (Hammond, 2001).
(iii) Interpretation of information
Incorrect interpretation of information is a further finding of inquiries into child deaths. Failure to distinguish fact and opinion can lead to relevant information not being appreciated, for example, if the source of the information is not trusted. Inquiries have often found, for example, that warnings of abuse from extended families or neighbours are unheeded because they are regarded as malicious. Reports are not responded to although the information they contain may be extensive. The inquiries also demonstrate that information may not be appreciated due to a false sense of security, it can be overlooked if it does not fit the current mode of understanding. On many occasions reports have highlighted that social workers tend to be too optimistic, they often see progress when it is not really there or is so small as to be ineffective. A recurring theme is the extent to which parents will lie and seek to deceive professionals and reports stress that workers must be on their guard against the risk of seeing what they want to believe. Professionals are slow to revise their judgements. Pre-conceived ideas about abusive families can affect professional judgement and information about family features which do not fit these preconceptions can be ignored or misinterpreted which can lead to dangerously low standards of childcare being accepted. For example, there is evidence that the professionals involved in the case of 'Paul' failed to take on new information. Inquiry reports repeatedly comment on workers' reluctance to alter their views and it has been suggested that the involvement of an independent colleague might bring a fresh perspective (Department of Health 1991; Munro 1998; 1999; Fitzgerald 1996; Ibbetson 1996; Cleaver et al 1998a; Hill 1990).
There are examples of difficulties in classifying information or distinguishing it from a flood of relevant data, for example, there is a lack of clarity about how to assess medical opinion where injuries or the clinical state of the child are concerning but not clearly non accidental in origin. Medical assessments must be put into context and seen in the light of previous information about the child (Department of Health 1991). The McFarlane inquiry asked the question why the medical information was not gathered, collated and interpreted effectively so that it could be used to trigger an appropriate inter-agency response. Clusters of signs can be more important than any one on their own, for example, in the Beckford case non attendance at nursery, disharmony between parents, the fact that Jasmine had not been seen for some time and absence of information about her health and development were important. Inquiry reports criticise social workers' failure to see the overall picture of the family or the risk emerging over time. They are engrossed in present day issues and fail to stand back and place these issues in a historical context (Department of Health 1991; Brandon et al 1999; Hill 1990). By the time of Kennedy McFarlane's discharge from hospital, despite repeated concerns, referrals and admissions a formal child protection investigation had not been triggered. No one had put all the pieces of the puzzle together creating a total picture of escalating harm (Hammond, 2001). Inquiry findings suggest that workers need to be responsive to new information and prepared to reassess and reappraise. They need to recognise that their former views were wrong even though reasonable at the time they were made, that mistakes are an inevitable part of practice and that recognising them is an essential element of good practice and that errors can be alleviated if people are aware of them but strive consciously to avoid them (Munro 1996; 1999; Cleaver et al 1998a; Fitzgerald 1996).
It is a characteristic of many of the cases in which a child dies at the hands of a parent that it emerges that no one from any of the agencies saw the child during the last few weeks of its life. Families refusing contact or avoiding contact with agencies has been a recurrent theme of inquiry reports. In some instances families have disappeared and their whereabouts have become unknown as they move between areas. Many children fail to attend nursery or school and there are many examples of failure to gain access by health visitors or social workers (Department of Health 1991; Hill 1990). Visits are often recorded without giving details of who was seen so the failure to see a child for a long time may not be apparent in the record. Out of 13 cases looked at by Munro (1998) where a child was withdrawn from public view the absence was only noted and seen as worrying in three. Hostility and violence may accompany the refusal to allow contact with agencies and professionals can be frightened of a parent and avoid contact. Professional fear has an inevitable impact on judgement and discretion (Brandon et al 1999). Even where children have been seen there has often been a failure to listen to them. In many cases where children were killed or seriously injured social workers failed to adequately observe the child's demeanour. It is essential that children are seen, not just the subject child but all children in the family, and it is essential that they are spoken to. The detection of changes in children's behaviour over time is important and listening to children is a lesson to be drawn from all inquiries (Department of Health 1991; Fitzgerald 1998).
Many inquiry reports highlight problems in delivering an effective service due to staff shortages, over high work loads, failure to provide adequate cover during periods of staff sickness or leave, absence of psychiatric involvement and threats of violence to staff (Department of Health 1991). Fear of violent men is a frequent theme of many inquiry reports into the circumstances of a child's serious injury or death, for example, that of Sukina Hammond in 1991. When a child's father is physically intimidating or where family members are known to be hostile or have a known record of violence professionals are often intimidated from pursuing enquiries, they may refuse to make home visits at all, yet children live in these homes and need to be seen and agencies therefore need to offer adequate support to professionals in contact with violent families (Munro 1998; O'Hara 1993; Cleaver et al 1998a; Fitzgerald 1998).
Problems connected to staffing were a feature of the McFarlane inquiry. Heavy workloads and problems with the availability of professional/specialist support was a feature of the case and the risks to children when key professionals are absent on leave and the dangers of expecting workers with no statutory responsibility, for example, health visitors, to monitor a high-risk situation were frequently highlighted in the inquiry. The inquiry also recommended that staff needed rapid access to debriefing and counselling and mental health services when a child for whom they were caring died (Hammond, 2001).