Final Overview Report Case RK, March 2016.
SERIOUS CASE REVIEW
In respect of the death of Rebecca Kandare January 2014.
Report by: Birgitta Lundberg
Independent Overview Report Writer
March2016
CONTENTS:
1. INTRODUCTION
1.1 The circumstances leading to the Serious Case Review – brief summary
1.2The Serious Case Review process –brief summary
1.3 The Terms of Reference – brief summary
2.REBECCA AND THE FAMILY
2.1The community context and family circumstances
2.2 Key events and conclusions
2.3 Information from the family
3. ANALYSIS
3.1 Analysis of services provided
3.2 Analysis of themes
3.3 Conclusion and Findings
4. LEARNING
4.1 Lessons to be learnt
4.2 Implementation of learning
5. RECOMMENDATIONS
5.1 Recommendations by the Overview Report Writer
5.2 Recommendations by the Wolverhampton Safeguarding Children Board.
6. APPENDICES
6.1Appendix1- The full Terms of Reference
6.2 Appendix 2- Serious Case Review Panel membership and agency participation
6.3 Appendix 3 -Individual Management Reviews
6.4 Appendix 4- Bibliography
1. INTRODUCTION
1.1 The circumstances leading to the Serious Case Review – brief summary.
Rebecca was just over 8 months old at the time of her death in early January 2014. Her parents and some relatives recounted that she had had cold like symptoms for, varyingly, a few days or a few weeks. An aunt noticed that Rebecca was unresponsive early in the morning one day, when the family was in their church building, and an ambulance was called via the 999 service. Attempts were made at resuscitation in the church, on the way toand in the hospital but she was pronounced dead an hour later.
The SUDI (Sudden Unexpected Death in Infancy) protocol was followed by the health agencies, which included taking a full history, physical examination, blood, urine and CSF (cerebrospinal fluid) investigations, a skin biopsy and a skeletal survey.
A forensic post-mortem was conducted and the findings were that Rebecca was chronically malnourished with substantial muscle loss, pneumonia in both lungs and severe rickets. The Forensic Pathologist recorded the cause of death as severe malnourishment and bronchopneumonia, which can be attributable to failure to thrive.There was no evidence of underlying natural disease, either congenital or acquired, to explain the failure to thrive and it was noted that she had been born a healthy baby in April 2013.
It was confirmed during this review that no advice or treatment had been sought by the parents from any registered health professionals prior to this call for an emergency service. Rebecca had not been registered with any General Practitioner surgery at any point and was last seen by a Health Visitor in mid May 2013 when she was 22 days old.
Child Protection medical assessments were carried out the following day in respect of the two older siblings, both of whom were vitamin D deficient. Joint Child Protection enquiries (Section 47 Children Act 1989) and assessments were started to safeguard the welfare of the siblings. The children were made subject of Interim Care Orders in the middle of January 2014.
Following full Care proceedings the children have subsequently been safeguarded in a long term placement. As mother became pregnant whilst the criminal investigations were taking place, the unborn baby was made the subject of a Child Protection Plan andjoined at birth to the Care proceedings for the siblings. The baby was removed at birthand placed with the siblings.
Both parents were arrested and interviewed on suspicion of causing their daughter’s death. They were later released with bail conditions under section 47 of the Police and Criminal Evidence Act 1984 including no unsupervised contact with the older children. As the parents answered bail early August 2014, they were re- interviewed separately and the conditional bail period was extended.
At this point the Crown Prosecution Service (CPS) reviewed the case and both parents were charged with murder. The caseswerereferred to the Crown Court and both parents were remanded to custody and bail applications were refused.The trial was rescheduled and after some delaythe final trial took place in November 2015.
Both parents pleaded guilty to ‘manslaughter’ and were given prison sentences of respectively 9 years and 6 months (father) and 8 years (mother).
The church group, which practised in the building where the call had been made from, is known as one of the apostolic churches of Africa or the Gospel of God church. There are a number of groups of followers of its founder, Johane Masowe, who is seen as a prophet. There are some variations in beliefs between the different groups of followers. The family belonged to alocal church, where the father of Rebecca was one of a number of Pastors. The parents had originally met through a similar church group nearby and then changed to this church group. This small group expects its followers to adhere to a range of beliefs about for example:dress codes for men and women, what types of work to do and limited contact with health agencies and medical treatments as they believe in the healing power of prayer.Any forms of treatment of ill health or preventative treatment such as immunisations are believed to be misleading as the underlying cause is believed to be spiritual, which can therefore only be addressed through prayer and other religious rituals. The church and its membership are described in the research available[1]as reluctant to trust state agencies or their representatives. The congregation is small in number and presents as being self-sufficient and separate from the local community.
1.2 The Serious Case Review process –brief summary.
Notification of a critical childcare incident was submitted to both the DFE and Ofsted on 17th January 2014 following information from the West Midlands Police to the Wolverhampton Safeguarding Children Board (WSCB) of the events.
A Serious Case Review Committee meeting took place and recommendations were made to the independent Chair of the WSCB, who agreed that the circumstances of the case met the criteria in Working Together to Safeguard Children 2013[2] and regulation 5 of the Local Safeguarding Children Boards Regulations 2006 namely, that the WSCB should be:
5(1)(e) / Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.(2) / For the purposes of paragraph (1) (e) a serious case is one where:
(a) / abuse or neglect of a child is known or suspected; and
(b) / Either - (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.
The Black Country Coroner’s office was informed by the Head of Safeguarding of the decision to undertake a Serious Case Review.
An independent Chair and an independent Overview Report Writer were commissioned to undertake the review supported by a Serious Case Review Panel, which consistedof senior managers from the relevant agencies. The managers and specialist advisors to the SCR Panel had not had previous involvement with any member of the family or direct operational responsibility for the case.
The membership of the SCR Panel and the Terms of Reference were agreed including the timeframe for the review. An additional Panel member with expertise in faith and cultural studies participated in the review in an advisory capacity. Individual Management Reviews (IMRs) and Information Reports were requested from the agencies involved and records were required to be secured.
The first SCR Panel meeting took place March 24th 2014 and was followed by a ‘Briefing meeting’ for the authors undertaking the Individual Management reviews of the agencies identified as having had contact in their services with family members and Rebecca. All nil returns were noted. All IMRs and Information Reports were received within the agreed timescale.
For full details of the agencies involved and SCR Panel membership see Appendix2.Serious Case Review Panel membership and agency participation.
A series of SCR Panel meetings, including a ‘Learning the lessons’ meeting took place between March 2014 and March 2015. The final draft Overview report was presented to the WSCB for approval in October 2015 as planned bearing in mind the timing of the criminal proceedings.
As the meetings with family members could only take place after the criminal process had been concluded, those meetings were arranged at the end of the trial in order to incorporate the learning from the family contributions.
1.3 The Terms of Reference – brief summary.
The Terms of Reference were agreed at the original scoping meeting and amended by the SCR Panel meeting in March 2014 to respond to updated information.
The review was asked to focus on the period of time from April 1st 2010 to February 28th2014.To gain a historical understanding of both parent’s ‘parenting capacity’, IMR authors were requested to comment on any relevant/significant incidents for the period April 2002 to February 2014.In addition they were askedto take account of involvement with the older siblings and any safeguarding action to protect them.
Extracts from the Terms of Reference:
“The aims of the review were agreed as:
To review the background and circumstances leading to the death of Rebecca and ascertain whether there are lessons to be learnt for:
- Individual agency working
- Effective inter-agency working
- Effective communication and information sharing
- Improving intra- and interagency working to better safeguard and promote the welfare of children
Involvement of relevant family members would be sought as follows:
A letter to be sent to the parents advising them of the SCR process, inviting them to participate in and contribute to the review when appropriate and to advise that professionals will be accessing all family records, including health medical records.
Some historical information may be critical to this review in line with recent National Biennial SCR studies. However, if the IMR authors felt that there was pertinent information available prior to the scoping period for this review, then they should include it in the chronology and IMR as it may shed some light on whether the circumstances leading to Rebecca’s death could have been predicted or prevented.”
For the detailed Terms of Reference see Appendix 1. The full Terms of Reference.
In addition to the generic terms of reference the SCR Panel agreed some specific questions for this review:
- What guidance is available for staff when assessing a family where faith group beliefs may impact on safeguarding?
- How are staff trained to identify risks that may be associated with faith group beliefs?
- What guidance is available to staff if they find it difficult to gain access to a family and children?
IMR authors were asked to address why actions were taken, or not taken, by the practitioners or their supervisors.
The purpose of the review should be to focus on the lessons to be learnt and therefore the IMRs and the Overview report should address the following questions:
- Are there lessons from this case for the way in which the organisationswork to safeguard and promote the welfare of children? Is there good practiceto highlight, as well as ways in which practice can be improved?
- Are there implications for ways of working; training (single and inter-agency); management and supervision; working in partnership with other organisations; resources?
- Are there implications for current policy and practice?
2.REBECCA AND THE FAMILY
2.1 The community context and family circumstances.
Wolverhampton is an ethnically diverse city which has experienced a great deal of change over the past decade as the city’s population has increased by 6% to just under 250,000 people since 2001 alongside increased levels of overcrowding and deprivation.
The city is ranked in the Indices of Deprivation 2010 as the 20th most deprived nationally and is now one of the 10% most deprived local authorities in England. Over the last decade there has been a 10% decrease in White British residents and a corresponding increase in Black Asian Minority Ethnic (BAME) residents. In 2011, BAME residents accounted for 36% of Wolverhampton’s population, a much higher proportion than had been initially anticipated.[3]
The majority of jobs in Wolverhampton have historically been in manufacturing, but recently service sector jobs have increased significantly. As a legacy of industrialisation, Wolverhampton is one of the most densely populated local authority areas in England, with a population density of 36 people per hectare based on the 2011 Census.
The two wards where the family lived and where the church was located are next to one another and quite central. There were local amenities and services within easy access including access to health agencies and the Children’s Centres.
The family:
Information about the parents and the extended family was provided initiallyby some relatives and church members. Following the conversations with father and mother in the respective prisons, most of the original information has been confirmed.
Both parents were born in Zimbabwe and came to the United Kingdom to join other members of their family already settled there. Father arrived as a child in 1999, having been brought up by his grandparents, to join his parents, who were living in different places in the UK and Mother came as a young woman in 2002 to live with her sisters. Mother was intending to train as a nurse.
Father lived for a period of time in an area near London but then returned to live in the West Midlands and the Wolverhampton area in approximately 2008. Father has had a long term relationship with a white British woman and her child, which has continued throughout the period,covered by the review and has played a part in the family dynamics.
The parents met through attending one Gospel of God Apostolic church group in Wolverhampton, which was also attended by Mother’s sisters. Shortly afterwards they changed to another similar church group nearby, where they have remained members. The parents were married in accordance with this church group’s beliefs in October 2010.They were subsequently married in a civil ceremony in January 2013 as witnessed with a formal marriage certificate.
The two older siblings were born in December 2010 and January 2012 respectively.
A picture emerges of a family where the parents have steadily become more and more involved in the church life and activities; attending the church building and often staying there. The family often attended the church twice per day (6.00 a.m. and 6.00 p.m.). The children were required to attend unless they were extremely tired. The family stayed at the church most weekends. Father developed a role in the church as one of the ‘Pastors’ undertaking specific tasks for the church by leading sermons and getting involved in supporting members as well as undertaking trips to Zimbabwe to meet other members and Elders. He was ordained as a Pastor in Kenya.
The church advocates a strict dress code for men and women and regulates most aspects of daily life and regular prayers. There are many daily duties for the members of the church which lead its members to interact as a small group with limited contact with other people in their local community.
This local church group has firm views about not becoming involved with state institutions and modern medical treatment including immunisations and routine checks such as regular child health checks. They believe ‘that God determines whether a person lives or dies and that they will be saved by the Holy Spirit’.This has been illustrated by a number of reports including a Unicef research report in 2012 about the take up of health services for children and women in Zimbabwe[4] and a Unicef report specifically about the Apostolic religion and maternal and child health services 2011[5].
The integrated chronology illustrates the changing behaviour of the family interactions with the Health visiting and GP services as the first born child initially underwent all checks and immunisations. When the second child was born the attendance began to falter and after the birth of Rebecca, there was no contact after a Health Visitor home visit in May 2013, 22 days after the birth.
There was one incidentof domestic violence reported to the police by Mother in March 2012. Various sources[6] have subsequently noted that Mother was taken to task by church members and the pastors for involving public agencies. Research about this particular group of the Gospel of God church notes that church members are held to account for their behaviour by public ‘naming and shaming’. [7][8] Both parents referred to this process or ritual as ‘cleansing’.
A significant part of the church’s belief about health agencies and medical treatments relates to child birth. The first child was born in hospital but the two subsequent births were reported several days after the event with the explanation that the church believes that mother and child must not be seen by any other person or leave the house for a period of seven days.