On Behalf of the Kent Safeguarding Children Board

ALFIE

THE EXECUTIVE SUMMARY OF A

SERIOUS CASE REVIEW

On behalf of the Kent Safeguarding Children Board

Keith Ibbetson

Author of the Independent Overview Report

October 2009

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1. INTRODUCTION

1.1 This is the executive summary of the Serious Case Review (SCR) conducted by Kent Safeguarding Children’s Board (KSCB) under Chapter 8 of Working Together to Safeguard Children (2006).

1.2 The SCR was commissioned to look at the services provided to two brothers ‘Alfie and Jack’ and their family. This followed an incident when Alfie was shot in the head by his mother. It is believed she had been drinking heavily the previous evening.

1.3 The purpose of a SCR is defined in Working Together is:

·  to draw together a full picture of the services provided for the young people involved and their family

·  to establish whether there are lessons to be learned from a case about the way in which local professionals and agencies work together to safeguard children

·  to identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result, and hence improve inter-agency working and better safeguard children.

1.4 In view of the nature of the incident, the Chair of the Kent Safeguarding Children Board (KSCB) agreed that a serious case review should be undertaken following a recommendation from the Serious Case Review Core Panel.

1.5 The details of the agencies contributing to the Review are set out at Appendix A. The KSCB constituted a Panel to manage and oversee the conduct of the review. The membership of the Panel is detailed at Appendix B. Mary Gordon was appointed as the Independent Chair.

2. KEY FACTS

2.1 Alfie and Jack’s mother experienced post natal depression after the births of both children. Through both episodes she was seen regularly and treated by her GP who did not believe that her condition was serious enough to require referral to a specialist mental health service.

2.2 In his early years Alfie had complex medical problems which required regular hospital visits and surgery, though the problems have not permanently impaired his health. The mother and the children were seen by two different health visitors who provided support for the mother in relation both to her depression and Alfie’s medical needs.

2.3 The first family contact with specialist mental health services and children’s social services came in 1998 after Alfie’s mother twice seriously assaulted him. The children were made subject to a child protection plan and received intensive social work and psychiatric support. Social services involvement ended at the end of 1998 when the children’s names were removed from the child protection register.

2.4 Between 1999 and 2007 the following services were involved with the family:

·  The mother received a range of psychiatric support, through outpatient appointments, visits from a Community Psychiatric Nurse and a number of inpatient psychiatric admissions

·  A number of the admissions followed from the mother taking overdoses or going missing from home

·  The mother was diagnosed as suffering from depression (which was at times considered severe) and a ‘borderline personality disorder’ (i.e. that her behaviour was characterised by unstable personal relationships, fluctuating self image and mood and impulsive behaviour with a strong tendency to suicidal thinking and self harm. [1])

·  Alfie received support from counsellors at both his primary and secondary schools

·  Members of the extended family continued to offer support

2.5 In 2007 it was recognised that the mother’s alcohol misuse was becoming more serious and she was referred to the substance misuse service provided by KCA. Arrangements were made for counselling and psychotherapy but the mother did not engage with services.

2.6 In mid 2007 the CPN also referred the family to children’s social services because of her concern about the potential impact that mother’s behaviour would have on the children, particularly drinking heavily and taking overdoses. No service provision resulted from this as there was no assessment of the children and their family and the mother provided assurance that there was no need for social services to be involved.

2.7 The mother’s condition and behaviour appear to have continued to deteriorate during late 2007, though this did not result in further referrals to social services. The children’s school continued to offer support to the boys though they were not aware of all of the developments taking place in the family.

2.8 Alfie was shot in early January 2008. Investigations have not identified clear precipitating factors or triggers, though his mother was known to have been drinking heavily leading up to this and the night before the incident.

2.9 Following the shooting the children were protected by their own actions and the intervention of their grandmother. Medical staff, the police and children’s social services became involved swiftly and the mother was arrested and charged. She admitted the offence and has had no face-to-face contact with her sons since.

2.10 Following the shooting there was a further period of children’s social services involvement during which a core assessment of the boys’ needs was undertaken. This involvement lasted approximately four weeks. Leading up to the criminal trial the children were supported by family members, a school counsellor and police liaison officers.

3. CONCLUSIONS AND LEARNING POINTS

3.1 So far as can be established Alfie’s mother had not seriously physically assaulted her children in the ten years leading up to this incident. She is not believed ever to have used a weapon before. Given the completely unexpected nature of the shooting and the lack of any clear trigger for this attack, it is impossible to say with certainty whether it might have been prevented by different professional interventions. However it is certain that Alfie and Jack would have benefited from earlier and more concerted provision of services at least from 2004 onwards when their mother’s drinking increased and her mental health deteriorated.

3.2 Staff in agencies working with the mother and the children during this period should have been more attuned to the potential impact of her condition and behaviour on the children and referred to children’s social services for assessment and support at an earlier point. The combined presence of alcohol misuse, depression and a personality disorder should have alerted professionals to the possible presence of a high level of need and risk.

3.3 The response of the children’s social services was inadequate when a referral was made in mid 2007. This was an important missed opportunity to undertake an up to date re-evaluation of the circumstances of the children.

Shortcomings in record keeping, information sharing and taking a full history

3.4 The review identified many gaps in the records of Alfie and Jack and other shortcomings in record keeping. It also identified that on a number of occasions professional staff did not have access to records about the family when they were making assessments and decisions.

3.5 There is particular concern that when children’s social services staff first considered the referral made in mid 2007 the check of agency information systems did not identify the previous, intensive input made by the department and the serious incidents that had taken place in 1998. Although they were some years previously they were very significant.

3.6 Although there have been some important improvements in record keeping systems since the events under review there is still much scope to improve systems and procedures for record keeping.

3.7 Services will also be made safer and more effective if professionals:

·  Always actively seek out and read past records in their own agency

·  Request all the relevant information from other agencies when they are undertaking an assessment

·  Adopt a curious and challenging attitude and take full histories when working with vulnerable children and their families

3.8 As record keeping systems will never be perfect professionals always need to be mindful of the possible gaps in records and so should always be cautious in assuming that the absence of information about risk means that there is no risk.

3.9 Professional supervisors and managers need to reinforce these attitudes. Before they endorse the completion of a task they must be vigilant in checking that staff have accessed all of the available records.

Missed opportunities to refer the children for additional support

3.10 On a number of occasions Alfie and Jack should have been referred to children’s social services for assessment and additional support.

3.11 At the time of the first assault on Alfie (April 1998) mental health professionals, the GP and the health visitor all failed to recognise the seriousness of what had happened and make a referral to social services. The second incident (May 1998) was identified and referred correctly and the decision to place the children’s names on the child protection register was correct.

3.12 In 1998 the children were removed from the child protection register before a full assessment had been completed and considered by all of the professionals involved. Subsequent changes in procedures have prevented this from reoccurring.

3.13 Once the children had been removed from the register there was a gap of nine years until the children were again referred to social services. During this time the mother suffered from chronic mental health problems, which – despite the support provided by other family members - had a continuing negative impact on the children.

3.14 From 2004 onwards the mother’s heavy drinking was well documented by mental health staff, but there was no referral about this until 2007. As well as the impact of these chronic and continuing problems the boys experienced their mother taking numerous overdoses and disappearing from home, resulting in a number of psychiatric admissions.

3.15 The failure to make referrals about these children points to the need to develop a better strategy for identifying the children of parents and carers with mental health problems and assessing their needs in a continuing way.

3.16 Adults with mental health problems who are also parents and carers are all known to either the mental health service or to General Practitioners (or both) and there is a need for mechanisms to ensure that such children are identified at an early point.

3.17 Different children will have different levels of need depending on a range of individual and family circumstances, but consideration should be given to developing mechanisms for oversight of the needs of such families. GPs are particularly well placed to do this as they will usually have responsibility for both parents and children

3.18 The work of the mental health partnership trust will also be central to the identification of children who are placed at risk by their parents mental illness and substance misuse and the trust needs to demonstrate how its staff are being equipped to do this in a systematic way.

3.19 Professionals working with adults with mental health problems and professionals working with children need to improve their capacity to recognise how children may be affected by mental health problems of their parents and to develop coordinated responses.

Professionals should not underestimate the needs of older children

3.20 This case underlines that the most vulnerable children are babies and young children but it also shows the need for professionals not to underestimate the needs of older children and adolescents, especially bearing in mind that they are likely to have been living with the stresses caused by parental mental illness for the longest period of time.

Missed opportunities to assess the children’s needs

3.21 At no point was there a thorough assessment of the impact of the mother’s mental health problems and alcohol misuse on her capacity to parent and on the health and development of her sons. This meant that professionals underestimated the negative effect on the children and relied on the family to meet their needs without there being sufficient support.

3.22 The counselling services provided to the children were of value, but insufficient in the circumstances. More support should have been provided to the children between the shooting and the criminal trial

The failure of agencies to recognise that this was a case which might require a SCR to be held

3.23 All agencies tracked their records to identify why it was that the case had not been identified earlier as requiring a SCR. Some agencies did not sufficiently appreciate that it was their responsibility to identify such cases and bring them to the attention of the LSCB. In other agencies there was evidence of a breakdown in the chain of communications to senior officers about the case and the possible need for review. Steps have been taken to rectify these weaknesses.

4. RECOMMENDATIONS FROM THE OVERVIEW REPORT

4.1 All agencies

4.1.1 The KSCB should make available an anonymised copy of the SCR overview report and Executive Summary to board member organisations and to the chairpersons of relevant children’s partnerships. The report should be brought to the attention of senior managers with responsibility for commissioning any services so that any relevant issues for commissioning of services can be identified and used to improve the future commissioning of services.