Falling through the net

Every week, a case emerges of a child who has been beaten or starved to death by a parent. The authorities routinely pledge that lessons will be learned from these all-too-frequent tragedies. So why do they appear endlessly to repeat themselves?

Last week in Birmingham the report following a Serious Case Review, or SCR, into the death of two-year-old Keanu Williams succinctly concluded what went wrong: “Keanu died because there was a failure across every agency to see, hear and respond to him. Keanu died because ­people missed opportunity after opportunity to intervene.”

This conclusion echoed the findings of the review two weeks earlier into the case of four-year-old Daniel Pelka, who was starved and beaten to death in Coventry in 2012. It is as good as certain that when a review into Hamzah Khan’s death in Bradford is published next year it will say the same. Hamzah, aged four, starved to death while in the care of his mother, Amanda Hutton, who has begun a 15-year prison sentence for manslaughter.

Birmingham City Council alone has conducted 20 such reviews in seven years and still does not adequately protect children. This was underlined by the statement by Peter Hay, the city’s strategic director of children’s services, that there were no assurances to be given for adequate protection in the future. “The situation is very serious and very frail,” he said. SCRs must be held when a child suffers serious injury or dies as a result of abuse or neglect. They are time-consuming for social workers and managers – 200 have to be completed every year – and arguably deflect from work to protect children. These are detailed inquiries in which evidence is taken from all agencies involved in the case. Neighbours, estranged parents and others may be interviewed in a process that can take upwards of a year.

The response to all reviews and inquiries, stretching back decades, tends to be that “lessons have been learned”. These lessons tend to be depressingly familiar – a shortage of social workers and heavy caseloads for those who are in post; a failure of professionals to work together and share information; not gaining entry to a home where there are good reasons for suspicion; accepting what an errant parent tells them; not actually seeing the child or seeing the child on its own if entry is gained; and a lack of professional curiosity.

Self-evidently lessons are often not learned. (The lesson about noting as a tell-tale sign the failure of parents to keep appointments had an extraordinary twist in the Hamzah case: the GP removed the family from the surgery list.)

Professionals in the cases of Keanu Williams and Hamzah Khan met but failed to act. But acting has to be preceded not only by sharing information; it also entails challenging and scrutinising each other’s assumptions and taking nothing on trust from either fellow professionals and parents.

Sometimes staff can be so afraid of doing the wrong thing that they do nothing at all. (In Birmingham, low staff morale prevented anyone challenging a decision that Keanu did not need a child protection plan.) In the case of Hamzah, professionals who either entered the home or saw any of Hutton’s seven children in the early stages of Hamzah’s life found little wrong; indeed, a police officer spoke positively of the living conditions and the children’s “good health”. How did Hamzah slip off the professional radar and at what point? The SCR will need to examine that and also explain why no alarm bells rang when Hamzah failed to start primary school in September 2009 (he died two months later), and when three of his siblings had serious attendance problems.

Other questions will be why adults in the family – there was one adult child – apparently did little or why neighbours did not notice the absence of a child for two years or at the very least have some idea of the drunken squalor and chaos in which Hutton and her children lived; and if they did, why there was no official action.

Especially in child protection, governments seek quick and easily understandable solutions and many of the “solutions” they impose are readily measurable, even if they are sometimes are not useful for the task in hand. Thus, child-protection failures have been met with more central control, more targets and reoganisations, and further guidance, procedures and regulations.

Ironically, only weeks before the news of the death of Peter Connolly (“Baby P”) in 2007, the former Audit Commission reported that reorganisation in the wake of the inquiry into the death of Victoria Climbié in 2000 had hampered efforts to improve services by causing too much time and energy to be invested in setting up structures and processes. This may be yet undermined by a major step forward: the government-commissioned report in May 2011 by Professor Eileen Munro. She concluded that child protection had become too focused on compliance and ­procedures, and had lost its focus on the needs and experience of individual children.

Among Professor Munro’s most important proposals were that she wanted to keep experi­enced social workers on the front line even when they become managers; the appointment of a principal child and family social worker in each local authority to report the views of the front line to all levels of management; doing away with unhelpful government targets, national IT systems and nationally prescribed ways of working; and a change of approach by SCRs away from what happened to why tragedies occur. Such a change of emphasis is welcome though the practical usefulness of SCRs remains questionable.

Welcome as the Munro reforms are and reduce paperwork as they would, social ­workers’ caseloads remain notoriously heavy and increased markedly after Peter Connolly’s death, with child-protection plans rising from 27,000 to 44,000 in England, covering a tenth of children who have contact with social ­workers. Peter Connolly’s social worker was said to have been responsible for 18 cases at the time of Peter’s death in August 2007 when Haringey Council’s guidelines stated that no more than 12 cases should be allocated to each social worker. A survey by a social-work education website found that one in six respondents had more than 40 cases.

But what has most certainly been a terrible week in the uneven history of modern social work also offered it a tiny but unexpected gleam of light. For while the shortage of good social workers seems chronic in some places – as in Birmingham – and there is evidence that would-be new entrants are deterred from entering the profession by media antipathy if matters go wrong, the good news was that around 1,000 people had applied for the new Frontline children’s social-work training ­programme.

Frontline aims to fast-track well-educated, self-confident and emotionally robust graduates into social work, based on the Teach First programme in education. After rigorous selection, which includes psychological testing, 100 will be chosen next summer to enter the two-year scheme. The training is practical and academic with a leadership development element. It seeks to provide course participants with skills, while developing the essential qualities of confidence, teamwork and optimism, some of which, of course, are innate or emerge through experience and maturity.

Frontline is, of course, not a cure-all, only a start, given the problems that children’s departments face (and the need for social workers is still likely to outpace demand by 2022) but it does inject innovation and hope into social work.

However, child protection cannot be ­separated from what happens locally and nationally. The stresses and strains of increasing poverty make parenting that much harder, while children’s services are only one local authority service subject to cuts. The Coalition Government’s gutting of Sure Start and the tearing up Every Child Matters, which aimed to provide comprehensive packages of support for parents in deprived areas, have removed helpful props from children’s services.

One child dies every week as a consequence of neglect and abuse. This figure is constant and the record of the United Kingdom compares favourably with other European countries. Yet children’s services (unlike, say, education) focus on the poor, which causes families to be extremely wary of any official intervention. Family support services, which include health visitors and nursery nurses as well as social workers, are treated as separate from child-protection services when they should overlap.

Three things need bearing in mind. One is a recognition that children will continue to be harmed and die. The most effective child-protection system can only diminish harm done to children (although the National Society for the Prevention of Cruelty to Children’s money-making “Stop It Now” campaign pretended otherwise). Secondly, social workers, in particular, will continue to be easily damned as intrusive, authoritarian agents of the state if they do take children into care, and damned if they don’t as lax and unable to defend the defenceless. Frontline may do something about overcoming professional hesitation in the future but, thirdly, what can change now is that we know enough about why professionals sometimes fail to stop children being killed by their parents. The lessons are there – we need, at long last, to start learning from them.