Inconsistent multi-agency working, “reactive” practice and over-optimism meant social workers and other professionals missed opportunities to intervene in a family where a toddler overdosed on methadone, a serious case review has found.

Two-year-old Frankie Hedgecock died in June 2015 after drinking a cup of methadone left on the floor by her mother Lucy King, who had fallen asleep. King was convicted of manslaughter through gross negligence in April 2017.

The serious case review, published by Kent Safeguarding Children Board, said no single agency or professional – all of whom “wanted the best” for the family – could have predicted Frankie’s death.

But it found there was a collective lack of insight into the lives of Frankie and her four siblings. This was exacerbated by an excessive focus on King and her partner, both drug users, and the absence of a chronology of events that might have enabled better analysis of their situation.

The review recommended all agencies use chronologies and called on Kent children’s services to provide the safeguarding board with reports on multi-agency participation in child protection conferences twice a year.

Missed appointments

Kent County Council children’s services had been sporadically involved with King since the late 1990s. Some referrals related to health professionals’ concern that her methadone use while pregnant could affect the welfare of her unborn children. Other referrals followed King’s failure to bring her children to check-ups and other medical appointments.

Members of the public also contacted children’s services on a number of occasions concerned for the wellbeing of King’s children. In 2010, one caller stated that the children “do not see the light of day”. Ambulance staff who attended the family’s home a few months later described it as run-down and cold, with no furniture, carpets or wallpaper.

However, social workers visiting the family home generally found that King and her partner were doing their best and that the children were happy and loved.

“Mother and father are conscientious parents and they are moving forward in providing a better home environment for their children,” said a January 2011 initial assessment completed in response to the ambulance staff’s concerns. “The walls had been painted, new furniture had been bought and much of the groundwork had been prepared for laying of new carpets, for wallpaper to be bought and new bedding.”

Serious assault

A number of incidents were reported during 2012. In March, police were called after being told three of King’s children had been left in a car crying and screaming, while in August they were told that a child had been screaming “in distress” from the house.

That same month police were called to a domestic abuse incident between King and her partner in a supermarket car park and a neighbour told officers that the children were often left on their own.

Referrals were made to children’s services but the case was closed in late August, after consultation with health visitors and a drug support agency, because a ‘Team Around the Family’ was already in place.

In late 2012, King’s partner was arrested for a serious assault, for which he was later sentenced to nine years in prison. Shortly after this, King disclosed that she was pregnant with Frankie and a child in need referral was made.

However, no further intervention from children’s services was deemed necessary. A social worker noted that King’s children were attending school and seeing their father regularly (despite him being bailed elsewhere), that grandparents were apparently offering support and that the Team Around the Family would monitor the situation.

After being born in February 2013, Frankie spent 65 days in hospital withdrawing from methadone, but at her one-year developmental review she was seen to be doing well.

During autumn 2014, a council housing manager raised concerns about the safety of King’s young children after seeing them playing unattended. In May 2015, meanwhile, the Turning Point drug support agency noted King’s continued dependence on illicit methadone on top of her prescription and that she had missed repeated medical review. Frankie died a few weeks later.

Mixed picture

The serious case review noted that a “high number” of professionals had been involved with the family and that there had been a number of positive observations. However, it set these in context of the series of reports made by anonymous callers and other professionals, and noted the “inconsistency” that King’s children must have experienced due to their parents’ lifestyles.

“Although the children were seen on a number of occasions and by a number of professionals, there was no documentary evidence of views from the children in seeking what their life was like,” the review said. “Apart from one assessment by a social worker, there was no other evidence that any of the children were seen alone and directly asked, ‘What was their life like?'”

The review said that professionals appeared to have focused too much on the parents’ needs rather than the needs of their children. It added that no agency had drawn together a chronology that might have enabled a “critical analysis” to be made. There were “numerous occasions” when neglect could have been considered, it concluded.

The review also found that multi-agency working had become disrupted, with agencies simply reacting to isolated incidents, in part because of the family’s “chaotic and transient” lifestyle. Opportunities for agencies to come together and agree a long-term plan were missed, the review said, and no systematic safeguarding risk assessment appeared to have been carried out.

“Overall, there was evidence within social care services and across the health services, of an absence of safeguarding supervision and case management oversight,” the review said.

Disguised compliance

In hindsight, the review said, professionals had recognised their over-optimism and over-dependence on the Team Around the Family, and that they had been blindsided by disguised compliance by the family.

Among a series of recommendations, it stipulated that all agencies make use of chronologies and ensure children’s views are sought, and that children’s services report regularly on multi-agency participation in child protection conferences.

The review noted that Kent council had introduced the Signs of Safety system, which should act to safeguard against the failings identified occurring in future.

Gill Rigg, the independent chair of Kent Safeguarding Children Board, said: “As a result of their contributions to the serious case review, the relevant partners drew up individual recommendations and action plans for improving the way they work to protect children better in the future.”

She added that the safeguarding board had accepted all the recommendations made in the report. “This is crucial as part of helping improve the safety and wellbeing of Kent children,” she said. “These have been implemented and lessons learned.”

A social worker whose case files were audited in the wake of the Operation Span investigation into child sexual exploitation in Rochdale has been struck off.

A HCPC conduct panel removed the social worker from the register after finding that her actions in five cases she handled between 2006 and 2012 had put the children involved at “unwarranted risk of harm” and “breached the fundamental tenets of social work”.

An independent social worker, hired by Rochdale Council to investigate the casework of her and other social workers in reaction to Operation Span, had highlighted numerous concerns.

Not speaking to children

These concerns included not visiting or speaking to children known to be at risk of sexual exploitation when conducting assessments, failing to initiate a section 47 enquiry and not informing a child protection conference or her manager that police were needed to access the home of one of the children.

The independent social worker also told the hearing the social worker was “very out of her depth” in her role as a duty officer and that her records were “very poor, minimal and haphazard”.

The hearing was also told there were no supervision notes on her cases and no evidence of general supervision either.

Significant risk

“Her failures posed a significant risk to the welfare of the children and young people in this case,” said panel chair Lesley White. “All five were very vulnerable and had been referred to the council’s children’s services because of serious concerns about them at that specific time, including sexual exploitation.”

The social worker did not attend the hearing, but told the HCPC by email that she had not worked as a social worker since leaving Rochdale Council in 2012 and had no intention of returning to the profession.

The first of the five cases concerned ‘Child 1’, a 13-year-old girl with learning difficulties and a heart condition who had been known to social services since the age of two due to concerns about her parents’ alcohol, drug and mental health problems. The case was assigned to the social worker, who worked as a duty officer, after it was reported in 2008 that Child 1 had an “inappropriate association” with a 60-year-old man and may be “performing sexual favours”.

Lack of embarrassment about sexual matters

The panel heard there was no record of the social worker visiting or speaking to the child. She also did not question the child’s lack of embarrassment when talking about sexual matters and did not explore the possibility of a care placement for the girl. The social worker also recommended a child in need rather than a child protection plan despite evidence of on-going risk of sexual exploitation.

‘Child 2’ was allocated to the social worker in 2008 after allegations of sexual exploitation and rape. A further referral followed that October when the 15-year-old came to school intoxicated and told staff and friends that she spent the weekend with a local family and engaged in sexual activity with three brothers.

The panel found the social worker did not see or speak to the child for her first assessment and accepted only the father’s assurances. The social worker also did not initiate a section 47 enquiry, as had been agreed at a strategy discussion.

No reason for closing the case

In the case of 12-year-old ‘Child 3’, who was also allocated to her in 2008, the social worker had conducted one joint interview with the child and then recommended no further action despite ongoing risk of sexual exploitation. Nor did the social worker record a reason for closing the case.

The panel found she also failed to record her preparation for a 2006 safeguarding meeting about ‘Child 4’, who was over the age of consent but vulnerable to sexual exploitation.

The final case concerned ‘Child 5’, who was referred in 2012 and was alleged to be a street prostitute who had been raped as a child and whose mother had also been sexually exploited. The panel found the social worker did not record the action she took to engage the child and referred to the family’s “issues” in her report but did not document what these were.

The panel concluded the social worker’s actions amounted to misconduct and had impaired her fitness to practise. Given the seriousness of the misconduct and no evidence of a desire by the registrant to address the concerns about her practice, the panel decided she should be removed from the social work register.

Most complaints to the Local Government Ombudsman about councils’ child protection and adult care planning functions were upheld during 2015-16, the watchdog’s annual review has revealed.

Sixty-eight per cent of complaints related to child protection that were investigated in detail by the ombudsman were upheld, as were 70% of those dealing with adult care planning.

The ombudsman provides an independent review of local authority decision-making where the person concerned has exhausted internal complaints processes.

Among all complaints about council-run adult social care services that were investigated, 58% were upheld, as were 53% of those concerning education and children’s services, above the average across all services of 51%.

Rise in social care complaints

Overall, 2,584 complaints about councils’ adult services were received, a rise of 4% on the previous year. The review said that: 

• Assessment and care planning continued to attract most complaints, at 602 (up from 576 the previous year). It highlighted poor communication, inadequate involvement of families, delays in assessing and reviewing and insufficient provision of information to help families make choices as being common faults.
• Complaints about councils’ provision of home care rose steeply – by 29% – to 281, from 218 in 2014-15. Among such complaints, 67% were upheld after investigation. Common problems included failure to provide services, communication breakdowns between councils and care providers and medical assistance not being sought in a timely manner. The report acknowledged the sector’s awareness of some of the issues raised.
• The ombudsman registered 278 complaints and enquires about charging for care, upholding 62% after investigation and highlighting inconsistent information and guidance as causes for concern.

‘Unsurprising’

A Local Government Association spokesperson said: “It is unsurprising that issues around adult social care are areas of concern for complainants, as this is where there has been increasing pressure on budgets and demand for services.

The spokesperson added: “Councils will continue to work hard to ensure people have their voice heard and are confident that their council will act on any feedback but the funding crisis in adult social care is taking its toll on councils’ ability to provide support to older and vulnerable people.”

Child protection concerns 

Education and children’s services, the most frequently complained about area of council operations, also saw the biggest rise in complaints – up by 13% to 3,438. Of these, 903 related to child protection.

As well as commenting on the high proportion of such complaints being upheld, the ombudsman’s review flagged up “regular” instances of councils failing to follow procedures with regards to the statutory children’s social care complaints processes. It also noted “some instances” where a council had taken a lack of consent from a young person to justify not investigating a complaint around child sexual exploitation, or for failing to take safeguarding action.

Dave Hill, president of the Association of Directors of Children’s Services, said: “An increase of 13% in the numbers of enquiries or complaints about the provision of services to children and their families sounds high, but it’s important to see these figures in context – our work with schools brings us into contact with millions of children each and every year.”

Hill added: “The services we provide are complex and local authorities are going through a lot of change driven by changes in legislation and austerity. We work hard to minimise the impact of this change on the communities we serve and when things go wrong we seek to learn lessons.”

Monday

Today I visit an 11 year old in foster care. He is studying for his SATs tests in school, looks tired and is worried that he will do badly. His parents expected him to be a high achiever, then criticised him a lot, so he lacks confidence in his skills.

We talk about some of the old SATd papers he is practising on and the extra tuition he has received. He comes over as someone who will do well, but helping them see it is difficult.

I talk to the foster carers about how they are helping him cope.

Tuesday

In the news a health professional has said that the habit of people bringing cakes into offices for snacking is helping to promote tooth decay in many adults. It’s common in our office too and very tempting, especially if people feel under stress.

Our computer system is off for maintenance this morning and the team have to resort to using pen and paper. It’s not easy for some of them but easier for what a child in care that I visited recently called the BBC generation – those Born Before Computers. He meant me!

Wednesday

I make a visit with a health visitor to a family where there are many concerns. We talk to the four-year-old in their bedroom. It’s very messy and there is an electric fire with a bare element, so we immediately warn the child’s mother about this.

The two-year-old child can only speak his father’s language and, as we couldn’t get an interpreter, we cannot speak to him. The health visitor does checks on the children, but the younger one loudly refuses to be weighed.

I talk about safer forms of heating with their mother and agree to see if we can help her fund buying new heaters. I will have to make an unannounced visit to them to make sure the dangerous heater is not being used and get some advice about fire safety.

Even a routine visit can generate a lot of work!

Thursday

I have a teenager on a child protection plan that won’t go to school and won’t discuss it. There is concern that he spends the day with similar children in a flat with two young parents who look after neighbour’ young children. They aren’t registered childminders.

As part of the child protection plan I visit to the flat. Someone looks through the letterbox and swears at me to go away. Realising I’m a risk, I quickly leave and will return with the police.

Friday

I am at a school seeing the child in care that I saw Monday. He feels more optimistic today. The headmaster tells me about the pressure everyone feels about the upcoming SATs tests. There is a fear that if their SATS results don’t improve, pressure will be applied to make the school become an academy. It’s difficult for teachers and pupils to live under this threat and carry on day-to-day.

Small wonder, then, that I see a plate of cakes in their staff room.

A mother and two children have been awarded £45,000 in damages after a judge found a council ‘abused’ a section 20 agreement and breached human rights law.

Judge Farquhar made the award after ruling West Sussex Council had acted unlawfully by exercising parental responsibility “in every conceivable area” of the children’s lives without the power to do so; failing to promote contact between the children and mother; and failing to issue care proceedings for almost two and a half years, which had denied the children independent representation.

Farquhar said the section 20 arrangement itself was valid but the council’s actions were the “clearest possible breach” of the right to a private and family life under Article 8 of the European Convention of Human Rights. He found the delay bringing care proceedings breached the children’s and mother’s Article 8 rights and their right to a fair hearing under Article 6.

He said: “I am satisfied that the inordinate delay in this case was unlawful and an abuse of the [section] 20 agreements that had been obtained.”

‘Breath-taking’ lack of urgency

The judge criticised the “breath-taking” lack of urgency around the case and said the section 20 agreement had led to “very poor outcomes” for the children.

He criticised the independent reviewing officer (IRO) for “a total failure” to challenge the council’s conduct in the interests of the children, adding: “This was clearly a case that should have come before the courts years before it actually did, yet the IRO did not appear to put any pressure upon the local authority to ensure this occurred.”

Farquhar awarded each child damages of £20,000 and £5,000 to the mother.

Defending the duration of the section 20 arrangement, West Sussex council argued the arrangement had not been used as a long prelude to proceedings but instead with a view to securing a long-term special guardianship order placement with foster carers. Farquhar said this excuse was “even worse” than the section 20 arrangement being used as a long prelude to proceedings.

“It suggests that they were exercising all of the parental responsibility without even thinking that proceedings were to be commenced any time in the foreseeable future”, he said

Loss of chance

The children, referred to as ‘X’ and ‘Y’, were cared for by their aunt via a residence order following care proceedings in 2008. In 2013 they entered care through the section 20 arrangement after the aunt said she could no longer take care of them. The children entered the arrangement with the aunt’s consent, and later the mother’s.

During the course of their time in care, the children were separated, had no contact with each other or any other family member. One was in a placement which was not culturally appropriate.

The judge said the council’s actions had “at best” seen the “loss of a chance” for the children to be placed together, for there to be any contact between the children and the mother, and for a culturally appropriate placement to be found.

He added: “It is apparent that the end result for these children is not a good one. It is not possible now to say that the outcome would have been any different if proceedings had been issued in early to mid-2013 which should have occurred. However, it is difficult to see how the outcome would have been much worse.”

The hearing took place in December 2015. The judgment was published online this month.