Liz Davies, writing for Channel 4 News highlighting the lessons that can be learned from recent deaths of children following abuse. Liz has a long record of critical engagement with social work policy and practice and has published widely in the UK news media on the cases of Baby Peter and Victoria Climbié. The text of Liz’s article, written following Kyra Ishaq’s mother’s conviction for manslaughter, is
reproduced below.

‘ALARM BELLS SHOULD HAVE RUNG’ As Khyra Ishaq’s mother is found guilty of manslaughter, social work lecturer Liz Davies writes that most serious case reviews following the deaths of children from abuse highlight the same factors. This case will probably be no different except that Birmingham professionals were, following the death of Baby Peter in Haringey, overwhelmed with the national trend of a vast increase in referrals and also 19 children in their area had died from abuse in the space of four years.

There is no doubt that alarm bells should have rung loudly and led to action to protect Khyra. School staff had made referrals to children’s services following their observation of neglect, bullying, absence and bizarre parental attitudes. Neighbours had witnessed neglect and cruelty and the extended family had been distanced from seeing her, but seemingly did not alert the authorities. The education social worker and police both visited and were either not allowed into the home or were refused sight of her. It took two months for a children’s social worker to visit, see Khyra on the doorstep and decide that she seemed safe and well. Three months later Khyra died. When there is suspicion or evidence of child abuse, denial of access to children should always trigger child protection protocols. When inter-agency working is failing at the coal face the Local Safeguarding Children Board should be alerted so that difficulties can be resolved, but we do not know as yet what action the school took when their voice went unheard and we do not know about the role of other key professionals such as the GP or health visitor. The social worker should have conducted a child protection investigation as the case had certainly reached the legal threshold of a reasonable cause to suspect actual or likely significant harm. This would have included police and social workers making initial checks and deciding if immediate protective action was needed.

There should have been a multi-agency strategy meeting to examine evidence from all agencies and plan an investigation. This would include collating known history, interviewing children on their own, medical examinations and interviews of the parents/ carers and other witnesses. A child protection conference to bring together all professionals and the family would make plans to keep the children safe from harm. Khyra was not defined as a child in need of protection and there were no child protection plans in place for her. However, in examining why these basic procedures were not implemented, and why Khyra was unprotected, we should focus our main attention on the impact of the government policy Every Child Matters on professional practice.

The agenda, which has so accelerated since the Victoria Climbié and Peter Connolly cases, emphasises prevention and a family support approach for all children in need and has distracted scarce professional resources away from the protection of those few children at risk of harm. A lack of highly skilled investigation of child abuse, and specialist social work teams, has led to errors of judgement and, as one tragedy follows another, we are witnessing the impact of this disastrous policy on vulnerable children and families. Key tools which enable professionals to protect children that have been tried and tested since the 80s, have been removed and this is a key reason why so many professionals, experiencing unsafe practice, are leaving the work. In 2008, on Lord Laming’s recommendation, the child protection register, the cornerstone of effective child protection, was abolished, leading to confused and inconsistent practice. The register used to identify to the emergency services children known to be at high risk of abuse, but this alarm no longer happens. Laming also recommended that police should focus on the investigation of crime.

This has led to a reduced police involvement in the investigation of harm to children where crime is not clearly indicated and has left social workers feeling isolated and unsupported. It is time for those child protection professionals, who know how to protect children but have not yet left the sinking ship, to make clear to their managers, politicians, Local Safeguarding Children Boards, professional bodies and inspectorates that, however committed and dedicated they are and however many long hours they work, flawed government policies and unsafe working conditions are making their task unachievable.

16 August 2010