Kevin
Harrington
Associates
Limited
AMY
A SERIOUS CASE REVIEW
Kevin Harrington JP, BA, MSc, CQSW
On behalf of the Kent Safeguarding Children Board
Chair Maggie Blyth
Serious Case Review Panel Chair
Keith Ibbetson
September 2012
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TABLE OF CONTENTS
TABLE OF CONTENTS ................................................................................................. 2
1. INTRODUCTION ..................................................................................................... 4
2. DECISION TO CONDUCT THIS SERIOUS CASE REVIEW ......................................... 4
3. SERIOUS CASE REVIEW PROCESS .......................................................................... 4
4. METHODOLOGY USED TO DRAW UP THIS REPORT ............................................. 8
5. CHRONOLOGY........................................................................................................ 8
5.1 Introduction ............................................................................................................. 8
5.2 Key events ............................................................................................................... 8
6. THE FAMILY.......................................................................................................... 11
7. THE AGENCIES...................................................................................................... 12
7.1 Introduction ........................................................................................................... 12
7.2 Kent County Council, Specialist Children’s Services ............................................ 12
7.3 Kent County Council, Education, Learning and Skills ........................................... 13
7.5 Kent Community Health NHS Trust ...................................................................... 15
7.6 The General Practitioners ..................................................................................... 17
7.7 Maidstone and Tunbridge Wells NHS Trust ......................................................... 19
7.8 Kent and Medway NHS and Social Care Partnership Trust ................................. 19
7.9 Kent Youth Offending Service ............................................................................... 19
7.10 Kent Probation .................................................................................................... 20
7.11 Housing Provider ................................................................................................. 20
7.12 South East Coast Ambulance Service NHS Foundation Trust ............................ 21
7.13 KCA Drug and Alcohol Services ........................................................................... 21
7.14 Health Overview Report ..................................................................................... 21
8. ISSUES IDENTIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW ............... 21
8.1 What were the facts in this case? ......................................................................... 21
8.2 Did agencies listen to the “voice of the child”? Did agencies know what life was
like for Amy?................................................................................................................ 21
8.3 Were Amy’s needs appropriately assessed, with particular reference to the
consequences of sexual abuse and neglect?.............................................................. 24
8.4 How were the outcomes of assessments used to inform practice and decision
making in relation to Amy? Were Amy and her family appropriately engaged and
involved by agencies? ................................................................................................. 26
8.5 How far was Amy helped to cope with the adverse circumstances in her life,
particularly her sexual abuse? .................................................................................... 27
8.6 Did assessments and services take sufficient account of the family’s race,
culture, language, and religious needs, and any disability needs? ........................... 27
8.7 Were Kent Safeguarding Children Board and individual agency procedures
followed? ..................................................................................................................... 28
9. ISSUES ARISING FROM AN OVERVIEW OF THE CASE ......................................... 28
9.1 Good practice and service improvements ........................................................... 28
9.2 The circumstances of Amy’s death ....................................................................... 29
10. REVIEW PROCESS .............................................................................................. 30
11. CONCLUSIONS: KEY LEARNING POINTS AND MISSED OPPORTUNITIES.......... 31
12. RECOMMENDATIONS MADE IN THE MANAGEMENT REVIEWS OF THE
PARTICIPATING AGENCIES ...................................................................................... 33
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12.1 Introduction......................................................................................................... 33
12.2 Kent County Council, Specialist Children’s Services .......................................... 33
12.3 Kent County Council, Education, Learning and Skills ......................................... 33
12.4 Kent Police ........................................................................................................... 33
12.5 Kent Community Health NHS Trust .................................................................... 34
12.6 Kent and Medway NHS and Social Care Partnership Trust ............................... 34
12.7 Maidstone and Tunbridge Wells NHS Trust ....................................................... 35
12.8 General Practitioners .......................................................................................... 35
12.9 Health Overview Report ..................................................................................... 35
12.10 Kent Youth Offending Service........................................................................... 35
12.11 Kent Probation .................................................................................................. 35
12.13 South East Coast Ambulance Service NHS Foundation Trust .......................... 36
13. RECOMMENDATIONS FROM THIS OVERVIEW REPORT ................................... 37
13.1 Introduction......................................................................................................... 37
13.2 Recommendations to the Kent Safeguarding Children Board .......................... 37
APPENDIX A: Biographical details of Independent Chair and Overview Report
Author ...................................................................................................................... 39
APPENDIX B: References ......................................................................................... 40
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1. INTRODUCTION
1.1 Amy Singleton 1died in 2011. She was ten years old and was found hanging by a
belt from a window in her bedroom. The circumstances of Amy’s death, in a context
of substantial current and historical involvement of various agencies with her family,
led the Kent Safeguarding Children Board (KSCB) to conduct a Serious Case Review
(SCR). This is the Overview Report from that review.
1.2 The death of a child is distressing for staff who have known that child and their
family. This review has been greatly assisted by the co-operation and commitment of
staff from all contributing agencies.
2. DECISION TO CONDUCT THIS SERIOUS CASE REVIEW
2.1 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires
Safeguarding Boards to undertake reviews of serious cases. The Regulation defines a
serious case as 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.
2.2 In this instance it was alleged that Amy had been sexually abused by a member,
or members, of her extended family. Allegations of neglect had also been made. It
was therefore agreed that the criteria for conducting a SCR were met. The review
was initiated in February 2012.
2.3 In line with statutory guidance, Ofsted 2 should be immediately notified of the
decision to conduct the SCR. As a result of an oversight that formal notification was
not sent until 30/7/12, although this did not lead to any delay in the process of the
Review. Guidance indicates that the target timescale for completion of SCRs is 6
months. It became clear that further time was needed to determine the scope of the
Review and complete it. An extension to the timescale was agreed by the LSCB Chair
and the review was duly completed in September 2012.
3. SERIOUS CASE REVIEW PROCESS
3.1 The purposes of SCRs are set out in “Working Together to Safeguard Children 3”
(Para 8.5). They are to
1
This is not the real name of the child who is the subject of this review. The names of all
family members have been changed to protect their anonymity.
2
The independent body, reporting directly to Parliament, responsible for inspecting and
regulating services to children and young people.
3
Working Together to Safeguard Children (2010) – referred to in this report as “Working
Together” – is a government publication containing statutory guidance on how organisations
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•
•
•
establish what lessons are to be learned from the case about the way in which
local professionals and organisations work individually and together to
safeguard and promote the welfare of children;
identify clearly what those lessons are both within and between agencies,
how and within what timescales they will be acted on, and what is expected
to change as a result; and
improve intra- and inter-agency working and better safeguard and promote
the welfare of children.
3.2 During February 2012 arrangements were made to appoint the independent
people who are required to contribute to the conduct of SCRs. Mr Keith Ibbetson
was appointed to lead the review and Mr Kevin Harrington was appointed to
produce this Overview Report, with an accompanying Executive Summary. Further
details can be found at Appendix A.
3.3 The LSCB constituted a SCR Panel (the Panel) to manage and oversee the conduct
of the review. The membership of the Panel is set out below.
Name / Designation
Mr Keith Ibbetson
Head of Safeguarding
Named GP for Safeguarding
Children
Acting Head of Safeguarding
(or deputy)
Designated Dr. for
Safeguarding Children
Designated Nurse for
Safeguarding Children
Team Manager, Safeguarding
Children
Assistant Head of Integrated
Youth Services
District Manager – Dover
Organisation
Independent
Kent and Medway NHS
and Social Care
Partnership Trust (KMPT)
NHS Kent & Medway
Role
Independent Chair
Panel Member
Kent County Council,
Specialist Children’s
Services (SCS)
East Kent Hospitals
University NHS
Foundation Trust
(EKHUFT)
NHS Kent & Medway
Panel Member
Panel Member
Panel Member
Panel Member
Kent County Council,
Family & Children
Services (Education)
Kent County Council
Panel Member
Kent County Council,
Family & Children
Services (Children’s
Social Care)
Panel Member
Panel Member
and individuals should work together to safeguard and promote the welfare of children and
young people in accordance with the Children Act 1989 and the Children Act 2004.
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Detective Superintendent,
Public Protection Unit
Senior Probation Officer
Manager
Mr Kevin Harrington
Administration Assistants
Kent Police
Panel Member
Kent Probation
Kent Safeguarding
Children Board
Independent Overview
Report author
Kent Safeguarding
Children Board
Panel Member
In attendance
In attendance
In attendance
3.4 It was determined that the following agencies should contribute to the Review.
Those agencies with substantial and / or recent contact would be required to submit
full Individual Management Reviews, in line with statutory guidance, whereas
agencies with less or less recent involvement should provide reports for background
information.
AGENCY
Kent County Council
Specialist Children’s Services
Maidstone & Tunbridge Wells NHS Trust
NHS Kent & Medway
Kent Probation
NHS Kent & Medway General
Practitioners
Kent Police
South East Coast Ambulance Service NHS
Foundation Trust
Kent Community Health NHS Trust
Kent County Council
Youth Offending Service
Kent County Council
Education Services
Housing Provider
KCA Drug and Alcohol Services
Kent & Medway NHS & Social Care
Partnership Trust
Medway NHS Foundation Trust
NATURE OF CONTRIBUTION
Individual Management Review (IMR)
IMR
IMR / Health Overview Report 4
IMR
IMR
IMR
IMR
IMR
IMR
IMR
IMR
IMR
IMR
Information Report
3.5 Amy’s death has also been considered by the Coroner – to establish cause of
death, and by police / Crown Prosecution Service – to consider whether a crime may
have been committed. It was decided in October 2011 that there would be no
criminal proceedings. The inquest was concluded in June 2012, with the recording of
4
Working Together (Paragraph 8.30) requires that in every SCR the appropriate Primary
Care Trust should draw up a health overview report focusing on how health organisations
have interacted together, which will also constitute the IMR for the PCTs as commissioners.
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an open verdict. The Kent Police representative on the SCR Panel acted as the link
between this Review and coronial and criminal investigations. The final report from
this Review will also be considered by the Kent Child Death Overview Panel. 5
3.6 The key issues for consideration in the review are summarised below. Agencies
were asked to:
• provide detailed accounts and analysis of their contact with the family from
2006 to 2012 and summarise any earlier contact with the family
• consider the “voice of the child” and what life was like for Amy
• evaluate whether Amy’s needs were appropriately assessed and met
• assess whether Amy and her family were appropriately engaged and involved
by agencies
• consider how far Amy was helped to cope with the adverse circumstances in
her life, particularly her sexual abuse.
• establish if assessments and services took sufficient account of the family’s
race, culture, language, and religious needs, and any disability needs.
• review whether Kent Safeguarding Children Board and individual agency
procedures were followed.
3.7 In the early stages of gathering information it became clear that the extended
family composition was complex and that there was a great deal of information
across a number of agencies about members of that extended family. This raised the
immediate issue of needing to ensure that children in the extended family were safe.
This was referred back to operational services and was immediately followed up by
them.
3.8 There were indications that agencies might have lessons to learn from their
involvement with extended family members. However it was judged that it would be
unhelpful to incorporate an examination of involvement with the extended family
into the review arising from Amy’s death. It would take a great deal of additional
time and would complicate the task of ensuring that this report was appropriate for
publication. Consequently it was decided to limit the scope of this review to
considering Amy and her immediate family. Reference to extended family members
is made only where it is relevant to an understanding of Amy’s circumstances. The
LSCB has accepted a recommendation that they should conduct a separate exercise
to identify any lessons to be learned from agencies’ involvement with members of
the extended family.
3.9 In conducting this review agencies were asked to give particular attention to
practice since August 2010 when an inspection by Ofsted led to a formal
Improvement Notice because
“the overall effectiveness of Kent’s safeguarding and services for looked after
children (was judged) to be ‘inadequate’.
5
The establishment of Child Death Overview Panels, reviewing the deaths of all children
under 18 and reporting to the LSCB Chair, became a mandatory requirement in April 2008
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Service improvements relevant to issues arising from this review are considered
throughout this report.
4. METHODOLOGY USED TO DRAW UP THIS REPORT
4.1 This Overview Report is based principally on the agency IMRs, background
information submitted and subsequent Panel discussions and dialogue with IMR
authors. Family involvement is discussed at section 6 below.
4.2 The report consists of
• A factual context and chronology.
• Commentary on the family situation and their input to the SCR.
• Analysis of the part played by each agency, and of their IMR.
• Closer analysis of the specific issues identified in the Terms of Reference,
detailed above.
• An account of issues arising from an overview of the case.
• Conclusions and recommendations
4.3 The government has introduced arrangements for the publication 6 in full of
Overview Reports from Serious Case Reviews, unless there are particular reasons
why this would be inappropriate. This has implications for the extent to which
certain matters can be detailed. This report is written in the anticipation that it will
be published. Consequently the information it contains is limited in order to
1) take reasonable precautions to prevent the identification of the child concerned
or other family members
2) protect the right to an appropriate degree of privacy of family members
3) avoid the possibility of heightening any risk of harm to other children.
5. CHRONOLOGY
5.1 Introduction
5.1.1 Each of the agencies involved in this review submitted a detailed chronology, in
tabular form, of their involvement with the family in the period under review. Those
submissions have been co-ordinated into an integrated tabular chronology. This
document is some 230 pages in length. This section of this report aims to summarise
that chronology in an accessible way. It does not include every contact, or failed
contact, and does not provide a detailed account of all the work carried out.
5.2 Key events
5.2.1 Amy started school in September 2005. Her health visiting records cannot be
traced so no background information is available before this date. There was early
6
See letter from the Parliamentary Under Secretary for State for Children & families dated
th
10 June 2010
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recognition that she needed additional help and an Individualised Education
Program (IEP) was set up.
5.2.2 In 2006 police and children’s services investigated a report that a member of
Amy’s extended family had sexually assaulted a child. Mr Singleton expressed
consequent concerns for Amy and she was taken to the family GP. The GP discussed
this with the Named Nurse for Child Protection, but no action was taken as a result.
In August the GP made enquiries with child mental health services (CAMHS) about
treatment for Amy for ADHD. At that time it was felt that she was too young for this
to be reliably diagnosed and treated.
5.2.3 Later that year SCS received an anonymous referral alleging neglect of Amy.
There was a delay of several weeks before SCS followed this up by writing to the
family. Mr Singleton responded, denying any cause for concern. Amy’s school
reported that they had no serious concerns. No home visit was made, Amy was not
seen by SCS and no further action was taken.
5.2.4 Mrs Singleton met with staff at Amy’s school regularly during 2007, and saw
the GP once, because of concerns that Amy’s behaviour was difficult and, in her
mother’s view, suggestive of ADHD. In school, although some academic targets were
being met or exceeded, her behaviour remained difficult to manage. There was
continuing concern about her coming to school unkempt and poorly clothed but
these were not raised directly with her parents.
5.2.5 In 2008 Mr Singleton reported to police that Amy had been sexually abused by
a member of her extended family, who denied this. The allegation of abuse was
confirmed by Amy. After an investigation by police, with limited input by SCS, it was
decided that there was insufficient evidence to support any further action. There is
no indication of consideration being given at that time to measures to protect Amy,
or other children with whom the alleged perpetrator might have contact.
5.2.6 A neighbour made allegations in June 2009 that Amy was physically abused and
neglected. Neighbours also reported that they had seen Amy displaying sexualised
behaviour in public. No action was taken by SCS for several weeks. A social worker
then visited the home but it does not appear that the allegations of child abuse and
neglect were investigated, or that the children were seen alone. The follow-up to the
interview was focussed on financial problems the family were said to be
experiencing. The case was closed by SCS in September. There had been no
assessment under child protection arrangements despite the nature of the original
referral.
5.2.7 Towards the end of the year Amy was assessed in school because of her special
educational needs. That assessment found that although Amy’s reading ability was
above average, her self-esteem and “emotional literacy” were very low. Various
strategies were suggested to assist the school in addressing these issues and the
school started a programme of specialist therapeutic play work with her.
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5.2.8 In February 2010 Amy was diagnosed as having ADHD and was started on
medication for this. Around this time her school had also tried to initiate a Common
Assessment Framework (CAF) 7 assessment. Although initially in agreement with this,
her father said that he would not co-operate if there were any involvement from
SCS. This led to considerable delay and the CAF was not initiated until September,
when agencies agreed that there would be no SCS involvement.
5.2.9 In March a member of Amy’s extended family pleaded guilty to a charge of
“engaging in sexual activity with a child” and received a custodial sentence. He had
previously been the subject of allegations of sexual abuse in respect of Amy.
5.2.10 A neighbour contacted the Head Teacher of Amy’s school later that month to
express concerns about her. The school decided not to pass these reports on to SCS,
on the basis that SCS were already aware of general concerns about the family. The
school subsequently received three letters, all apparently from concerned
neighbours, expressing concerns about Amy. These letters did not lead to any action
being taken. School staff had concerns that Amy’s packed lunch was insufficient and
offered to fund free meals but report that her parents declined this offer.
5.2.11 The CAF was initiated towards the end of 2010. It was decided that the
approach should be consistent with Tier 2 of the CAF arrangements – there is a fuller
discussion below but Tier 2 involvement indicates that the level of need was not
judged to require referral to SCS. Amy was described as “borderline Child in Need 8”
– Children in Need should be seen as requiring intervention under Tier 3 of the CAF
arrangements. The Special Educational Needs Co-ordinator (SENCO) at the school
was identified as the Lead Professional. It was agreed that a Team Around the Child
(TAC) be set up including Amy’s parents, a local parenting support service, school
staff, the School Nurse and an ADHD nurse. It was suggested the TAC might consider
referral to an early intervention service, Support Services for Kids and Young People
(SSKY).
5.2.12 There were a number of attempts to set up the initial TAC meeting but Amy’s
parents did not respond. In mid-December Amy made comments to a member of
school staff which suggested that she was concerned about being sexually abused by
members of her extended family. This was discussed with her father who said that
7
The CAF was established by the former Department for Children, Schools and Families. It is
described on the Every Child Matters website as
“a standardised approach to conducting assessments of children's additional needs and
deciding how these should be met…The CAF promotes more effective, earlier identification of
additional needs, particularly in universal services. It aims to provide a simple process for a
holistic assessment of children's needs and strengths; taking account of the roles of parents,
carers and environmental factors on their development”
8
Children in need are defined in law as children who:• need local authority services to achieve or maintain a reasonable standard of health
or development
• need local authority services to prevent significant or further harm to health or
development
• are disabled.
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these people were no longer considered part of the family and would not be visiting
the home. There was no referral to SCS.
5.2.13 The first TAC meeting was held in February, attended by Amy’s mother, the
SENCO, the headteacher, class teacher and school nurse. A plan of interventions was
agreed including referral to the educational psychologist for assessment and referral
to SSKY. The ADHD liaison nurse was to be asked to review Amy’s weight. That plan
was pursued throughout the year, during which there were continuing concerns
about Amy’s health, presentation and general wellbeing. A review in September
judged that a “Tier 2” approach remained appropriate and the situation did not meet
the criteria for a referral to SCS.
5.2.14 In October Amy was found hanging from the window of her room. Her
parents called an ambulance which arrived within minutes. Amy had been put to bed
at 21:30 after taking medication. She came downstairs once more and then returned
to her room, apparently untroubled. Her father checked on her at 23:30 and found
her hanging by a fabric belt attached to the window. Advanced life support was
commenced by the attending ambulance crews but her condition did not improve
during this time. She was taken to hospital without delay and a Consultant
Paediatrician attended from home but her life could not be saved.
5.2.15 Police had been routinely notified of the incident by ambulance staff and
attended the hospital. There was no evidence of injuries or signs of sexual assault.
Police spoke with Mr Singleton who told them about an incident of attempted sexual
assault on Amy by a member of her extended family some months previously. This
had not been reported to any agency at the time. Police then went to the home
address, noting a range of concerns about the home conditions.
5.2.16 There was no evidence to suggest Amy was depressed or intended to take her
own life. No suicide note was found. The police investigation considered the
hypothesis that Amy could have been experimenting with a practice where an
individual gets a “high” by self asphyxiating but there was no evidence to
substantiate this. Computers were recovered from the house but none were found
to contain material which raised any concerns. Police concluded that there was
nothing to indicate the involvement of any other person in Amy’s death.
5.2.17 A decision was made to conduct a child protection investigation as there
might be concerns for other members of the family. A joint investigation by police
and SCS subsequently found no evidence to indicate that any further action was
necessary.
6. THE FAMILY
6.1 Amy’s parents were contacted twice during the process of the Review to see if
they wished to contribute in any way. They declined invitations to meet the chair of
the Review and the author of this report. Mrs Singleton replied to the second
invitation, advising that she and her husband were still trying to come to terms with
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what had happened. She said that they had been optimistic that good progress was
being made in relation to Amy’s ADHD, although they remained disappointed that
this could not have been diagnosed earlier.
6.2 In that correspondence Mrs Singleton spoke warmly of the assistance the family
had received from Amy’s school, which she felt was evidenced in her school reports.
She said that police had also been helpful, both at the time that the abuse of Amy
was reported and around the circumstances of her death. However, Mrs Singleton
said that they were disappointed that SCS had not been involved more fully in
supporting the family.
7. THE AGENCIES
7.1 Introduction
7.1.1 Each of the agencies contributing to this review has carried out an internal
review (IMR), detailing and analysing their involvement with the family. This section
of this report confirms the nature of that involvement and comments on the analysis
contained in the IMR.
7.2 Kent County Council, Specialist Children’s Services
7.2.1 This report confirms that SCS had contact with Amy’s family on a number of
occasions before her death, as a result of allegations or concerns about physical or
sexual abuse or neglect. The report notes evidence of unnecessary delay and failure
to carry out appropriate checks with other agencies. There was only one Initial
Assessment when there were at least three occasions when a more comprehensive
assessment should have been carried out.
7.2.2 The report highlights the significance of the weak response to the allegation
made by Amy’s father in 2008 that Amy had been sexually abused. Although a
Strategy Meeting took place, SCS were not otherwise involved in the investigation,
which was carried out solely by police. This incident seems to mark the onset of Mr
Singleton’s animosity to SCS. It was a missed opportunity for SCS to intervene with
the family at a point where
“it was accepted by both professionals and her family (my emphasis) that (Amy) had
experienced sexual abuse”.
The Panel was provided with evidence of considerable efforts to improve
collaborative working between police and SCS and was satisfied that this was not
now a systemic problem which required a recommendation from this Review.
7.2.3 The report goes on to detail the delay and subsequent failure to follow child
protection procedures by SCS in response to allegations of neglect in 2009. The
children were not seen, the circumstances in which they lived and slept were not
thoroughly investigated and routine checks with other agencies were not carried out
comprehensively.
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7.2.4 One other service within SCS had been involved. SSKY is a local authority early
intervention service. The worker who made initial contact with the family shared
similar concerns to other agencies about Mr Singleton’s hostility to SCS and about
differential treatment of Amy within the family.
7.2.5 A number of issues are detailed as having led to these weaknesses in the
service provided to Amy and her family. Many of the aspects which give cause for
concern were identified more widely across the county in the Ofsted inspection in
2010. Of key importance is the lack of management oversight and direction to
underpin any of the agency’s responses to matters of serious concern. There were a
number of instances of delay and lack of purpose which may have been linked to
major problems of high vacancy levels across the organisation. It is clear that there
were very serious difficulties arising from the introduction of a new computer
system in 2008 which led to problems in tracking incoming work. Mr Singleton’s
overt hostility to social workers is correctly highlighted as probably having
contributed to some of the weak responses. The reaction to the family’s
presentation, across all agencies, indicates a disturbing lack of knowledge and skill in
recognising and responding to concerns about sexual abuse.
7.3 Kent County Council, Education, Learning and Skills
7.3.1 This report considers the involvement of Amy’s school and the local authority’s
Special Educational Needs services. The report summarises the general perceptions
held by education staff:
“Amy … presented as needy in terms of seeking adult attention and experiencing
difficulty with peer relationships. .. sometimes untidy, occasional issues regarding
adequacy of diet. .. cleanliness and hygiene”
7.3.2 The school was not adequately involved in the investigation, in 2008, into the
alleged sexual abuse of Amy. The headteacher is said to recall discussing this with
police at the time but kept no written records. There were inappropriate responses
by the school in 2010 to a number of expressions of concern. Information from a
neighbour that there were concerns locally about the treatment of children of the
family was not passed on by the school to SCS. Some weeks later the headteacher
discussed the issue with the Area Children’s Officer for Child Protection 9 (ACOCP).
This officer advised that the information should still be reported to SCS but it does
not appear that this was done. After the summer break the school received three
written expressions of concern about the children but did not make a referral to SCS.
7.3.3 The implementation of the CAF was stalled for 6 months as a result of Mr
Singleton’s overt hostility to any SCS involvement. This seems to have been accepted
at face value by the school, rather than prompting concerns as to why he should
allow this to impede the arrangements to help his daughter. This again suggests a
lack of confidence in the relationship between the two agencies, and / or a lack of
familiarity with CAF arrangements.
9
An officer with an advisory role on safeguarding for education staff.
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7.3.4 A further concern arises from the school’s response to comments by Amy
suggesting that she feared sexual abuse by members of her extended family. The
school did not share this information with SCS. Instead the headteacher spoke to Mr
Singleton – an action which in some circumstances might have placed Amy at greater
risk – and accepted reassurances from him that no further action was necessary.
Even if, as the IMR points out, this had been a reference to historical abuse, it was
both an error in judgment and a missed opportunity for agencies
“to have a discussion and come to some joint understanding about Amy’s wider
needs in respect of her previous experiences of alleged sexual abuse”.
7.3.5 The final report of concern about Amy was made to the school by neighbours
in March 2011. This led the headteacher again to talk to the ACOCP. There is no
recording of this discussion but the IMR reports that
“ In the absence of further new evidence and given father’s hostility to SCS it was on
balance thought to be more effective to concentrate on developing an effective
working relationship with the school and seek assistance elsewhere for the difficulties
with neighbours. The school therefore contacted the housing association and local
police community support officer”.
Effectively the concerns of neighbours about the welfare of the children were not
shared with the appropriate agency but were redefined as a housing problem /
neighbour dispute.
7.3.6 There is a more encouraging account of the school’s direct work with Amy and,
eventually, of the beneficial consequences of the CAF:
“At the time that the school last saw Amy it appeared that after a long period of
concerns about her home life there was evidence that she was benefitting from their
input and that the family were at last co-operating with plans for the children”.
7.3.7 Overall, there is a positive picture of the school’s commitment to Amy, both
through the input of individual members of staff and more widely. Equally however
analysis of their involvement indicates that the school did not understand or follow
safeguarding requirements. The principal contributory factors appear to be a failure
to keep abreast of those requirements and an ineffective working relationship with
SCS.
7.4 Kent Police
7.4.1 Police involvement consisted of their part in the 2008 allegation of the sexual
abuse of Amy. The IMR is satisfied that, although this should have been a joint
investigation, it was appropriate that police went ahead when SCS were unable to
provide any input. The police investigation is judged to be satisfactory and the report
notes that
“interviews were conducted with professionalism and took into account the needs,
views and wellbeing of Amy”.
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7.4.2 Police had no other contact with Amy before her death. However there is
cumulative evidence of a range of inappropriate and illegal sexual conduct, by
various members of this extended family, over a period of years. This evidence was
not seen in its totality, and did not lead to assessments co-ordinated with other
agencies. For example, when a member of the extended family was imprisoned for
sexual abuse
“there was no consideration given to his potential threat to child members of his own
family; including Amy. In view of the family history, some form of risk assessment
would have been appropriate”.
7.4.3 This IMR also recognises the threat arising from the ingrained nature of
inappropriate sexual conduct across this family. When the person mentioned in the
previous paragraph was released from prison, in a very short space of time he was
living with a woman with young children, in total disregard of his Sexual Offences
Prevention Order (SOPO):
“This again shows how (he) had little regard for the consequences of his actions”.
7.4.4 The decision about how widely to “cast the net” is a difficult one for police. It
may lead to the accumulation and requirement to analyse very large amounts of
material, much of which may not be directly relevant to the principal focus of an
investigation. The extensive information gathered in this review about criminal
activities of members of the extended family is a case in point. However the IMR
notes that
“one of the people interviewed remarked, “We can’t go looking for victims”.
and the IMR author responds that
“In some cases this is exactly what we should be endeavouring to do”.
Police do hold and have access to very extensive information about people and a key
learning point from this review turns on the need to put that information together
and make best use of it.
7.4.5 The IMR identifies some lapses in routine record-keeping and notes the
possible consequences of referrals being received “out of hours”, when agencies
may have more limited resources. This was the case when the abuse of Amy was
reported, and police proceeded on a single agency basis. The report also raises the
issue of how agencies might improve their response to situations where a young
person is alleged to be the perpetrator of a sexual offence, which may be indicative
of that young person also being the victim of abuse.
7.5 Kent Community Health NHS Trust
7.5.1 The author of this IMR attempted to research the agency’s early involvement
with Amy and her family, which would have been held in Health Visiting notes, but
these could no longer be traced. There has consequently been very little information
available about Amy’s early life. This is a matter of concern for this review and more
widely. Health records should be stored and kept appropriately until the person to
whom they refer reaches the age of twenty-five. As the IMR notes, the consequence
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is that information about Amy’s early years and the family’s relationship with health
visitors is lost.
“The missing health visiting record may indeed have had a significant impact on the
understanding of Amy's pre school life… (particularly because)…within two months of
entering school, Amy needed an individual education plan”.
7.5.2 The Panel accepted that all appropriate steps had been taken both to
investigate this issue, and to confirm that current arrangements were satisfactory.
Consequently this Overview Report, in line with the IMR, does not make a
recommendation about this matter. In the light of the records being missing the
report principally addresses the involvement of health services in the management
of Amy’s ADHD and their collaboration with the other agencies involved in the TAC.
7.5.3 Amy was originally referred by her GP for investigation of possible ADHD when
she was under six years of age. It is explained that in normal circumstances this is too
young for ADHD to be diagnosed and treated with medication. She was re-referred
by her school when she was a little over eight years old and
“her behaviour had deteriorated to the extent she had difficulty with friendships, her
sleep was an issue, she would compromise her safety by walking out in front of traffic
and would talk to strangers”.
7.5.4 She attended for paediatric assessment with her father who told the
paediatrician about the sexual abuse of Amy. There was subsequently a specialist
assessment leading to the diagnosis of ADHD and treatment which continued
throughout Amy’s life. Overall there seemed to be a positive reaction and an
improvement in Amy’s behaviour. Specialist ADHD staff joined and contributed to
the TAC from February 2011 onwards.
7.5.5 The report identifies that the information about the sexual abuse of Amy,
which was disclosed to the paediatrician initially assessing her, did not prompt any
further enquiries and was not included in the referral to the ADHD Clinic. One ADHD
nurse has confirmed having no knowledge of this until after Amy’s death. The overall
report from that service is that the history was taken into account in her assessment
and treatment but there is no explanation of how they became aware of it. If they
did take it into account – and there is no evidence that they did – it is clearly
unsatisfactory that an agency should be allowing such a potentially significant issue
to be considered without making any reference to it in records.
7.5.6 The IMR comments on any possible association between Amy’s ADHD and her
state of mind at the time of her death:
“The … medication for ADHD which Amy was on at the time of her death lasts
approximately 10 - 12 hours. After this time there would be no residual drug left in
the system leaving the person essentially non-medicated, from approximately 8 pm
until the following morning…. During interview ( the …paediatrician) stated that at
the time of her death Amy may not have had any medication in her system so the
ability to moderate her risk taking behaviours was reduced”.
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7.5.7 The clear conclusion of the IMR is that Amy’s ADHD was diagnosed
appropriately and managed well. It is similarly clear in questioning how the
knowledge that she was said to have been sexually abused by a family member could
not have prompted any further enquiry.
“Possible sexual abuse did not appear to be considered in a holistic assessment. No
one appeared to consider was the perpetrator still in contact with Amy, how long had
the abuse being going on and how was it discovered”.
The doctor to whom the comment was originally made reported that
“As Mr Singleton stated the police had been involved (she) did not believe at the time
that she should make any further enquiries as she considered the case had been
investigated and closed”.
7.5.8 This leads to a fundamental concern which is to some extent captured in this
IMR – the sub-optimal response to the issue of sexual abuse and, to a lesser extent
here, neglect. This comes in a context, otherwise, of the professionals working well
together to tackle Amy’s diagnosed condition of ADHD. There are reports of
improved supervision arrangements and reassurances that this would not happen
now, but there must be a key learning point about improving professionals’
understanding of their responsibility for sharing information.
7.5.9 The issue of Amy’s weight was explored by the Panel.
“Amy’s weight was on the 75th centile at 5 years 3 months, was between 75th and
50th centile by 8 years 6 months dipped to just below the 50th centile at 9 years 1
month and remained steady until a small reduction by 9 years 7 months with another
slight reduction by 10 years 1 month to between 50th centile and 25th centile”.
This pattern in itself was judged by the Medical Advisor to the Panel to be not
unusual. However, in the context of other evidence, including concerns about
general neglect, the IMR notes that this pattern of slower growth than might be
anticipated could give cause for concern.
7.5.10 Finally this agency has provided information about reported associations
between suicide and the ADHD medication taken by Amy. It notes that
“There are theoretical risks of increased suicide with …However nothing has been
proven, and research has not shown an increased incidence of suicide over the
normal rates in those on medication. The Medicines and Healthcare Products
Regulatory Agency (MHRA) information …states ‘1 report of suicidal ideation and /or
suicide attempt has been received in patients treated with (this medication)… The
incidence of suicidal ideation is uncommon, and incidence of suicide attempts not
known”
The report concludes that there was no reason not to use this medication because of
possible risk of suicide.
7.6 The General Practitioners
7.6.1 The IMR considers information held by the GPs for Amy and her extended
family. For the purposes of this SCR, this Overview Report focuses on Amy and her
immediate family.
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7.6.2 Mr and Mrs Singleton have experienced a range of illnesses and conditions. Mr
Singleton has been seriously unwell, requiring treatment that will have significantly
affected his daily living. The report is satisfied that, medically, these matters were
generally dealt with thoroughly. Their emotional / psychological consequences might
have been further explored but Mr Singleton does not appear to have welcomed
this. There is no indication of any consideration of the consequences of the parents’
health issues for their parenting responsibilities. The report notes that Mrs Singleton
had been in hospital very recently before Amy’s death and makes a general
observation that
“the time prior to and following the procedure (may) affect the ability to care for
dependants and this is something we should consider supporting as a health service
during pre-operative assessments”
7.6.3 In 2006 Mr Singleton sought the GP’s advice because Amy was reported to
have been present while another child was sexually abused. The GP appropriately
discussed this with the Named Nurse for Child Protection, but this did not lead to
any cross-checking to ensure that SCS were fully aware. Similarly, when more
conclusive evidence of Amy’s sexual abuse emerged, this was not shared by SCS with
the GP. This Review has also identified a difficulty in the information sharing
arrangements more generally in relation to sexual abuse between children. Even
when information was shared in respect of the abused child, that information
sharing did not extend to the child perpetrating the abuse and other siblings.
7.6.4 The GP appropriately followed up concerns about Amy’s ADHD, enabling early
diagnosis and treatment (if it is agreed that such a diagnosis could not reliably have
been made at age six, when the concerns were first raised). There are no concerns
about the GP’s continuing involvement in the management of her ADHD.
7.6.5 The report contains further information from the GPs about Amy which may be
significant:
“ In 2003 Amy was ‘pointing at herself when weeing’ - there is no clear
documentation regarding the duration of these events or how this was investigated
at all, just that the examination was normal”
Amy also has recurrent presentations with head lice, continuing until shortly before
her death.
“(These) were perhaps a missed opportunity as this is often an indicator of possible
neglect”.
7.6.6 There were practical difficulties:
“Unfortunately there was no informed global family assessment and this would have
been very helpful. As the whole extended family (was)… also registered across Kent
this fragmentation does not allow any full cohesive analysis of this vulnerable family”
This “fragmented” approach, and consequent flawed assessments, are key factors in
understanding the failure of agencies to grasp the substantial, cumulative evidence
of indications of child sexual abuse.
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7.7 Maidstone and Tunbridge Wells NHS Trust
7.7.1 This report deals with hospital services provided to Amy and her family. Amy
had one direct contact with Maidstone Hospital following a minor accident when she
was four. Other members of her immediate family had treatment throughout the
period under review for a range of conditions, including serious illness. Amy died at
Maidstone Hospital and the report describes the circumstances of her death.
7.7.2 The IMR raises the issue of the effects on front-line staff of child deaths or
serious injury. In this case those effects will have been aggravated by comments
made by Mrs Singleton, who spoke to a nurse about the sexual abuse of Amy. The
report appropriately makes a recommendation about the need for staff in such
critical situations to have time and support which enable them to reflect on the
events with which they have had to deal. There are no other matters arising for this
agency to be considered in this Overview Report.
7.8 Kent and Medway NHS and Social Care Partnership Trust
7.8.1 This agency (KMPT) was involved only after Amy died. The family GP referred a
sibling for assistance in coping with Amy’s death. The referral was made in late
October and prompted a series of attempts to elicit more information and gain
written confirmation that the GP’s referral had been made with parental consent.
There was no response from the family and, in January, the GP, concerned that the
situation had deteriorated, made a further referral.
7.8.2 Amy’s sibling was eventually seen once in February, as a result of which it was
decided that there was no need for secondary mental health support but a referral
was made for bereavement counselling. The report comments that
“Feelings of significant loss are a natural response following sudden unexpected
death. It does not necessarily mean that there is a need for secondary mental health
involvement”
7.9 Kent Youth Offending Service
7.9.1 Kent YOS contributed to this review as a result of their involvement with
members of Amy’s extended family. The review appropriately focuses on the detail
and outcomes of their work in relation to one young person’s criminality and finds
“much to commend the work for in terms of the focus on both meeting needs and on
reducing the risk of reoffending”
7.9.2 However, the most striking issue for the purposes of this review is that the YOS
was apparently entirely unaware of allegations that he had sexually abused Amy in
2008. They remained ignorant of this until their involvement in this Review. Although
the events preceded their involvement it is of concern that routine checks with
partner agencies did not bring this to light.
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7.9.3 This concern is aggravated by the fact the YOS did understand from March
2009, as a result of routine checks in December 2008, that there had been other
allegations of sexual abuse within his family by this young person. This was not taken
into account in any of the work undertaken by the YOS. Even when there was liaison,
agencies did not share this important information:
“There was no discussion of this risk when there was liaison between YOS and
Children’s Social Services which occurred in September 2009 at the point when he
became homeless”.
7.9.4 The consequences of this for the YOS’ work will be considered as part of a
separate management review but, for the purposes of this review, it raises again a
persistent concern about the quality and reliability of information – sharing between
agencies. This is aggravated by the account of the agency’s understanding that their
relationship was effective:
“In addition to the Case Manager contact there was regular informal contact
between YOS and CSS which was described as positive by the Practice Supervisor and
Team Manager. They felt that the relationship between YOS and CSS allowed the
teams to discuss young people and their families, and through doing so to identify
solutions to issues or to share information that might assist in service delivery. Both
YOS and CSS are based in the same building and would frequently have discussions
about young people”.
7.9.5 The agencies need to review their arrangements for liaising with each other
and sharing information, as the allegations should certainly have been the subject of
further discussion between them. A number of recommendations from the IMR seek
to address this.
7.10 Kent Probation
7.10.1 This report relates solely to a member of Amy’s extended family who was
convicted of “engaging in sexual activity with a child”. He minimised the seriousness
of this and sought to blame the child involved. The report then provides evidence of
his disregard for the requirements of his release on License and his status as a
convicted sexual offender. Within a short time of his release from custody he was
known to have been living at addresses where children were also resident. He also
failed to notify this Offender Manager of various changes in his circumstances. The
report does not include any information about Amy but it adds to the cumulative
concerns about sexual abuse running through this family.
7.11 Housing Provider
7.11.1 This agency is not named in order to protect the anonymity of the family. It
was the landlord for the Singleton family. It dealt with neighbour disputes involving
the family and staff were aware of neighbours’ concerns that Amy was being
mistreated. These allegations were apparently passed to them by Amy’s school (who
did not pass them to the appropriate agency, SCS). The Housing Provider accepts
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that they should also have approached SCS about this. There are no other matters
arising from the information supplied by this organisation.
7.12 South East Coast Ambulance Service NHS Foundation Trust
7.12.1 For the purposes of this Review this Trust was significantly involved only on
the occasion of Amy’s death. The Trust gave appropriate advice and attended
without delay. There are no matters arising for this agency which concludes that
“At the time of Amy’s death, SECAmb provided a very rapid response to the 999 call
and all possible advanced life support interventions were undertaken, sadly without
success”
7.13 KCA Drug and Alcohol Services
8.13.1 This agency was involved with a member of Amy’s extended family. No
matters relevant to this review arise from that contact.
7.14 Health Overview Report
7.14.1 The Health Overview report considers the submissions made by all the NHS
agencies involved in this review. It largely echoes the findings of those reviews and
those contained within this report. However the report does not identify any issues
relevant to the commissioning of health services. This is its principal purpose.
7.14.2 This does reflect a wider, national issue about how Health Overview reports
might best contribute to the SCR process. New (draft) guidance does not clarify this.
It may be that in future the LSCB and health commissioners will decide whether
there should be a specific report of this nature. In this case there is a
recommendation that the LSCB and health commissioners produce a brief guidance
note so that if such reports are commissioned in future authors will have clear
expectations as to their purpose and expected contents.
8. ISSUES IDENTIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW
8.1 What were the facts in this case?
8.1.1 The factual content of the IMRs and chronologies has been drawn together and
summarised in Section 5 of this report. This has been accepted by all the agencies as,
for the purposes of this review, an accurate description of the events leading to the
death of Amy Singleton and the involvement of the participating agencies with Amy
and her family.
8.2 Did agencies listen to the “voice of the child”? Did agencies know what life
was like for Amy?
8.2.1 There is substantial evidence, across the agencies, that Amy herself was not
given an adequate priority in their responses to the various issues which raised
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concern. Professionals did feel for her and tried to support her. Overall though, the
requirement to understand her individual circumstances, and respond appropriately
was not given sufficient weight.
8.2.2 The agency with the greatest direct involvement with Amy, as would be
expected, was her school. The IMR recognises that
“Schools have day to involvement with children and through this are probably best
placed amongst all professionals to identify and act upon any concerns about
children”
8.2.3 In Amy’s case the school identified her particular educational needs quickly and
responded appropriately. They
“had prepared an individual education plan (IEP) within two months of her
commencing school”.
This was followed by continuing support through a School Action 10 programme. The
school also recognised, to some extent, her broader social and emotional needs:
they were aware of
“Amy’s needs as a sad isolated and vulnerable child, who sometimes sought adult
attention inappropriately”.
Consequently arrangements were made for her to be involved in therapeutic play at
school. This confirmed a
“need to be nurtured and a wish to do more “girly” things”.
8.2.4 The IMR concludes that
“Amy felt sufficiently trusting to express her worries and concerns to a range of
adults in school”.
However, the concerns for Amy were not seen by the school as particularly unusual:
“The school responded to what they were seeing - a sad child, with a difficult home
life – in this way not unlike other children in the school”.
This Review has demonstrated that Amy’s experience was probably very different to
the home lives of other children in the school.
8.2.5 The report from SCS is more straightforward in accepting that
“assessments…did not fully consider the context of her life or attempt to understand
her family fully. The children’s voices were not heard, or sought and therefore their
view and understanding of their life was unheard”.
This report also highlights the way in which agencies redefined the issues that they
were considering. After the 2009 assessment the family’s financial situation became
a leading concern, although their poverty and its consequences were accepted at
face value – there was no recorded attempt to explore how the family spent its
money. Amy’s school had offered financial assistance to enable Amy to participate in
extra-curricular activities and to arrange for her to have free school meals, all of
which was refused by Mr Singleton.
8.2.6 Police visiting the home on the night of her death also found that
10
This is the initial stage of the statutory arrangements for supporting children with Special
Educational Needs.
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“the living conditions were far below the standard (one) would expect for a family
with young children…the house was very untidy and very dirty and had clearly not
been cleaned for quite some time. The children’s beds had sufficient bedding on them
but again, the bedding was very dirty and had obviously not been washed for a
number of weeks”.
8.2.7 The possible significance of Amy’s behaviour with adults was not recognised.
The GP IMR notes that
“Once under the Community Paediatric team it was clear that Amy was showing
recurrent “stranger danger (and) lack of awareness and cuddling people she hardly
knew inappropriately”.
This could be an indicator of familiarity with adult sexualised behaviour, or the
craving for attention of a neglected child or both.
8.2.8 Little is known about Amy’s relationship with her mother and, equally, there is
little information about Mrs Singleton herself. There is evidence that she was
struggling with illness, her husband had had major surgery and the family’s financial
circumstances were difficult. She was unemployed for some time during the period
under review. Before that her work would have required her to be away from home
for long spells during the day and evening. Mrs Singleton largely co-operated with
the school’s attempts to assist Amy but did miss a number of TAC meetings. She was
aware of at least some of the evidence suggestive of child sexual abuse within her
family. In May 2011 she indicated to the TAC meeting a knowledge of some sort of
inappropriate behaviour involving Amy. This failed to arouse any professional
curiosity or prompt any further investigation, but equally there is no indication of her
taking action to protect her daughter.
8.2.9 Mr Singleton seems to have been the dominant figure in the household and
there is evidence that his aggression towards agencies may have intimidated them.
The school preferred to communicate with Mrs Singleton. He was consistently
hostile to SCS, threatening violence to any social worker who visited him after Amy’s
death. We know little about his relationship with Amy.
8.2.10 There are strong indications of both neglect and sexual abuse of Amy and a
number of allegations of child sexual abuse across her extended family, which might
explain her presentation. Her presentation may have been “normalised” by her
school, where she was said to be not significantly different from other needy
children. It was not identified by SCS in their contacts with her. There appears to
have been a reluctance to recognise that abuse, and particularly sexual abuse, might
provide an explanation for Amy’s presentation. A range of organisational pressures
and individual weaknesses contributed to that and also affected the one joint
investigation with police. All the agencies involved with this family could have done
more to protect her.
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8.3 Were Amy’s needs appropriately assessed, with particular reference to the
consequences of sexual abuse and neglect?
8.3.1 Amy’s ADHD was identified, assessed and treated appropriately. The
Designated Doctor for Child Protection, who was a member of the Review panel,
confirmed that national (NICE) guidelines were followed and appropriate medication
was given. There was, of course, a perverse consequence of this diagnosis – all her
difficulties could be attributed to this condition, both by family members who might
wish to avoid investigation of other causes, and by professionals who might also,
perhaps unintentionally, be seeking to avoid the possibility of other factors. It is clear
that, whether through failure to keep adequate records, read records fully or
because professionals genuinely did not have access to the information, the alleged
sexual abuse of Amy was not fully taken into account in assessing and responding to
her needs. Moreover, as the Education IMR notes,
“the diagnosis of ADHD may have contributed to some professionals identifying
concerns for Amy rather than considering fully the wider family and environmental
issues”.
8.3.2 Amy’s needs as a child who had probably suffered sexual abuse and neglect
were never adequately assessed. The only formal agency response to concerns of
sexual abuse was the action taken following Mr Singleton’s allegations, in 2008. This
led to a police investigation but SCS were not involved in that investigation and took
no subsequent action to assess what Amy’s and her family’s support needs might be.
At this time there was already knowledge “in the system” of allegations of historical
abuse involving various members of the extended family. A comprehensive
assessment should have pulled together this accumulating evidence to identify all
the indications of sexual abuse and inappropriate sexual activity across this extended
family.
8.3.3 Agencies received four allegations of neglect and inappropriate treatment of
Amy from neighbours. There was never a formal assessment by SCS. The most
substantial response to any of these allegations was the action taken in 2009 in
response to a neighbour reporting a range of concerns - neglect, physical, and
emotional abuse and the use of sexualised language and access to inappropriate
magazines by Amy. This was recorded as a child protection referral but was not then
followed up as such – there should have been a strategy discussion and a timely
multi-agency response. Instead there was a single agency response from SCS, three
weeks later, consisting of one visit by appointment, following which the only issue
followed up was the family’s assertion that they were living in poverty. The child
protection aspects of the referral were either neglected or avoided. As the SCS IMR
suggests this suggests a “neglect case mindset” 11 - where acceptance that there may
be neglect serves to move any analysis away from considering that a child might also
be physically and / or sexually harmed.
11
Brandon M, et al, (2009) Understanding Serious Case Reviews and their Impact, DCSF
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8.3.4 Amy and her family were engaged, at the time of her death, in a CAF process.
As described above, these are national arrangements for helping children who have
needs additional to those being met through universal services. The CAF is not an
appropriate way of tackling the issues of neglect and sexual abuse which feature
prominently in this case. An informed appraisal of Amy’s circumstances at this time
against the authority’s guidance 12 would have indicated that Amy’s experience
required the need for the direct involvement of SCS, through child protection, or, at
least initially, child in need arrangements. Given Mr Singleton’s hostility to SCS, it is
unlikely that he would have co-operated with child in need provision, so that the
case would probably then have been escalated to Tier 4, the threshold for
implementation of child protection arrangements. There is an indication in the IMR
that the school took this into account in deciding that Tier 2 represented the
appropriate level of concern:
“They also had considered the revised Threshold and Eligibility criteria …and did not
feel that the criteria for a Tier 4 child protection referral were met whilst
acknowledging that Tier 3 services would require parental consent – which would not
be given”.
Anticipating parental opposition should be an aggravating feature, leading to
escalation of intervention rather than to the school stepping down their approach.
8.3.5 The use of CAF does indicate the recognition, principally at school, that Amy
did have additional needs, building on the early action to support her educational
special needs. The initiation of the CAF was delayed by six months as a consequence
of Mr Singleton’s professed hostility to SCS and the school’s lack of challenge to that.
That lack of challenge raises questions about the school’s own relationship with SCS
– collusion with Mr Singleton’s judgment effectively endorsed it and suggested that
the school did not view it as entirely unreasonable.
8.3.6 In any event the CAF process became the main opportunity for the
professionals involved to work together and develop interventions to support Amy.
The agencies formed a Team Around the Child (TAC). That TAC had met three times
before Amy died. Collaboration from Amy’s parents had been patchy. Mr Singleton
had not attended any meetings. Mrs Singleton attended the first two. A number of
meetings were cancelled because the parents sent apologies. The range and
combination of services which the agencies sought to put in place to help Amy build
resilience and self-esteem was impressive. KCHT judge that
“The CAF process in itself was thorough and highlighted many issues”.
8.3.7 The difficulty is that these services were all predicated on the assumption that
a CAF intervention was appropriate. This was reviewed by the Head Teacher and the
SENCO after the third TAC meeting and they concluded that this was still the correct
method and level of intervention. To some extent this is understandable – the
threshold guidance is in some respects equivocal about levels of intervention and
about which factors lead to which conclusions. But there was enough knowledge in
the system, if it had been properly researched, to reveal that there had been
12
Threshold criteria.pdf
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multiple concerns about sexual abuse in the family. Police had discussed this with
the Head Teacher during their investigation in 2008. There was also knowledge of
anxiety in the community about Amy’s general welfare.
8.3.8 It is disappointing that the Head consulted twice with the education service’s
child protection adviser for the school but this did not lead to action to escalate the
agencies’ approach. These were general discussions, not supported by a search of
what was known to the various agencies. Yet the fact that there were two such
consultations reflects the underlying unease about Amy.
8.3.9 The Education IMR reminds us of the increasingly difficult position of Head
Teachers:
The issue of supervision and support of Head Teachers in dealing with pastoral care
and welfare issues…may become more of an issue as schools and Head Teachers
become increasingly autonomous (and possibly isolated). Senior staff in schools often
perceive themselves as having increased responsibility for welfare issues and
managing risk but feel that their support systems in this field are variable across the
county. In this case the support and advice from the ACOCP was found to be very
helpful but the ACOCP role is an advisory function with no line-management
responsibility”.
The support and advice from the ACOCP was effectively a false reassurance.
8.3.10 This combination of factors – a lack of shared knowledge about the
background of concern, the (false) reassurance afforded by applying the CAF
process, the lack of challenge to Mr Singleton’s resistance and the lack of confidence
the school felt in SCS – contributed to a failure in inter-agency working which meant
that the levels of risk and harm to Amy were under-estimated.
8.4 How were the outcomes of assessments used to inform practice and decision
making in relation to Amy? Were Amy and her family appropriately engaged and
involved by agencies?
8.4.1 As indicated above there was no appropriate assessment, perhaps the most
fundamental failing arising from this review. Even the ADHD assessment, which has
been judged to be medically sound, may not have been fully informed by knowledge
of previous alleged sexual abuse. The CAF assessment was certainly not adequately
informed by all the evidence which would cause concern for Amy.
8.4.2 Had there been a thorough assessment one would have expected that a lack of
engagement by the family would have featured prominently as a cause for concern.
That should have been considered in the light of Mr Singleton’s hostility to SCS and
the apparently perverse refusal to accept the school’s offers of funding extracurricular activities and free school meals.
8.4.3 Amy herself appeared to participate enthusiastically in any activity in which her
parents allowed her to take part. In terms of therapeutic and supportive measures
the most significant input was through the play therapist but she was also said to
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enjoy Brownies and other “normal” activities. Despite the problems in her family,
and her overall presentation, the agencies’ descriptions of her do not suggest that
they were seeing a child who was consistently unhappy – which may go some way
towards explaining the weaknesses in the overall response.
8.5 How far was Amy helped to cope with the adverse circumstances in her life,
particularly her sexual abuse?
8.5.1 The evidence submitted to this SCR suggests that the adverse circumstances in
Amy’s life were her special educational needs, her ADHD, emotional abuse and
neglect within her family and sexual abuse within her extended family.
8.5.2 There was an impressively swift and sustained effort to help Amy to meet the
challenges arising from her educational needs. Her ADHD was diagnosed early and
accurately, the prescribed treatment for the condition was appropriate and
compliance with that treatment was good. The agencies and professionals involved
in the CAF process tried hard to use those arrangements to support her – the
matters which may have served to weaken all these initiatives have been set out
above.
8.5.3 Emotional abuse and neglect were not sufficiently clearly identified. Her school
recognised that she was needy and did a great deal to support her, in the face of a
lack of consistent co-operation from her family. Those efforts were undermined by a
failure across the agencies to recognise the nature and extent of emotional abuse
and neglect, evidenced in her presentation, the referrals by neighbours and the ways
in which her parents responded to attempts to assist her.
8.5.4 There is compelling evidence to suggest that Amy was sexually abused by one
or more members of her extended family, and there is further evidence of sexual
offences against children and inappropriate sexual activity across that extended
family. The most clearly evidenced sexual abuse of Amy was when she was six or
seven years old. There was a disjointed approach to the assessment of that concern,
with no adequate input from SCS. Amy was offered no specialist help targeted at the
consequences of that experience. Her GP was not made aware of it. Her school were
not adequately informed about what had happened and consequently were not in a
position to offer targeted support. There is no evidence that her family provided
continuing support. From the evidence we have seen she was very much alone.
8.6 Did assessments and services take sufficient account of the family’s race,
culture, language, and religious needs, and any disability needs?
8.6.1 Amy’s ethnicity was white British and there does not appear to be any racial
diversity in the family. This would not be unusual in the area in which the family
lived. When she died her mother declined any religious support and there is no
indication of any family member having religious beliefs.
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8.6.2 The potential significance of ill health and disability in the family is widely
recognised by the agencies. There is evidence that Mr Singleton had an active
lifestyle before suffering a life-altering condition. One of the IMRs suggests that this
may have led some professionals to be over-tolerant of difficult and aggressive
behaviour from him. His wife had a number of medical conditions and had
undergone a surgical procedure the day before Amy’s death. An exclusive focus on
Amy’s ADHD may have contributed to the failure of agencies to conduct a more
comprehensive assessment.
8.7 Were Kent Safeguarding Children Board and individual agency procedures
followed?
8.7.1 There is evidence of non-compliance with child protection procedures across
the agencies. The extent of this non-compliance ranged from the failure by SCS to
ensure that they were appropriately involved in the 2008 investigation of sexual
abuse of Amy, to failures by the police and the school fully to record all that they had
done during that investigation.
8.7.2 Non-compliance with procedures is a “dry” judgment. The important issue for a
review like this is to identify the factors behind that failure. They range from
individual lack of thoroughness to a number of systemic weaknesses. There are clear
indications of an unsatisfactory working relationship between school and SCS, which
is likely to have contributed to the poor communications evidenced here. The police
were over-tolerant of the failure by SCS to become fully involved in the investigation
of sexual abuse of Amy – possibly indicating that they had low expectations of SCS
input into investigations. If the ADHD team were aware of the issues relating to
sexual abuse they did not make a record of them. The YOS was unaware, throughout
their extended contact with a young person, that he had been the subject of an
investigation into alleged sexual abuse of Amy. The paediatrician who saw Amy in
2009 and referred her to the ADHD service did not pass on the information that she
had been sexually abused and, in interview, suggested that the responsibility to do
so was still not fully understood.
9. ISSUES ARISING FROM AN OVERVIEW OF THE CASE
9.1 Good practice and service improvements
9.1.1 SCS have detailed a number of fundamental changes to service arrangements.
These largely arise from the wider task of improving services in response to Ofsted’s
judgment in 2010 that the overall effectiveness of Kent’s safeguarding services was
inadequate. They are significant to the issues arising from this case review. The
supervision of staff has been overhauled to become more reflective, supporting staff
in considering “what life is like” for the children with whom they are working. More
work is being done to ensure that children are directly involved in assessments. The
management and oversight of assessments has been improved and supported by
more helpful, analytical performance data. The co-ordination of CAFs has been
specifically targeted for improvement with new staffing resources within SCS. Overall
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the authority is committed to changing organisational culture, so that learning and
service improvements are prioritised and supported.
9.1.2 The school mentioned in this review demonstrated a clear commitment to Amy
and worked hard to lead the establishment of arrangements to support her and
promote her development and learning. The individual commitment of key staff is
clear and the plans made under the CAF arrangements provided a broad range of
initiatives designed to support Amy and promote her education and development.
9.1.3 The clinical assessment, diagnosis and treatment of Amy’s ADHD were
thorough. This was in part a consequence of very early intervention from the GPs.
9.2 The circumstances of Amy’s death
9.2.1 It is not the purpose of SCRs to identify the cause of death. That task falls to the
Coroner who has returned an open verdict and commented that
"I am satisfied there is no suggestion it was (Amy’s) intention to take her own life”.
9.2.2 We do know that suicide and suicidal ideation are common among children
who have been mistreated and are at risk of continuing mistreatment. These
children often have many different problems and are unable to form good
relationships with peers or others to help them build resilience. Being suicidal is
essentially about the intent to cause self-injury or death, regardless of the cognitive
ability to understand finality, lethality, or outcomes more generally.
9.2.3 A number of aspects of the circumstances of Amy’s death are not suggestive of
suicide. Suicide is often preceded by self destructive behaviour and repeated selfharming, of which there is no evidence here. Similarly there is no evidence of Amy
having researched suicide on the internet, again a factor often associated with
suicide. There have been media reports of incidents of children who have allegedly
committed suicide as a result of persistent bullying at school and, although she was
said not to make friends easily, there is no evidence of Amy being bullied.
9.2.4 The Panel heard that there had been some discussion about whether Amy had
been experimenting with something called the “choking game” where people get a
“high” by holding their breath or using a ligature around the neck. The Education
IMR confirms that there was an incident of this nature in Kent during 2011.
Information about this was subsequently sent to all Kent schools. We do not know
whether Amy was aware of the “choking game”. There is no evidence to link this
with her death.
9.2.5 We cannot tell what was in Amy’s mind when she died. The evidence from this
Review suggests that agencies did not give adequate weight to the impact of abuse,
and may have underestimated how unhappy she was. However there is no evidence
that she ever had suicidal ideas or plans. Nor is there evidence of extreme distress or
recklessness. Agencies could not have been expected to take the eventuality of her
tragic death into consideration in their work with Amy.
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10. REVIEW PROCESS
10.1 The Panel needed to spend some time determining the scope of this review, so
that it adopted the most efficient way of considering the issues leading to Amy’s
death, while also ensuring that wider concerns were addressed. Once that had been
resolved the process of this Review has been satisfactory. There has been full cooperation from all agencies and all timescale targets have been met. As described
above, there has been no family input but that was perhaps understandable, in all
the circumstances. The Panel was satisfied that nothing further could have been
done about this.
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11. CONCLUSIONS: KEY LEARNING POINTS AND MISSED OPPORTUNITIES
11.1 There was a lack of awareness across the agencies of the nature and prevalence
of sexual abuse. When Amy was known to have been abused, the alleged
perpetrator suggested that the allegations against him could be attributed to Amy
having access to pornography. In the unlikely event that this was true, it would in
itself have been the cause of harm. In the context of this family it was highly
suggestive of more extensive and damaging abuse. There was an equally improbable
acceptance that this was an isolated event, when a thorough consideration of agency
records would have identified the numerous concerns about inappropriate and
illegal sexual conduct across the extended family.
11.2 Where there was knowledge of abuse, there was a limited understanding of its
potential consequences for those involved. An over emphasis on disclosure or
physical / forensic evidence, and a lack of confidence in challenging the denial of
abuse, left Amy at continuing risk.
11.3 There was a failure not only to draw together a composite picture of the
concerns felt about the family but also to appreciate the cumulative consequences
of neglect and abuse. Where broader safeguarding concerns were raised – four
times by neighbours directly, as well as three written expressions of concern and the
issue of alleged sexual abuse of Amy – there is no evidence that staff looked back, to
understand the history of the family’s contact with child protection services. This has
been recognised by a number of the agencies which have made recommendations
about systematic use of chronologies when assessing and working with families.
11.4 None of the agencies involved with her identified and responded appropriately
to the isolated position of Amy within her family. The school were unable to build an
effective working relationship with the father so worked almost exclusively with
Amy’s mother. They did not challenge parental behaviour such as delaying the
implementation of the CAF, and refusing free school meals for Amy, while
complaining of the family’s poverty. Her father’s antipathy to social workers was
accepted at face value and went unchallenged.
11.5 There is almost no evidence of agencies working together to assess and deal
with child protection concerns. SCS were not involved in the most clearly evidenced
allegation of sexual abuse. Neither they nor police should have allowed the
investigation to proceed on that basis. For most of the investigations which were
carried out, the evidence of agency checks and subsequent feedback is minimal.
11.6 There were a number of organisational and resource issues. The SCS IMR notes
that
“There appeared a general lack of management oversight or supervision in any of the
interventions prior to Amy’s death”.
That report also identifies management practice which is even more concerning than
a failure to supervise, referring to a manager who
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“appeared to attribute much of the responsibility (for unacceptable delay) to other
team members”.
11.7 There was a great deal of information about this extended family in agency
records. None of the agencies’ investigations and assessments were fully informed
by the information they held. Even during the course of this Review it has become
clear that agencies had been working with family members without being aware of
important information. The introduction of a new computer system had been
extremely problematic for SCS, although it is not clear that there were specific
consequences for the management of this case. It is acknowledged that there are
real challenges in drawing together relevant information from health records held, in
this case, by five GP practices and numerous other healthcare providers. However,
while acknowledging that some records may not have been kept or accessed, the
more significant problem was the failure to take account of what was known about
the family. This was a practice issue, not a technological challenge.
11.8 The prioritisation of referrals by SCS, and the thresholds applied, were based on
immediate risk. There is little evidence of arrangements which promote the capacity
of staff to deal with abuse which is not directly evidenced. Police similarly could have
taken a broader view and researched historical information more thoroughly to
inform their decision-making.
11.9 A number of agencies have expressed their optimism about the improved
management of future cases as a result of the establishment of the multi-agency
Central Referral Unit (CRU). They may well be right but this is a service for receiving
new referrals. Its introduction will not necessarily address issues arising in cases
where there is already continuing involvement. The Panel pointed out that this
provision will also not be dealing with children with disabilities or unaccompanied
asylum seekers, both widely evidenced as particularly vulnerable groups.
11.10 In some ways the CAF process served to redefine and contain the problem of
Amy’s continuing unhappiness rather than bring its causes to light. The agencies
have not yet developed arrangements for evaluating the quality of CAF interventions
and this review demonstrated a looseness in the interpretation of guidance on
thresholds.
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12. RECOMMENDATIONS MADE IN THE MANAGEMENT REVIEWS OF THE
PARTICIPATING AGENCIES
12.1 Introduction
13.1.1 This section of the report details the recommendations made by agencies, in
so far as they relate to the issues considered in this Review. Some agencies have
made recommendations which relate to wider concerns and members of the
extended family. As explained above, those matters are being followed up in
separate processes.
12.2 Kent County Council, Specialist Children’s Services
12.2.1 Specialist Children’s Services should ensure that there is consistent use of
chronologies in accordance with procedures.
12.2.2 Specialist Children’s Services should ensure that there is a continued
improvement in the quality of analysis contained in social work assessments.
12.2.3 Specialist Children’s Services should raise awareness of the recognition,
assessment and complexities of sexual abuse.
12.2.4 Specialist Children’s Services should raise awareness of the challenges and
approaches when working with hostile and resistant families.
12.2.5 Specialist Children’s Services should ensure that social work staff have a
greater understanding of the complexities of working with neglect.
12.3 Kent County Council, Education, Learning and Skills
12.3.1 Amy’s Primary School should be reminded of the importance of
maintaining accurate written records of any contact with statutory agencies such
as the Police and Children’s Social Services.
12.3.2 A more pro-active stance in following up concerns with other agencies should
also be addressed as part of the learning for the schools involved in this case.
12.3.3 Where there is parental refusal to consent to a CAF or significant delay
then schools and those advising them need to be reminded of the advice
contained in the Thresholds and Eligibility Criteria March 2011 to consider the
impact of this on the child and whether a consultation with or referral to CSS is
required.
12.4 Kent Police
12.4.1 When an allegation of familial sexual abuse has been made against a child,
consideration should always be given to establishing whether there has been similar
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abuse committed toward siblings or other children within the extended family.
Where appropriate, an assessment of risk should be conducted in relation to those
children.
12.4.2 The introduction of the Central Referral Unit (CRU) should improve the joint
response of both the Police and Social Services Department to incidents reported
during ‘out of hours periods’. Once the CRU has been properly established, it should
be the subject of a post implementation review, and this anticipated improvement in
‘out of hours’ activity should be tested.
12.4.3 Officers working within Child Protection should be reminded that decisions
made following the report of alleged child abuse or neglect must not only be
recorded, but the reason for making those decisions should be made clear.
12.4.4 When a child is alleged to be the perpetrator of a sexual offence, this may be
indicative of that child also being the victim of abuse. In such cases, information
should be shared with Children’s Services and decisions then made as to whether
any additional safeguarding activity is required.
12.5 Kent Community Health NHS Trust
12.5.1 Where a history of possible sexual (or any) abuse is shared there must be a
written record of how this is considered, managed and informs the assessments of
the child.
12.5.2 In situations where the family details are complicated or when understanding
the family make up is necessary a genogram should be completed and kept in a
prominent position in the records.
12.5.3 All staff should be reminded of their responsibility to keep accurate records
which reflect communication and decisions in the assessment processes.
12.5.4 A genogram is beneficial and should support an assessment of the likely
impact of bereavement, or any loss of a significant person, on a child or young
person.
12.5.5 The child should be at the centre of all assessments and the ‘voice of the
child’ heard and not be lost in the chaos of family dysfunction and issues.
12.5.6 Non engagement and low levels of compliance should be assessed in relation
to the impact of those behaviours on the child.
12.6 Kent and Medway NHS and Social Care Partnership Trust
12.6.1 Review Screening process of all referrals to Child and Adolescent Mental
Health services (CAMHS) Tier 3.
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12.7 Maidstone and Tunbridge Wells NHS Trust
12.7.1 The Trust should ensure with immediate effect that safeguarding supervision
is offered to staff in Accident and Emergency Departments.
12.8 General Practitioners
12.8.1 Safeguarding training of the primary care teams involved to take place so as
to be fully compliant with forthcoming CQC requirements.
12.8.2 Safeguarding training to address the need to communicate with all agencies
and with other GP practices where the family is fragmented and registered with
multiple practices.
12.9 Health Overview Report
12.9.1 This report details the recommendations from the health agencies involved in
the review but makes no further recommendations.
12.10 Kent Youth Offending Service
12.10.1 Kent YOS should review the present practice guidance (August 2011) for
both YOS and SCS staff to ensure that it supports effective joint work with children /
young people and their families where there is a shared case responsibility.
12.10.2 Kent YOS and SCS should evaluate the costs and benefits of seconding SCS
Social Workers into YOS teams.
12.10.3 Ensure that staff within both SCS and YOS can, as appropriate to role and
responsibilities, access the electronic case records used by both services.
12.10.4 Kent YOS should ensure that all assessments and plans produced by YOS are
quality assured and counter-signed by Practice Supervisors and Team Managers in
line with YOS procedures.
12.10.5 Kent YOS should ensure Team Managers and Practice Supervisors include
within supervision the opportunity for reflective practice as required by the YOS Staff
Supervision Policy.
12.11 Kent Probation
12.11.1 When supervising offenders and, on receipt of information regarding
convicted sexual offenders residing in accommodation with children, consideration
must be given by Offender Managers to making a referral to Children’s Social
Services in order to safeguard the welfare of children.
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12.11.2 Offender Managers must identify full family composition when working with
offenders, ensuring a holistic assessment of the individual in order to identify at an
early stage whether there are any potential safeguarding issues.
12.12 Housing provider
12.12.1 The housing provider should ensure that any information received relating to
potential safeguarding concerns is passed to appropriate agencies, i.e. Police or SCS,
even when it is believed that the agency is already aware.
12.12.2 The housing provider’s safeguarding procedures should ensure that staff in
the agency participate fully in all aspects of local interagency arrangements for
safeguarding.
12.12.3 The housing provider should take steps to improve the accessibility and
accuracy of available information that is relevant to safeguarding.
12.13 South East Coast Ambulance Service NHS Foundation Trust
12.13.1 No recommendations
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13. RECOMMENDATIONS FROM THIS OVERVIEW REPORT
13.1 Introduction
13.1.1 These recommendations arise from this Overview Report which reflects the
views of the SCR Panel and the independent Overview Report author. They have
been endorsed by the KSCB. Where they are particularly significant they may overlap
with the recommendations, set out above, made by individual agencies. They are in
line with the Government’s guidance 13 that Serious Case Reviews should
“focus on a small number of key areas with specific and achievable proposals for
change”.
13.1.2 In this case those “key areas” relate largely to fundamental safeguarding
practice. This was not a review where the principal lessons to be learned are new,
complex or intricate. Some of the recommendations necessarily arise from the
review and are detailed here even though the agencies have already taken action to
address those issues. There is one recommendation that relates to the process of
any future Serious Case Reviews.
13.2 Recommendations to the Kent Safeguarding Children Board
13.2.1 The Board should, with reference to the findings of this review, ensure that
there are satisfactory, multi-agency arrangements for
a) recognising and responding to cases of sexual abuse within families
b) recognising and responding to cases of chronic neglect
and that agencies’ compliance with those arrangements is routinely monitored and
evaluated. This recommendation is not restricted to new referrals: agencies should
also address its implementation in their continuing work with families.
13.2.2 The Board should promote an emphasis on ensuring that the “voice of the
child” is heard across all partner agencies, that practice in this regard is evidenced
and monitored and that agencies are able to show how their policies and practices
are influenced by the children and families with whom they work.
13.2.3 The Board should, by dissemination of the lessons learned from this review,
emphasise to staff in all agencies the importance of ensuring that assessments are
informed by thorough research into any previous contacts between agencies and
families and that chronologies and reference to previous contact are routinely used
to inform assessments of risk.
13.2.4 The Board should ensure that there are clear arrangements for working with
hostile or resistant families, that front line staff are appropriately supported in this
work. The Board should regularly review arrangements in this area across all partner
agencies.
13
“Working Together” (2006) Paragraph 8.34
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13.2.5 The Board should review and strengthen as necessary
a) arrangements for sharing information within and between agencies about
children and young people who may be perpetrators of sexual abuse
b) arrangements for working directly with children and young people who may be
perpetrators of sexual abuse
13.2.6 The Board should satisfy itself that the implementation of the CAF is helpful in
leading to more purposeful interventions with children and their families and that
thresholds between non-intervention, the use of the CAF and referral to children’s
social care are well understood and consistently implemented.
13.2.7 The Board should seek to ensure that all schools have the necessary
safeguarding systems in place and to a good standard, and that the relationship
between schools and the local authority allows for the proper level of support and
challenge. The local authority should satisfy itself and the Board that the level of
input to schools is proportionate and appropriate.
13.2.8 The Board should liaise with commissioners of health services to produce a
brief guidance note so that, if Health Overview Reports are required in any future
SCR, authors will have clear expectations as to their purpose and expected contents.
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APPENDIX A: Biographical details of Independent Chair and Overview Report
Author
Independent Chair: Mr Keith Ibbetson
Keith Ibbetson began his career as a residential social worker in 1981 in Lambeth. For
the next 16 years he worked as a social worker and manager in children’s services in
Hertfordshire and London. Since 1997 he has worked as an independent consultant
in children’s services, specialising in child protection, quality improvement initiatives
and the development of preventative services. He has been involved in more than
thirty Serious Case Reviews and independent management reviews, as panel chair,
overview report writer and in implementing the findings of reviews.
Independent Author of Overview Report; Mr Kevin Harrington
Kevin Harrington trained in social work and social administration at the London
School of Economics. He worked in local government for 25 years in a range of social
care and general management positions. Since 2003 he has worked as an
independent consultant to health and social care agencies in the public, private and
voluntary sectors. He has a particular interest in Serious Case Reviews, in respect of
children and vulnerable adults, and has worked on more than 35 such reviews. Mr
Harrington is involved in professional regulatory work for the General Medical
Council and for the Nursing and Midwifery Council. He has served as a magistrate in
the criminal courts in East London for 15 years.
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APPENDIX B: References
Footnotes have been used to indicate specific quotations from or references to
research, practice guidance and other documentation. This Overview Report has
been generally informed by the following publications
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Working Together to Safeguard Children,(HM Government 2010)
The Victoria Climbie Inquiry (Lord Laming 2003)
The Protection of Children in England: A Progress Report ( Lord Laming
2009)
The Annual Report of Her Majesty’s Chief Inspector of Education,
Children’s Services and Skills 2007/08
Safeguarding London’s Children: Review of London Serious Case Reviews
First Annual Report (London SCB 2007)
Joint Area Review, Haringey Children’s Services Authority Area Review of
services for children and young people, with particular reference to
safeguarding (2008)
Improving safeguarding practice, Study of Serious Case Reviews, 20012003 Wendy Rose & Julia Barnes DCSF 2008
Analysing child deaths and serious injury through abuse and neglect: what
can we learn – A biennial analysis of serious case reviews 2003-2005
Understanding Serious Case Reviews and their Impact - a Biennial Analysis
of Serious Case Reviews 2005-07 DCSF 2009
Developing an effective response to neglect & emotional harm, Gardner
2008
Child maltreatment in the United Kingdom: A study of the prevalence of
child abuse and neglect ( Cawson, Wattam, Brooker, Kelly November
2000)
Review of the involvement and action taken by Health Bodies in relation
to the case of Baby P ( Care Quality Commission (2009).
Learning together to safeguard children: developing a multiagency
systems approach for case reviews. ( SCIE 2009)
The Munro Review of Child Protection: Final Report (HMSO May 2011)
The Munro Review of Child Protection: Interim Report (HMSO February
2011)
Publication of Serious Case Review Overview Reports: Letter from
Parliamentary Under Secretary of State for Children and Families 10th
June 2010
ADHD - Quick Reference Guide (NICE 2008)
ADHD as a cultural construct (Timimi & Taylor, British Journal of
Psychiatry 2004)
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