BROOKE
THE EXECUTIVE SUMMARY OF A
SERIOUS CASE REVIEW
On behalf of the Kent Safeguarding Children Board
Serious Case Review Author
Richard Green, NSPCC
2008
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1. INTRODUCTION
1.1
This is the executive summary of the Serious Case Review (SCR) conducted by
Kent Safeguarding Children’s Board (KSCB) under Chapter 8 of Working
Together to Safeguard Children (2006).
1.2
The SCR was commissioned following the death of Brooke an infant girl who
died aged less than four weeks. Abuse is suspected to be a factor in this
death. She became seriously ill whilst in the sole care of her father. She was
taken by ambulance to a local hospital and then onto a second hospital in
London, where she was pronounced dead. Her father is currently on bail on
suspicion of murder.
1.3
The purpose of a SCR is defined in Working Together (2006) as being to:
 Establish whether there are lessons to be learned from the case about
the way in which local professionals and organisations work together to
safeguard and promote the welfare of children.
 Identify clearly what those lessons are, how they will be acted upon and
what is expected to be changed as a result.
 As a consequence improve inter-agency working and better safeguard
and promote the welfare of children.
1.4
In view of the nature of the incident, the Chair of the Kent Safeguarding
Children Board (KSCB) agreed that a serious case review should be
undertaken.
1.5
The details of the agencies contributing to the Review are set out at Appendix
A. The KSCB constituted a Panel to manage and oversee the conduct of the
review. The membership of the Panel is detailed at Appendix B. Mr Richard
Green was appointed to produce the Overview Report.
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2.
KEY FACTS
2.1
Brooke had two siblings, referred to as Andrew and Susan. Andrew was
removed from the care of Mr S (Brooke’s father) and his then partner after he
sustained extensive facial bruising deemed to be non-accidental injuries (NAIs). At
the time Mr S was subject to a referral order, supervised by the Kent Youth
Offending Service (KYOS) for a serious assault on a family member.
2.2
Following the removal of Andrew a fact finding hearing concluded that either
parent could have caused the injuries but they were not malicious in intent. Two
expert reports were filed; one focussed on the parents’ learning disabilities, the
other concluded that Mr S posed a risk of injury to children.
2.3
Both Mr S and his partner accepted cautions for charges of neglect; neither
parent was prosecuted on charges of physical assault following representations from
CAFCASS to the Crown Prosecution Service. Hazard warning flags were placed
against Mr S and his partner on CSS records. His maternal grandparents under the
terms of a Residence Order cared for Andrew.
2.4
Susan was born (to Mr S and his then partner) a few months after Andrew
was removed. She was joined to the care proceedings and initially placed with her
mother in a parent and child foster placement. There was a report of domestic
violence between Mr S and his partner and an allegation that he was having a sexual
relationship with a girl who was underage.
2.5
Susan’s mother was permitted to return home with Susan. Shortly afterwards
Mr S joined them, after which the home conditions were noted to have deteriorated,
and the parents to have disengaged from professionals. Some months later Susan
was seen by four professionals to have facial bruising. However, no child protection
enquiry was conducted into this and she remained in the family home for a further
two months, until a Residence Order was granted to her paternal grandparents.
2.6
Some years later Ms B fell pregnant by Mr S. She had been well known to CSS
as a child because of extensive concerns around intra-familial sexual abuse and
neglect, and had spent much of her childhood being looked after. She also had a very
troubled adolescence, having been depressed and taken an overdose at one point.
The GP records contained much of this information but were not accessed by health
staff.
2.7
The paternal grandparents (who cared for Susan) twice sought to alert
agencies that Ms B was pregnant by Mr S and of their concerns for the unborn baby.
The first time they alerted the health visitor but the information was not successfully
transmitted to CSS. The second time they notified Susan’s social worker direct but
she did not act on this information.
2.8
Further concerns were identified during labour. One example is when Mr S
was highly agitated and Ms B confided confidential information to the midwife (the
content of which is unknown as it was not shared). After Brooke’s birth further
information came to the attention of health staff about Ms B’s troubled background
and the fact that Mr S had a child who was cared for by his parents.
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2.9
Brooke died from injuries sustained whilst in her father’s care. She had a
fractured skull and various cranial bleeds. All were suggestive of non-accidental
injury (NAI). She also had a small bruise to her cheek.
2.10 There was some confusion as to whose permission was required to remove
Brooke’s body to the mortuary (caused by different police/coroner protocols in Kent
and London) and a lack of clear communication to Social Services out-of-hours
service. As a result Mr S’s hazard warning flag did not appear until a few hours after
Brooke’s death.
3.
CONCLUSIONS AND LEARNING POINTS
3.1
When the report of Andrew’s facial bruising was received, immediate and
appropriate action was taken to protect him. This included placement with his
maternal grandparents and the instigation of care proceedings. There was however a
lack of good liaison between KYOS and CSS.
3.2
Appropriate steps were taken to protect Susan before and after her birth,
including child protection registration and placing her in a parent and child foster
placement.
3.3
Both the fact finding (that the injuries to Andrew were not malicious) and the
criminal court ruling that Mr S and his partner should be cautioned for neglect only
were unhelpful, in framing this as a neglect case and minimising the risk of physical
injury. The issue of whether Susan was safe pending the final court hearing was not
adequately addressed; specifically the facial injuries should have prompted a child
protection enquiry and an urgent review of the care plan, but did not.
3.4
There was substantial evidence that any child of Mr S and Ms B would be at
high risk, the evidence being clearer in respect of Mr S (because of the injuries to
both children he had cared for) but also in respect of Ms B, an assessment in
childhood having predicted she would have enormous difficulties caring for a child.
3.5
There were two optimum opportunities to recognise the risk in relation to
Brooke and act upon it, when the paternal grandparents notified first the health
visitor and then the social worker of their concerns. The first was missed due to poor
information sharing, the second due to poor individual practice.
3.6
Risks to Brooke might also have been identified within health had the
community midwife accessed the GP records, and had a Concern and Vulnerability
Form been completed during the pregnancy (rather than after as was the case).
3.7
In the post-natal period after Brooke was born both the receipt of the
Concern and the Vulnerability Form and the subsequent identification of concerns by
the health visitor might have prompted the accessing of information on the GP
records, and possibly a referral to CSS.
3.8
Following Brooke’s death the situation was handled with considerable
sensitivity by hospital staff but there was some confusion and poor communication
between agencies. This led to delays in the police and CSS becoming aware of a
suspicious death and in removal of the body to the mortuary.
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3.9
The involvement of the paternal grandparents to this review was most
helpful; in future SCRs family involvement would be facilitated by the production of a
document explaining SCRs to them.
3.10 A number of factors, primarily but not exclusively relating to Mr S, meant that
it was highly predictable that Brooke would suffer physical abuse/neglect. Many
children are at high risk of physical abuse/neglect but only a fraction die as result of
this. Knowing exactly which will die is not possible due to the inherent
unpredictability of human nature. Whilst Brooke’s suffering physical abuse/neglect
was highly predictable, her dying as a consequence of this was not.
3.11 The identification of Mr S as the father and the extent of Ms B’s childhood
problems would certainly have led to a multi-agency pre-birth assessment and, in all
probability, care proceedings and action to protect Brooke as soon as she was born.
Had these connections been made Brooke’s death might well have been averted. A
number of opportunities to do this were missed within CSS and health agencies, and
it is a sad conclusion of this review that her death was preventable.
3.12 The case illustrates the vulnerability of infants to serious/fatal abuse. The
identification of vulnerable children in the ante-natal period is crucial. CSS had a
system to do this – the Hazard Warning Flag. The problem was not the system but
the failure of the social worker not acting upon the information given to her by the
PGF, and, on another occasion, by the health visitor not referring information given
to her by the PGF through the County Duty system.
3.13 This case also illustrates the role the ante- and post-natal health team needs
to play in conducting holistic assessments, of which safeguarding is one core
component. As in point 2 the problem is not the systems that seem to be in place
(clear expectations around accessing records, the Concern and Vulnerability Form)
but these not being implemented on the ground.
3.14 Important information was held in GP records about Ms B but the more
telling information about the father was not. There needs to be a review of how
information about adults who pose a risk to children is stored and shared across all
statutory agencies.
3.15 The response to the report of bruising to Andrew by a member of the public
is a model of how an inquiry should be undertaken, demonstrating the exercise of
sound professional judgment which led to a very positive outcome for him.
Conversely, when facial bruising was seen on Susan there was a striking failure to
instigate a child protection enquiry, this representing very poor judgment.
3.16 A specific feature of this case is that the risk to Susan – most notably the
facial bruising but also the domestic violence, deteriorating home conditions and
parental disengagement – took place when she was subject to an interim care order
pending a final court hearing. The care proceedings did eventually serve to safeguard
her but meanwhile she was placed at considerable risk. The learning point is that
children are not inherently safe by virtue of being subject to care proceedings and
that their immediate need for protection must be addressed.
3.17 This case demonstrates the importance of agencies discharging their
functions with regard to the safeguarding of children, as is now enshrined in
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legislation (section 11 Children Act, 2004). Neither KYOS nor CSS appear to have
appreciated the role the former might play in safeguarding the children, leading to
KYOS playing virtually no part in multi-agency forums and conducting an assessment
which overlooked Mr S’s conviction against a child.
3.18 Both parents’ reactions during labour point to considerable trauma and
stress. It is not uncommon for parental trauma/stress to manifest during labour and
it is thus crucial that the named midwife is consulted and that reporting procedures
are used.
3.19 This case illustrates the need to listen to non-professionals who ‘blow the
whistle’ as the paternal grandparents tried to do in this case.
3.20 The professional response following Brooke’s death was good in many
respects but would have been significantly improved by prompt communication of
child protection concerns to the police, senior medical management and clarity
between the two police forces, hospital and coroner as to the protocol to be
followed.
3.21 Finally, there were two court judgments in this case, one made within the
criminal court and the other in the family proceedings court, which seem unhelpful.
These seem to have contributed to an erroneous belief that this was a ‘neglect case’.
KSCB needs to explore ways of involving the judiciary in SCRs henceforth, at both a
local and national level.
4.
RECOMMENDATIONS FROM THE OVERVIEW REPORT
4.1
National recommendation
4.1.1 Government Departments to consider how to involve the judiciary, when
appropriate in Serious Case Reviews.
4.2
Kent Safeguarding Children Board
4.2.1 KSCB to revise the procedures that all new incidents of harm are to be
reported to the County Duty Team and that the implementation of these procedures
is regularly audited
4.2.2 KSCB to ensure that individual roles and responsibilities are understood in
respect of suspicious deaths and that assurance is provided that each agency is
competent in respect of responding to suspicious deaths.
4.2.3 KSCB to ensure that a multi-agency system of identifying and sharing
information about adults who pose a risk to children is implemented
4.2.4 KSCB to review multi- and single-agency training and ensure that the
following areas are included and their individual learning is evaluated for effective
implementation in practice.
a) The vulnerability of infants to serious/fatal abuse.
b) The fact that children are not inherently safe by virtue of being subject to care
proceedings.
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c) The importance of listening to non-professionals who raise concerns.
4.2.5 Review the procedures for communicating with Children’s Services/the Police
where there are concerns about children at risk of harm/neglect/abuse – and to
ensure that staff are equipped to implement the procedures through effective
training.
4.2.6 KSCB to discuss this through the local Family Justice Council
4.3
Kent Police
4.3.1 Specify in a policy what samples should be obtained from the child following
a suspicious death. The policy to be widely circulated and audited as to its
effectiveness
4.3.2 Specify in a policy what permission is required from the coroner in respect of
obtaining forensic samples. The policy to be widely circulated and audited as to its
effectiveness
4.3.3 Ensure that the practice of recording all actions and times is strictly adhered to.
4.4
Kings College
4.4.1 Develop, introduce and audit a policy for working in partnership with the
police. The policy to include what should be expected from the NHS for the Police
when responding to suspicious deaths; what the individual roles / responsibilities are
of the officers attending and lines of communication/ escalation
4.5
Kent and Medway NHS
4.5.1 When mothers are identified as being at risk of suffering from mental health
difficulties, an appropriate risk assessment must be made with a subsequent referral
to Primary Care and MIMHS for full assessment when this is indicated.
4.6
Kings College NHS
4.6.1 Ensure that legal advice is available to NHS staff 24/7 so that they are
supported in the relevant speciality.
4.7
Maidstone and Tunbridge Wells NHS
4.7.1 Audit the implementation of recommendation of a previous Serious Case
Review (2006) to include information about social circumstances and any previous
recorded concerns/risks at the time of ante-natal bookings. Where any risks are
identified by the midwife these should be included in the birth plan.
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APPENDIX A: Agencies contributing to SCR
AGENCY
NATURE OF CONTRIBUTION
Children’s Social Services (CSS)
IMR (Individual Management Review)
Kent Police
IMR
West Kent PCT
IMR
Kent Youth Offending Service
IMR
Local NHS Trust
IMR
Kent and Medway Social Care
Partnership Trust
IMR
London Metropolitan Police
IMR
Local hospital
IMR
Children’s Safeguards Unit (Education)
IMR
CAFCASS
IMR
South East Coast Ambulance Service
IMR
South East Thames Retrieval Service
IMR
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APPENDIX B : Constitution of SCR Panel
Designation
Organisation
Role on Panel
Business Manager
KSCB
Independent Chair
Designated Nurse
East Kent
Panel Member
Area Children’s Officer
Education
Panel Member
Detective Superintendent
Kent Police Public
Protection Unit
Panel Member
Lead GP for Child
Protection
East Kent
Panel Member
District Manager
Children’s Social
Services
Panel Member
Interim Service Manager
CAFCASS
Panel Member
Area Manager
Youth Offending
Service
Panel Member
Senior Probation Officer
Probation
Panel Member
Designated Doctor
East Kent
Panel Member
Acting Safeguarding Policy
and Performance Manager
Children’s Social
Services
Panel Member
Senior Consultant
NSPCC
Independent Overview
Report Author
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