The executive summary of the Serious Case Review report concerning the death of “Child T” (Alex Sutherland) is generally clearly written and provides sufficient information to see the basic facts of the case (http://www.manchesterscb.org.uk/prof-scr.asp ). But I began to get depressed when I reached the conclusions and recommendations.
The report casts the net of responsibility for the failings widely:
“The Panel considered that no single agency was responsible for failing to protect Child T from the chronic neglect which he suffered at the hands of his mother, but rather he was the victim of the multiple failures of all those agencies with whom he was involved (with the exception of GMP) to recognise the risks to which he was exposed and to take appropriate protective action.” (para 7.2, page 23).
The report then goes on to blame a combination of “single agency failings” and “generally poor inter-agency communication and collaborative working’, without engaging in any rigorous systematic analysis of the causes of the disaster. The result is a series of recommendations that seems to me unlikely to make any serious contribution to improving the safety of child protection services in Manchester or elsewhere. Two that struck me as being particularly weak were the following:
(For University Hospitals of South Manchester) “All patients attending the trust to be asked routinely about dependants that they are responsible for.”
(For Manchester Children’s Social Care) “Revise procedures to ensure social workers speak directly to family members as part of assessments.”
Resisting the temptation to fulminate - or even to wonder what people having in-growing toe nails removed in South Manchester will think when they are given the third degree about who are their nearest and dearest – I will swiftly move on to the crux of the issue which goes something like this.
Alex Sutherland suffered neglect as a result of his mother’s alcoholism. From the first involvement of statutory services to the last, it seems clear that the primary focus of all the agencies involved was concern for Alex’s care as a result of his mother’s drinking. Not only that but several referrals from members of the public also cited maternal drinking and consequent neglect. Yet having initially embarked on a child protection approach to Alex’s case, Manchester children’s services subsequently produced a Child in Need plan (instead of a Child Protection Plan) and then continued to work with Alex and his mother on the basis that he was a child in need but not in need of protection.
In view of what is known about Alex’s condition and the facts of the case, that decision – not to hold a child protection conference that would probably have resulted in a Child Protection Plan – seems to me to have been the crucial mistake. But it is not addressed in the Serious Case Review Executive Summary. Nor does it receive any attention in the press coverage.
Recognising this error is the beginning, not the end, of a proper analysis of what went wrong in this case. Bad decisions of this sort are not usually a matter of individual failings. They are normally the product a complex matrix of environmental, organisational and inter-organisational factors that result in individuals loosing situational awareness. One might speculate that staff and other resource shortages, and local and national procedures and policies, may have contributed to a climate in which an apparently clear case of child neglect was not treated as such. But it seems we shall never know.