The case of Paris Vince-Stephens, a sixteen-weeks old from Bristol who was killed by her father in 2013, is the subject of a Serious Case Review (SCR) report published last week.
The report makes clear that a considerable number of child protection concerns had never been addressed in this case, including the sexual exploitation of the mother by the much older father, when she was as young as 14, physical injuries to Paris’s older sibling, known serious drug abuse by both parents and a substantial history of domestic abuse.
The author of the serious case review report says that it is perplexing that this case was never seen as child protection, by children’s social care and by other agencies. Despite “clear evidence” of domestic abuse, substance misuse and physical abuse no agency seemed to have thought the children were suffering significant harm. She reports that she, the Internal Management Review authors and members of the SCR Panel all agree that this was a clear case of child abuse but they are at a loss to explain why the case was not seen as such. (Paragraph 3.2.1) She writes:
“Everything seemed to be minimised – the horrific domestic abuse, drug-taking and the injuries to the children, including the incident … when (the mother) said that (the father) had shaken (the older sibling)…. There seems to have been inertia amongst staff from other agencies, who were not reporting high levels of concern to social care, despite the high level of risk.” (Paragraph 3.2.3)
So at the heart of this tragic case there is an unsolved puzzle, a mystery: why in the face of apparently clear evidence of child abuse did nobody appear to recognise it or to act on it? And the serious case review provides no answer.
I do not blame anybody for not being able to find the causes of this tragedy. But I am puzzled why there is not more concern about the mystery. The BBC quotes the chairwoman of the Bristol Safeguarding Children Board as saying about the service failures: "every action has been taken to ensure that they do not reoccur". But how can this happen when we do not know what the causes of this comprehensive loss of situation awareness are? How can people in Bristol be putting things right when they still don’t know what went wrong?
When an airliner crashes in the deep ocean and the wreckage cannot be found (for example Malaysian Airlines Flight 370) this is generally recognised as one of the most worrying situations. Until the plane and its black boxes are recovered, nobody knows whether or not other similar aircraft are flying around with a similar potentially fatal fault. That is why governments and safety agencies are prepared to spend lots of money trying to find the wreckage.
I think something similar should happen with Serious Case Reviews. When, as in Bristol, a Serious Case Review fails to uncover an explanation of what has gone wrong, I think government should fund additional enquiries with a view to discovering the causes of the tragedy. If Ofsted were up to the task this would be a job for an inspectorate. But it is manifestly obvious that Ofsted does not have the knowledge or skills for an undertaking like this. So perhaps Government needs to commission research and enquiries by academic researchers or other independent experts. Whatever happens it is simply not good enough to throw-up our hands and accept that there is no explanation for highly trained and hard working professionals, from all the agencies involved, failing to recognise what was a clear case of serious abuse.