The Lesson of the Khyra Ishaq Tragedy

Welcome opportunities for travel in September and October have kept me away from the blog. But I have done some reading, in particular looking at the Khyra Ishaq Serious Case Review Report.

A crucial and very worrying part of the report focuses on the events of 19th and 20th December 2007. What follows is my précis of pages 49 – 51 of the report.

On 19th December a child protection referral was made by the Deputy Head Teacher of the child’s school to Birmingham Children’s Social Care. The concerns expressed were that the child and a sibling had been taking food from other children’s bags and cramming food into their mouths. Both children were reported to be thin but generally clean and tidy. It was also reported that the child had been out of school following a meeting between school staff and the mother, after which the mother had been very hostile towards school staff.

The response by Children's Social Care to this referral was as follows:

• It was stated that the Children’s Social Care team manager had recommended that the school education social worker and the school nurse should deal with the matter
• It was also suggested a CAF (Common Assessment) was required, with the education social worker as the lead practitioner, even though the mother was uncooperative and hostile.

Later the same day, the Deputy Head spoke again to Children’s Social Care. Again s/he emphasised that this was a child protection referral and raised further concerns about the sibling cramming food into her/his pockets, loitering in the dining room and reporting feeling cold. S/he also stated that there had been a sudden change in the mother’s behaviour and described her as “concerned and agitated”. Again s/he was told that the recommended approach was for the education social worker to prepare a Common Assessment.

The following day, 20th December 2007, the Deputy Head again contacted Children’s Social Care, asking for an update on the referral. S/he was told that it was not being progressed and that an initial assessment would not be undertaken. Again the Deputy Head requested a home visit and was told that Children’s Social Care had decided not to proceed. The Deputy Head was not satisfied with this response and requested that the concerns be taken to the line manager. But s/he was told that the manager would not accept the referral and had suggested a CAF. The Deputy Head was told if the school remained concerned then the police could be contacted for a “Safe and Well” check. This was subsequently undertaken by West Midlands Police, who visited the home but were not admitted. Officers did however see the children on the doorstep and were reassured.

There is no doubt that crucial errors occurred at this point:

1. The failure to accept what was clearly a child protection referral
2. The ill-judged advice that a CAF should be completed, instead of a child protection assessment
3. The ill-judged recommendation that the police should be requested to perform a Safe and Well check (these are checks generally performed by the police when children who have been reported by their parents as missing subsequently return home).

The report gives some context to these failures:

• There was a history of high levels of vacancy in Birmingham Children's Social Care, with a vacancy  for qualified social workers of 14% when the report was written (June 2009).
• Social care staffing per capita was 22% lower than the national inner city average. 
• The Social Worker involved in the case had an excessive workload of 50 allocated cases.

We know generally that decision-making can be adversely affected by over-work and difficult working conditions. One can imagine - although the report provides no detail - that staff in a hard-pressed child protection team where trying to keep too many balls in the air. Any referral that could be marked "NFA" would be a welcome outcome. And we can imagine that a decision-maker in this case may have erred because s/he wanted this not to be a child protection case, looking perhaps for any details which would mean that it did not need to be allocated. The alternatives of the Common Assessment and the Safe and Well Check may have predisposed to turning down the referral.

There are two morals. The first is that over-worked teams cannot function safely. The pressure to increase referral thresholds is too great. The second is, perhaps, less obvious. While the Common Assessment Framework has been welcomed in many quarters as part of an early intervention approach, there has been too little attention given to how it operates alongside child protection inquiries. An inherent danger will always be that a CAF will be undertaken or recommended where a child protection assessment is required. Thought need to be given to how this danger can be reduced or eliminated.