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.
