Serious Case Reviews & Extraordinary Council Meeting. Introduction (1 of 9)

Introduction
This has post has been a couple of days in the writing as I decided that I would explore not just the Serious Case Reviews (SCRs) but the wider issues involved – as it was not possible to cover all this in the council meeting (and the Presiding Officer would not have allowed me to anyway). I don't apologise for it being long, but for ease of reading, I have split it into 8 different sequential posts:

• The Council Meeting
• The Background
• The SCR reports, divided
• • Publication
  • Editing
  • Style & Content
• The children's circumstances
• Accountability
• Recommendations

However, they should all be considered as a piece.
You will also note that my usual sardonic tone is absent. I don't apologise for that either.

Read the reports yourself here Serious Case Review reports

Also of interest the Western Mail editorial here

Serious Case Reviews – The Extraordinary Meeting (2 of 9)

The meeting

It was not an accident that there was no formal motion before the Council – not even the usual catch-all that the "Reports should be noted". I believe it was anticipated what would have happened had there been an opportunity for amendment or a vote. The reason given for the absence of any motion, was that they were not the Authority's reports and Council therefore could do nothing with them. We had had them "For Information only" and that was the only basis on which the Council could be called.

This was not adequate and was not what I wanted when I pressed for the meeting. Yes, we got an opportunity to discuss it, but not in any meaningful democratic sense. I was frustrated and angered by this outcome, which meant that no action could be taken.

I had hoped that Thursday night's Extraordinary (i.e. Special) Council Meeting about the Serious Case Reviews (SCRs) would at least have prompted contributions from the Administration's members – which the debate on latest CSSIW report the previous week had so signally failed to do. But I was disappointed, as they refused to be disturbed from their usual indolence. Not even the added spark provided by the story in Wednesday's Western Mail (WM) about the alleged 'doctoring' of certain passages in one report (lessening or removing criticisms), could light their fires. They seemed indifferent to the possibility that they might have been mislead.

It was left to the Opposition to make the running on questioning the detail of the reports. For the Administration, John Newbury read out a prepared speech that was at least about the subject under discussion. Audrey Clement however, provided a self-justification, apparently seeing the very mention of her name as some sort of criticism that had to be responded to. Apart from these two I cannot recall anyone on the Administration side saying anything at all. No that's not strictly true, as over in the 'wild man' corner, the usual sotto voce grumblings, groanings and mutterings were audible, particularly when I tried to continue with my questions and was forced to sit by the Presiding Officer. Indeed, it was the intervention of Rene Kinzett that made her retreat and allow me to follow up a supplementary to the Director of Education.

Her behaviour was scandalous and if there were any doubts remaining about her fitness to continue as Chair of Council, she comprehensively disposed of them. Prior to the meeting, I had questioned the appropriateness of Cllr Fitzgerald chairing this Council, given that these children died during her occupation of the Social Services portfolio, that got nowhere. Cllr Fitzgerald was completely out of touch with the mood of the meeting or, indeed, the necessary sensitivity required to handle what was going to be an emotional meeting anyway. Huw Rees would have done this entirely differently. The Acting Deputy Monitoring Officer (if that is the role she had), provided no guidance and Cllr Fitzgerald's manner was so bad, that the Chief Executive had his head in his hands at several points. Indeed, I was given an apology after the meeting was over – not from Cllr Fitzgerald, of course.

This was not a good Council meeting, and did not show the Council at its best, wholly engaged with an important issue, unlike the discussion that followed the screening of A Swansea Love Story the night before.

Serious Case Reviews – Background (3 of 9)

Background

This meeting nearly never happened (as with last week's to discuss the latest CSSIW (Care & Social Service Inspectorate for Wales) report into Swansea's Children & Family Services, where only 2 out of 14 measures were shown to have improved and they were to do with political and corporate leadership, rather than the actual services themselves). From the outset, there was no intention to have a full Council debate on either of these serious matters. It was only considerable pressure from me (with RK's support), that they took place. Even so, the allowed extent (the remit) of both meetings was unsatisfactory and limited.

Councillors first saw the CSSIW report just before they arrived in the Chamber for the meeting, which meant that most members had about 10 minutes to read it before the Inspectors' presentation. (Entirely fortuitously, I got just over an hour to read it). I had already objected that this procedure, insisted on by CSSIW, was not only contrary to the law, in that it did not allow the three days publication of papers required by the Local Government Act & the Council's Constitution, but was also entirely unreasonable. I can speed read (loads of practice), many can't. Most Members would only be able to read (and comprehend) the report after the meeting was over and, if they then had questions, would be unable to ask them. I had sought to get the CSSIW Inspectors to return to Council. I asked them directly when we met the Minister and later at their presentation. They refused. In fact, the Chief Inspector over-ruled one of his Inspectors who had already accepted an invitation to attend the Scrutiny Board, on the grounds that 'that was not the way they did things'!

In regards to the SCRs, the Social Service Department's view was not to have a Council meeting at all. It was concerned about the effect that dragging this all up again in public would have on the families and that there would be disclosure of the children's identities. The first argument might just about stand for Child E (Chloe), but not for the others – Mother and sister in prison for causing the death of Child B (Carly) and given away by the mother and generally ignored by his carer (and everyone else) Child D (Kyle). It seems to me that any 'rights' the families might have had, had been sacrificed. In any event, should these rights over-ride those of elected members in being able to arrive at an informed judgement? What was the purpose of these reports being published if the elected representatives of the people of Swansea were not allowed to debate them? I expressed the view that the only way to deal with issues such as these was to be full and frank. If we (the Council) accepted the conclusions, if we had nothing to hide, then full and frank disclosure was the only way to proceed. To do otherwise would be, at least, to play into the hands of those who would allege a 'cover-up'.

Under Cllr Fitzgerald's tenure, as Cabinet Member, she had had to be dragged, kicking and screaming, into providing any information on the SCR or circumstances surrounding the death of Aaron Gilbert. It was only Labour motions that got anything before Council – and even then her behaviour bordered on the contemptuous. Readers may need reminding, that Cllr Mrs Fitzgerald denied absolutely that Swansea Social Services had any involvement in Aaron Gilbert's death, even though a Social Worker had been suspended and disciplinary action initiated. That she misled Council seems beyond doubt.

Therefore, following Cllr Fitzgerald's sacking and Nick Tregonning's appointment, I discussed with him how he would deal with future cases. I was pleased that he agreed with my analysis and with his assurance that he would not try to hide anything and that such matters would be quickly brought before Council. I was therefore particularly disappointed when, following the initial presentation on the SCRs to Council, Nick seemed to waver and be inclined to resist a meeting/debate.

Considerable backstage negotiation then went on, which resulted in yesterday's meeting, although the ground rules were restrictive and were still being negotiated up to the meeting. I understand that not having a meeting was not a view shared across the Corporate Management Team and it was good that Nick Tregonning subsequently changed his mind. I was pleased that common sense won out over the Department's wish for anonymity being maintained with the children being referred to by letters. I thought this wrong – we had failed these young people, and the very least we could do was remember that they were real and use their names and not treat them as statistics. Not least, as their identities had already been made public anyway.

Serious Case Reviews – Publication (4 of 9)

The Reports - Publication

The full Serious Case Review reports are never made public, only the Executive Summary. As a result councillors have to take the Summaries on trust. I find that inadequate. That's not about distrusting our officers, it's about confidence in the system. Confidence, that we have identified what went wrong and that we know what we need to do to put it right. I am not sure that these reports give us that.

The first big issue is the considerable delay in publishing these reports, why they were published when they were and why they were published together. These children died in 2007 & 2008. A clue to how long they have been around is in the anonymisation. Child A was Aaron Gilbert (who died in 2005) – these three reports are for Child B, D & E. (Child C has not been published for reasons that, in the information I have been given, I entirely accept as valid). I accept that where criminal prosecution is likely/pending or the judicial process is in train, it could be difficult to publish certain information. However, of these three specific cases, only one gave rise to criminal proceedings (Child B - Carly). Although it seems certain that proceedings would have been considered in Child D (Kyle), in the third case (Child E – Chloe) they don't seem relevant at all.

So a more reasonable publication order would have been E (Chloe), almost immediately after her death in 2008, followed by D (Kyle) after decisions had been taken on proceedings, and finally Child B (Carly, who had died in early 2007) after the whole judicial procedure, including appeals, had been dispensed with. But no, the three reports were published together in March 2010. No satisfactory explanation has been given for this. Council was told that the reports were only finalised the day before publication. That is entirely unconvincing.

Why then were they all published together? Council was assured that this was just a co-incidence. Again, unconvincing.

I know that the Authority was expecting to get major headlines and the national news with at least one of the cases. So was it 'managing' the release to mitigate the damage? Well, it would be surprising if it didn't, but again Council was told that wasn't the case. Did the Authority want them out of the way before what they hoped was a good (or at least not too bad) CSSIW report? Again, that would not be unreasonable. Again Council was told that was not the case. What role did CSSIW have in governing the publication date? The Chief Inspector's dissembling and rather ill-tempered responses to my questions on this subject at Council, just created more suspicion – whether it is warranted or not I simply have no idea. What is clear is that what was always going to be a difficult period for the Authority was made worse by the way it was handled. The Authority probably couldn't believe its luck when Birmingham published just before Swansea and captured all the headlines. Or was that known? And was it that that dictated the publication date? We have still to get to the bottom of all of this.

Serious Case Reviews – Editing (5 of 9)

The Reports – Editing

It was my questions that elicited the admission from the Director of Social Service, that the passages quoted in the WM article about the Kyle SCR were accurate. (I take no particular credit for that – it was just the advantage of being first. Someone else would surely have raised it, if not me). I think the Director was quite open about it. However, I do not accept his reasoning; that it was to make the report easier to read and that the report remained critical of Social Services. He did not seem to accept the point of the significant difference of emphasis between the earlier draft and the published version.

For example, that;

"...over several years ...social work staff...and their managers failed to apply the law, appropriate procedure or elementary standards of professional practice..."

is considerably more critical (and a great deal more concerning) than

"...between 2002 and 2005...social work staff and their immediate managers failed to apply the appropriate procedures or standards of professional practice...".

And then there is the complete excision of the "at least" 15 occasions that various agencies referred information to Social Services regarding Kyle's;

"persistent involvement" in "risky and criminal behaviour, self-harming or drug and alcohol abuse and inadequate parenting from the age of 12...they (the agencies) expected action to be taken.

The review found no evidence that the failures identified...were due to ...staff being overwhelmed with work...

Management and supervision... had not picked up these issues over many years

(Kyle's) circumstances were not known to senior managers ...until his death".

which becomes

"Referrals were not properly considered or acted on...Judgements were not properly reached and assessments of risk were inadequate or not carried out. No enquiries were carried into the child's presentation...there was no proper consideration of Child D's circumstances and his needs... Information shared with social services...did not lead to any appropriate assessments of Child D's needs"

Yes both versions are critical, but placed side by side, I believe that the differences are stark. They might say substantially the same thing – but they don't certainly mean the same thing! Whilst the published version is damning, the draft version is considerably more so.

These are the ones I know of, thanks to the WM and the InsideOut blogsite. Are there others? Of course, I don't know. I have written to the Authority seeking the release of certain information that would clear all this up. I have already been told that some of the information I seek is confidential, and was provided to the SCR on that basis. I have two means to access information, one in my representative capacity and the other as an FOI. Negotiations on both continue. Of course someone could always send me the draft!

Serious Case Reviews – Style & Content – (6 of 9)

The Reports – Style & Content

The three reports themselves were entirely different in size and scope. The first (Carly) was very detailed, properly numbered, logical in its layout and easy to read (in the stylistic sense). The second (Kyle) was similar (it was written by the same person) but would have benefited from a more consistent layout. The third was simply inadequate. If I had produced a report like this when I was working for Coopers & Lybrand I would have had it thrown back to me and been told to do it again. Let's not forget the authors of these reports are getting paid for writing them.

I found it surprising that there was not a standard format, so that one report can be compared to another and that the ground they cover can be seen to be consistent.

The layout of all three reports is different. Report B is 23 pages long, and gives a clear picture of the circumstances that lead to Carly's death. Report D is 13 pages long, is not quite as clear on the circumstances of Kyle's death and contains 3 and half pages of recommendations. Report E (Chloe) is none of these things.

It is only 8 pages long (and that includes the title page) and has slightly more than half a page of recommendations. And of those scant pages only four short paragraphs are about Chloe herself. Four! Seven sentences and one of those was about the Coroner's verdict and another about her family being known to various agencies. One sad life (and even sadder death) disposed of in 142 words.

The whole tone of this report (read to me) as that summary suggests – as cold & dismissive. As 'care less' as the response of the agencies it reports on to the obvious screams of a child in distress and her mother desperately seeking to understand what she could do. This is best demonstrated by quoting two paragraphs;

9.7. "With hindsight, it is possible to speculate that a holistic, child-centred assessment of the family during this period, taking the full history into account, might have led to a clearer understanding of the degree to which the mother was struggling to meet Child E's needs and a more intensive and better coordinated preventative support plan. However, the lengthy history and complex nature of the factors in Child's (E) life mean that this may not have resulted in a different outcome."

9.9. "There are many young people who suffer a difficult childhood and adolescence, but who have sufficient resilience or have developed coping mechanisms which allow them to make a successful transition into adulthood."

In other words, more might possibly have been done, but it probably wouldn't have made any difference. And anyway other young people have got over it. So that's all right then!

My response to this report was one of anger. All the findings are vague, superficial and lack detail. If you were searching for clues as to why the various agencies failed to prevent Chloe's death, you won't find them here, other than they didn't seem to talk to one another, but we are assured they, "...did their best...".

Clearly their best wasn't good enough.

Serious Case Reviews – Children’s circumstances (7 of 9)

The children's circumstances

It is inevitable that you have an emotional reaction to reports like these. Reading the details of the death of a child is always a harrowing experience. Not just at the waste of a life – but (in two of these reports) on the presentation of a life whose sheer dreadfulness is difficult to comprehend.

Carly's personal circumstances were desperate from very early in her life, with her Mother and sister both being heroin addicts. She seemingly became an addict around 14, being supplied by her mother and sister. All this was known to all the agencies involved and yet, after a spell in secure accommodation where she got 'clean' she was returned to her mother and within days was dead from heroin allegedly supplied by her family, whilst an agency worker knowing she had gone back on heroin said nothing.

However, the most harrowing was Kyle's report. I was really upset by this one – still am. It is difficult to conceive of a life so hopeless (in the sense of being devoid of hope) or so appalling. It reads like the favelas of Brazil – but this is Swansea today! Given away by his mother to a neighbour immediately after birth, he never went to school from the age of 10, but became involved in criminal activity from the age of 11. Thereafter he was repeatedly involved in substance abuse (alcohol and an enormous variety of drugs), violence, petty criminality, inappropriate sexual (potentially paedophilic) activity, was seen unkempt and smelly, picked up, arrested and imprisoned. He had involvement with many agencies over nearly all his life – being referred to Social Services at least 15 times. Yet in 2007 he disappeared off the radar, but nobody asked why. It was known where he lived, yet it seems no-one went to check on how he was doing. The following year he's found dead.

What kind of life was this? What view did he have of the world? His mother didn't care for him at all and his carer didn't care enough and for 17 years no-one else seemed to either. I am sure that some did (well I must trust that they did) but if they did, they didn't care enough, so he grew up without either love or hope.

There was no doubt that this child was 'trouble', but Kyle was a child. It seems from reading the report that that was what all the agencies forgot. They saw the 'problem', but not the child and so countless opportunities were missed.

I have been approached by concerned individuals wanting an independent review of these latest deaths. I am not convinced of the need for that as yet. When I have seen (or not) the information I have requested, I will look at this again.