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Paragraphs: 5.162
- 5.169 | 5.170 - 5.179 | 5.180
- 5.187 | 5.188 - 5.193
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5.162
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It is plain from the sequence of events that I have just described
that the handling of Victoria's case by Brent Social Services is
littered with examples of poor practice and a consistent failure
to do basic things competently.
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5.163
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While there can plainly be no excuse for the failure of the front
door duty system, it was not helped, in my view, by a structure
that was far from conducive to efficient social work intervention.
In particular, I regard the following aspects of the system to have
contributed to the failure by Brent Social Services ever to undertake
a proper assessment of Victoria's needs:
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•
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The taking of referrals by the One Stop Shops
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•
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The lack of efficient IT and administrative support
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•
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The division between 'child protection' and 'child in need' intake
teams
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•
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The disproportionate use of agency workers in the duty teams.
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I consider each in turn.
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5.164
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The manner in which social services receive and process information
concerning vulnerable children can be critical to the effectiveness
of the services that those children eventually receive. The process
used to deal with Ms Ackah's referral on 18 June 1999 was unnecessarily
complicated and carried with it too great a chance that important
information would be lost or misinterpreted.
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5.165
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Ms Ackah's call was first received by the council's main switchboard,
which then passed it on to a One Stop Shop. The One Stop Shop, for
these purposes, would seem to have acted as nothing more than a
staging-post for such referrals, which were then passed on to the
social services duty team.
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5.166
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The aspect of this system that causes me most concern is that a
person in Ms Ackah's position who wishes to pass on information
about a child who is potentially in need of protection, speaks,
in the first instance, to someone who has little or no training
or experience in the taking of referrals concerning vulnerable children.
The majority of the work of a One Stop Shop of the type in operation
in Brent, will be the handling of routine inquiries about various
aspects of the council's work. The handling of sensitive information
about a child, perhaps coming from a hesitant referrer, requires
skills of a different nature.
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5.167
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The problem is compounded when, as in Victoria's case, the administrator
who takes the call is expected to classify the referral as being
of a particular type. Cases involving vulnerable children do not
come with convenient labels attached, particularly when the referrer
is a member of the public who may have only a sketchy knowledge
of the child's circumstances.
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5.168
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In my view, the solution lies in the establishment of a dedicated
24-hour telephone number manned by specialist staff in children
and families' services in accordance with the recommendation I made
earlier in paragraph 5.71. I recognise, however, that such arrangements
may take time to implement and that even after their implementation,
referrals will continue to be made to various points in the local
authority network. In such cases, it is vital that proper and efficient
use is made of the information provided.
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5.169
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The fact that the first referral to Brent Social Services concerning
Victoria was handled in the first instance by a One Stop Shop, not
only caused unnecessary delay in its being picked up by the relevant
team within children's services, but it contributed to the fact
that the referral was effectively 'lost' afterwards. The management
of referrals from members of the public must proceed in accordance
with procedures that are simple, clear and universally understood
by all front-line workers. The procedures in Brent met none of these
criteria. In an effort to ensure that they are met in the future
in Brent and elsewhere, I make the following recommendation:
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Recommendation
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All front-line staff within local authorities must be trained
to pass all calls about the safety of children through to the appropriate
duty team without delay, having first recorded the name of the child,
his or her address and the nature of the concern. If the call cannot
be put through immediately, further details from the referrer must
be sought (including their name, address and contact number). The
information must then be passed verbally and in writing to the duty
team within the hour.
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Paragraphs: 5.162
- 5.169 | 5.170 - 5.179 | 5.180
- 5.187 | 5.188 - 5.193
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5.170
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Once the handling of Ms Ackah's referral got off to a bad start,
the prospects of ever redeeming the situation and realising that
much still needed to be done to ensure a proper response to the
concerns she had highlighted were significantly reduced by the lack
of any effective administrative system in operation in Brent at
the time.
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5.171
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The overriding impression I received from the evidence that I heard
on this issue was of a lack of any 'system' worthy of the name for
the logging and tracking of referrals. I was told, for example,
that it took an average of three weeks for a new referral to be
logged onto the relevant database, and that a delay of 12 weeks
was not unheard of. I also heard evidence of files going missing
and faxes containing important information concerning vulnerable
children arriving in offices in which there was no system in place
for recording their arrival, or distributing them to the correct
member of staff.
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5.172
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The haphazard and chaotic nature of the administrative systems
which were supposed to assist Brent's social workers in the efficient
discharge of their responsibilities is perhaps most graphically
illustrated by the fact that Victoria managed, during the time that
her case was open in Brent, to acquire five different 'unique' identification
numbers on the various systems that were designed to ensure that
the progress of her case was effectively monitored.
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5.173
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Further confusion was created, in my view, by the division of Brent's
intake team into separate 'child in need' and 'child protection'
teams. Later in this Report I consider the validity of such a distinction
and whether it serves any useful purpose in the safeguarding of
children. For the present, it is sufficient simply to observe that
the organisation of Brent's intake teams in this manner meant that
there was often doubt as to whether a particular case was in the
right place. As Ms Roper put it, "What we found ... was that there
was a considerable overlap between the two teams and what that meant
was that a large number of cases ... were classified as child protection
cases when really what was required was a child in need assessment.
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5.174
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One of the consequences of the overlap she described would seem
to have been that children would be transferred between the two
teams depending upon the existing view as to the child's appropriate
classification. The two most unfortunate side effects of such an
approach are risk that important information concerning the case
will be lost in the transfer, and the disruption in the continuity
of care that will inevitably result when a case is passed between
social workers.
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5.175
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In addition, at times of heavy workload and stretched resources,
the temptation to reclassify a case so that responsibility for it
could be transferred onto another team could result in social workers
being too eager either to downgrade or play up the seriousness of
a particular case.
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5.176
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Finally, the effectiveness of the service offered by Brent's front
door teams was further undermined, in my view, by the policy to
assign the majority of permanent staff to the long-term teams, with
the result that there was a disproportionately high number of agency
staff working in the duty teams. While I am in no position to judge
the general competency of individual agency workers employed by
Brent at the time, I was told that many had recently arrived from
abroad and were inevitably unfamiliar with local procedures. Regular
briefing sessions had to be held in order to familiarise recently
arrived agency workers with basic elements of their roles.
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5.177
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As was pointed out in the SSI May 2000 inspection report, intake
work is highly skilled and demanding. Important decisions have to
be taken, sometimes in the absence of detailed information about
the child concerned, and there can often be limited time available
for careful reflection and consideration as to how best to respond
to the child's immediate needs. The use of agency staff unfamiliar
with basic aspects of the work only increases the chances of mistakes
being made and important information being missed.
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5.178
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Overall, the evidence I heard leads me to the view that the procedures
adopted by Brent for the taking of referrals, together with the
manner in which its intake teams were structured and resourced,
contributed to the chaotic and haphazard manner in which the two
referrals concerning Victoria were dealt with and, in particular,
the failure to adequately monitor the progress of her case during
the period for which it was open in Brent.
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5.179
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The effective safeguarding of children is a difficult and highly
pressurised task. It is rendered virtually impossible if those who
are charged with achieving it are not supported by proper systems
and structures to work within. I take the view that the chaotic
procedures for the monitoring and tracking of cases adopted by Brent
Social Services during the period with which I am concerned, contributed
greatly to the inadequate response made to both of the referrals
they received concerning Victoria.
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Paragraphs: 5.162
- 5.169 | 5.170 - 5.179 | 5.180
- 5.187 | 5.188 - 5.193
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5.180
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Although the front-line staff who came to deal with Victoria's
case were not helped in their task by the structure within which
they operated they were, in many cases, guilty of inexcusable failures
to carry out basic elements of their roles competently. In Brent,
as elsewhere, the social workers involved would have needed only
to do the simple things properly in order to have greatly increased
the chances of Victoria being properly protected.
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5.181
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Despite the poor quality of the systems in place for the taking,
recording and monitoring of referrals in operation in Brent at the
time, both of the referrals concerning Victoria eventually came
to the attention of staff who should have been in a position to
have responded properly to them. With regard to Ms Ackah's referral,
for example, two qualified social workers went out to visit Victoria
at her home. Properly handled, this visit could have been the first
step in the formulation of an effective plan to safeguard and promote
Victoria's welfare. In the event, the planning of the visit was
so poor that the social workers concerned arrived in Nicoll Road
without any real idea of what they were doing there. This, together
with their failure to make even the most basic inquiries when they
discovered that Kouao and Victoria were not at home, meant that
the opportunity to protect Victoria afforded by the visit, and by
the referral that prompted it, was squandered.
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5.182
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Also, basic failures undermined the effectiveness of Brent's response
to the second referral. The fact that Victoria was placed under
police protection on the evening that the referral was received,
clearly demonstrates that the matter was considered to be a serious
one that required a positive response. In fact, no assessment of
Victoria's needs was ever undertaken in response to this referral.
In the first instance, such an assessment would have involved nothing
more taxing than speaking to those involved. As it turned out, neither
Victoria nor Kouao nor Avril Cameron nor Priscilla Cameron nor the
referrer (Dr Ajayi-Obe) were ever spoken to by Brent Social Services
for the purpose of gaining an understanding of Victoria's needs
and circumstances.
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5.183
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Time and again the written record of Brent's handling of Victoria's
case demonstrates a complete absence of any proper reflection or
analysis of the information available to them. Perhaps the most
glaring example is provided by the failure to speak to Ms Cameron.
Taking another person's child to a hospital and expressing the suspicion
that the child is being deliberately harmed is not something that
anyone would undertake lightly. It seems inconceivable that anyone
who applied their mind to Victoria's case file in any meaningful
way could have failed to pick up the fact that the lady who had
brought Victoria into hospital in the first place had yet to be
spoken to.
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5.184
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In my view, the proper handling of Victoria's case would have involved
at least the following basic steps:
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•
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Victoria should have been seen and spoken to.
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The accommodation in which Victoria and Kouao were living should
have been visited and assessed for its suitability.
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Whatever background information was available from Ealing Social
Services and the French authorities should have been obtained.
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Legal advice as to Kouao and Victoria's status and the options
available to social services in dealing with them should have been
sought.
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Avril and Priscilla Cameron should have been spoken to in order
to understand why they had come to the view that Victoria had to
be taken to hospital.
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Kouao should have been interviewed about the injuries to Victoria
and the concerns that had been expressed by the Camerons.
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A multi-agency discussion should then have taken place involving
representatives from the Central Middlesex Hospital, Brent Child
Protection Team and Ealing Social Services, at which a plan to promote
and safeguard Victoria's welfare should have been agreed.
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5.185
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The steps listed above amount to no more, in my view, than standard
social work practice of a type that should reasonably be expected
in every case of alleged deliberate harm. Their impact on the outcome
of Victoria's case is likely to have been very significant indeed.
The fact that none of them were taken in Victoria's case is attributable
not just to poor practice on the front line, but also, in my view,
to a lack of clear managerial direction and, in particular, effective
supervision.
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5.186
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As far as the deficiencies in the supervision offered to those
working on Victoria's case is concerned, it is necessary to do little
more than observe that her case file was never read thoroughly by
any manager for the duration of the time that her case was open
in Brent. Effective supervision takes time. It involves reading
the case file and applying some thought to the decisions taken on
the case. In Brent, such supervision would appear to have been one
of the primary casualties of an intake team which was simply unable
to cope adequately with the work required of it.
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5.187
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It is little wonder, therefore, that basic omissions such as the
failure to speak to Victoria or Ms Cameron before the case was closed
were never picked up and challenged by the managers involved in
the case. There can be no excuse for the closure of a case before
the basic steps necessary to secure the well-being of the child
have been taken. I therefore make the following recommendation:
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Recommendation
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Directors of social services must ensure that no case that has
been opened in response to allegations of deliberate harm to a child
is closed until the following steps have been taken:
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• The child has been spoken to alone.
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• The child's carers have been seen and spoken to.
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• The accommodation in which the child is to live has been
visited.
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• The views of all the professionals involved have been
sought and considered.
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• A plan for the promotion and safeguarding of the child's
welfare has been agreed.
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Paragraphs: 5.162
- 5.169 | 5.170 - 5.179 | 5.180
- 5.187 | 5.188 - 5.193
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5.188
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A lack of priority was given to the standards of the day-to-day
work of front-line social workers by the managers responsible for
the operation of the intake teams. This was replicated further up
the organisation by the low priority accorded to children's services
by Brent's senior officers and elected councillors.
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5.189
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Despite the efforts of central government to move the protection
of children further up the local government agenda through the Quality
Protects initiative, I heard much evidence to indicate that children's
services in Brent were significantly underfunded at the time that
Victoria arrived in the borough. I have set out in detail in paragraphs
5.40-5.41 the extent to which Brent spent less on children's services
than the sums allocated to it for that purpose by central government
in the Standard Spending Assessments for the periods up to and including
the one with which I am primarily concerned. I have also made reference
to the various arguments deployed by witnesses from Brent in an
effort to persuade me that underspending of this nature should not
be interpreted as being indicative of a lack of focus on the protection
of children. I do not seek to rehearse those matters here.
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5.190
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For present purposes I wish simply to record my conclusion on this
issue which is that the lack of priority and resources accorded
to children's services by Brent over several years leading up to
Victoria's arrival in the borough, contributed significantly to
the deterioration of the service offered to vulnerable children
by the intake teams which handled her case. I found those teams
to have been in a deplorable condition in mid 1999. An almost total
lack of effective supervision meant that poor practice went unnoticed
and unchallenged. A lack of sufficient numbers of staff with the
skills and training necessary to perform the tasks required of them,
meant that the systems in place were on the verge of collapse.
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5.191
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As I have already made clear, a lack of resources and management
attention cannot provide an excuse for front-line workers for failing
to perform basic aspects of the job for which they have been trained
and employed. That said, the fact that the teams with which I am
concerned were allowed to deteriorate into the state in which I
found them during the course of this Inquiry can only be the result
of wholly inadequate monitoring by those who were ultimately responsible
for the provision of a proper service to vulnerable children in
Brent.
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5.192
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As I stated at the outset of this section of the Report, I have
little regard for the concept of what Mr Daniel referred to as "professional
distance" between those at the top of the organisation and those
working on the front line. It is the job of senior officers and
elected councillors to inform themselves about the quality of services
being offered by their front-line staff, and to take appropriate
action to remedy deficiencies as they are revealed.
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5.193
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Perhaps the most disturbing aspect of the evidence I heard regarding
Brent Social Services was the lack of concern, and even interest,
that the senior figures in the council appeared to show in the condition
of their children's services intake teams. I regard the regular
monitoring of front-line work by senior managers and elected councillors
to be an essential component of the effective delivery of services
to children. In an effort to ensure that such monitoring takes place,
I make the following recommendation:
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Recommendation
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Chief executives of local authorities with social services responsibilities
must make arrangements for senior managers and councillors to regularly
visit intake teams in their children's services department, and
to report their findings to the chief executive and social services
committee.
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