|
|
|
Paragraphs: 6.1 - 6.12
| 6.13 - 6.17 | 6.18 - 6.25
| 6.26 - 6.37 | 6.38 - 6.49
| 6.50 - 6.57 | 6.58 - 6.59
| 6.60 - 6.71 | 6.72 - 6.79
| 6.80 - 6.94 | 6.95 - 6.108
| 6.109 - 6.120 | 6.121 -
6.129 | 6.130 - 6.140 | 6.141
- 6.149 | 6.150 - 6.158 | 6.159
- 6.171
|
|
|
|
6.1
|
Victoria spent some 308 days in England. For 211 of them, and in
response to a clear child protection referral, she had an allocated
social worker from the North Tottenham District Office (NTDO) of
Haringey Social Services. Their single responsibility to Victoria
throughout this period was to safeguard and promote her welfare
in accordance with the Children Act 1989. Their clear and overwhelming
failure so to do is the subject of this section.
|
|
6.2
|
As with the other agencies involved in Victoria's care, it is not
enough to consider the omissions and failings of individual practitioners
in Haringey without considering the context in which they were working
at the time. It is also necessary to understand the extent to which
the organisation in which they served, and the working practices
of the organisations, can, and must, shoulder the blame for serious
lapses in individual professional practice. The evidence on this
in Haringey is, in my judgement, overwhelming.
|
|
6.3
|
Although the failings in Lisa Arthurworrey's (Victoria's social
worker) practice were many and serious, she was badly let down by
her managers and the organisation that employed her. In particular,
council members and the senior management of Haringey must be held
to account for the yawning gap between safe policies and procedures,
and poor practice in their children and families' services. As Pauline
Bradley, a social worker at Haringey, observed, they "were way out
of touch with what was happening at the grass roots and did not
really seem to care". Yet Gurbux Singh, chief executive at the time,
felt able to distance himself from these failures. He told the Inquiry,
"It is absolutely clear that Haringey has messed up and it is absolutely
clear that there were fundamental failures ... but I am not clear
in my own mind as to where the line of responsibility lies. That
is my own dilemma." It is not a dilemma I share, as I have already
made clear in respect of Gareth Daniel, chief executive of Brent
council. For Mr Singh to seek to hide behind the cloak of corporate
responsibility and to say that beyond making sure that effective
systems and processes were in place - which they clearly were not
as this section will demonstrate - he "could not honestly think
of what else I could have done to ensure that the tragedy which
happened did not happen" entirely misses the point. As chief executive,
Mr Singh carried overall responsibility for the way in which the
council operated and performed. If there was a gap between local
policies and practice it was exactly his job to know about it, to
keep his members informed and to take timely and corrective action.
|
|
|
|
6.4
|
Haringey is an outer London borough with many of the characteristics
and problems of an inner city area. In its 1998 position statement
to the Joint Review of Social Services in Haringey Council, Haringey
noted that it is the thirteenth most deprived authority in England.
A large proportion of its residents were described as experiencing:
|
|
|
"Severe poverty, unemployment and deprivation, which manifests
itself in all areas of their lives, such as the lack of adequate
affordable housing, poor levels of educational attainment, poor
health and high numbers of children in need."
|
|
6.5
|
I heard evidence that Haringey has one of the most diverse populations
in the country, with 160 different languages spoken locally, a long
tradition of travellers settling in the borough and a high proportion
of asylum seeking families (nine per cent of the total population).
The pressure this places on all departments within the local authority
is inevitable - none less so than for the children and families'
services.
|
|
|
|
6.6
|
The NTDO was one of two district offices in the borough accommodating
the Haringey Children and Families Service. The other area office
was some five miles away in the west of the borough in Hornsey.
Based in north Tottenham, in cramped and rather dingy premises,
were two investigation and assessment teams (IAT A and IAT B) and
four children and families' long-term teams. Members of each of
these teams would staff the duty team on a rota basis. It was the
duty team that handled in the first instance most of the referrals
- including Victoria's - that came into the office, although they
operated a completely different system from the duty team in Hornsey.
|
|
6.7
|
Once the social worker on duty had conducted an initial assessment
of referrals, cases were transferred to an IAT. It was generally
understood, but not made explicit in local guidance, that cases
should not be held open for more than three months by an IAT, and
usually not beyond a case conference, before being transferred to
a long-term team for implementation of a care plan. Despite this,
Victoria's case remained throughout her seven-month period in Haringey
with the IAT and the social worker to whom it was originally allocated.
This adds further weight to the recommendation made in paragraph
4.14 that managers of duty systems must be aware of how many cases
are open on duty, what is being done on them and by whom, and when
the action needs to be completed. It also demonstrates the need
for managers to be aware of when key deadlines in the progress of
a case are missed. The fact that a case spends an excessive amount
of time open on duty can often indicate that it has been allowed
to drift. In an effort to ensure that such signs are not missed,
I make the following recommendation:
|
|
|
Recommendation
|
|
|
Directors of social services must ensure that where the procedures
of a social services department stipulate requirements for the transfer
of a case between teams within the department, systems are in place
to detect when such a transfer does not take place as required.
|
|
6.8
|
Within each IAT there were six social workers and a senior practitioner
accountable to a team manager, who was in turn responsible to the
commissioning manager for children and families. Until the changes
brought about by restructuring in early November 1999 (to which
I shall return), Angella Mairs managed team A and her senior practitioner
was Rosemarie Kozinos. Carole Baptiste managed team B and her senior
practitioner was Barry Almeida. Both team managers reported to David
Duncan, commissioning manager, who in turn reported to Carol Wilson,
assistant director of children's services and chair of the local
Area Child Protection Committee (ACPC). Both team managers took
turns managing the duty team. Accordingly, following Victoria's
admission to the North Middlesex Hospital in July 1999, it was Ms
Baptiste who allocated Victoria's case to Ms Arthurworrey, a social
worker in her team.
|
|
|
|
6.9
|
At the time she was allocated Victoria's case, Ms Arthurworrey
had been employed in Haringey for nine months. Although she told
the Inquiry that she was not given "any sort of induction" when
she started with Haringey other than to be shown around the building
and told to read the department's child protection guidelines, Ms
Arthurworrey was not wholly inexperienced because this was her second
children's services post since qualifying as a social worker in
1997. Surprisingly, though, she had yet to conduct and see through
to completion a joint section 47 inquiry of suspected deliberate
harm to a child with the police.
|
|
6.10
|
In Bernard Monaghan's subsequent review of staff involved in Victoria's
case, he concluded, "All the staff directly concerned with the VC
case had received appropriate training to equip them to deal with
the practice matters that arose during their involvement." Mr Monaghan
found "no basis to believe that a lack of appropriate training of
staff was a contributing factor". Indeed, Ms Arthurworrey told this
Inquiry that by June 1999 her training was adequate and it was not
a factor relevant to Victoria's case in terms of her conduct of
it. I do not share that view. Setting aside Ms Arthurworrey's limited
experience in child protection inquiries, she was not trained in
the Memorandum of Good Practice and could not therefore
take a section 47 child protection inquiry through to its conclusion.
|
|
6.11
|
Common sense dictates that before any social worker conducts section
47 inquiries they should:
|
|
•
|
be trained in how to complete such an inquiry;
|
|
•
|
have had experience in participating in section 47 inquiries while
shadowing a more experienced colleague;
|
|
•
|
ideally be trained in the Memorandum of Good Practice.
|
|
6.12
|
Ultimately it was the responsibility of Ms Wilson to ensure that
staff in her department carrying out section 47 inquiries were competent
to do so. In order that this happens in future, I make the following
recommendation:
|
|
|
Recommendation
|
|
|
No social worker shall undertake section 47 inquiries unless he
or she has been trained to do so. Directors of social services must
undertake an audit of staff currently carrying out section 47 inquiries
to identify gaps in training and experience. These must be addressed
immediately.
|
|
Paragraphs: 6.1 - 6.12
| 6.13 - 6.17 | 6.18 - 6.25
| 6.26 - 6.37 | 6.38 - 6.49
| 6.50 - 6.57 | 6.58 - 6.59
| 6.60 - 6.71 | 6.72 - 6.79
| 6.80 - 6.94 | 6.95 - 6.108
| 6.109 - 6.120 | 6.121 -
6.129 | 6.130 - 6.140 | 6.141
- 6.149 | 6.150 - 6.158 | 6.159
- 6.171
|
|
|
|
6.13
|
The atmosphere within the NTDO duty and IATs was hectic in 1999.
Shanthi Jacob spoke of the "bombardment factor" and Mary Richardson,
director of social services in Haringey at the time, stated:
|
|
|
"Undoubtedly North Tottenham was the busiest social work office.
As a consequence of that, by definition staff probably held, on
average, slightly more cases than their Hornsey counterparts ...
there was regular and fairly unremitting pressure on the north Tottenham
office."
|
|
6.14
|
It was an issue recognised by the Joint Review team in early 1999,
who referred in their report to potential staff "burn out", which
needed to be addressed quickly.
|
|
6.15
|
Ms Arthurworrey told the Inquiry that initially her caseload at
Haringey was manageable, but it slowly increased. By the end of
August 1999 she was responsible for 19 cases (of which half were
child protection). This is seven more cases than the maximum laid
out in the Duty Investigation and Assessment Team Procedures
devised by Ms Mairs. Mr Duncan argued that it was hard to imagine
how a social worker could work on more than 12 cases at a time.
Yet Ms Arthurworrey said she was unaware of the guidance, and during
1999 Mr Duncan said he knew, though Ms Wilson said she did not,
that staff in the NTDO IATs were dealing with a high number of cases
and that the average caseload was in excess of the recommended maximum.
|
|
6.16
|
Haringey Social Services admitted that Ms Arthurworrey's caseload
in the second half of 1999 was higher than they generally considered
desirable, but they argued that this did not affect her ability
to deal with Victoria's case. Ms Arthurworrey did not, they said,
identify any tasks at the time that she could not carry out because
of workload pressures. However, the fact remains that Ms Arthurworrey
failed to complete a number of key tasks in relation to Victoria's
case, and she worked considerably in excess of her scheduled hours,
notching up by the end of 1999 some 52 days of time off in lieu,
which could not easily be taken because of workload pressures. It
also overlooks entirely the additional need for effective supervision
- so demonstrably absent in Victoria's case - when social workers
carry active caseloads of this size.
|
|
6.17
|
Ms Bradley, a social worker in one of the long-term teams and a
UNISON representative, described the situation as "conveyor belt
social work". She said that the "ethos seemed to be particularly
about getting the cases through the system and meeting the targets,
meeting the statistics, getting them through the system", rather
than doing the work that needed to be done.
|
|
Paragraphs: 6.1 - 6.12
| 6.13 - 6.17 | 6.18 - 6.25
| 6.26 - 6.37 | 6.38 - 6.49
| 6.50 - 6.57 | 6.58 - 6.59
| 6.60 - 6.71 | 6.72 - 6.79
| 6.80 - 6.94 | 6.95 - 6.108
| 6.109 - 6.120 | 6.121 -
6.129 | 6.130 - 6.140 | 6.141
- 6.149 | 6.150 - 6.158 | 6.159
- 6.171
|
|
|
|
6.18
|
The personalities of those in charge of the two IATs contributed
much to the way the teams worked. Marina Hayes, a social worker
in IAT B, recalled that the team was "very divided, and there were
a lot of deep conflicts. At times the working environment felt hostile,
and it was not a comfortable place to work constructively in". Ms
Hayes stated that there seemed to be "two camps in the I and A team.
It felt to me that there were insiders and outsiders within the
office." Ms Hayes also said, "There were historical conflicts that
were just never resolved. Probably nobody knew what they were about.
They were just part of the culture. They were part of the dynamic."
Ms Hayes found the atmosphere less than supportive, in fact she
found work in the NTDO a struggle.
|
|
6.19
|
Similarly, Ms Arthurworrey recalled that there always appeared
to be conflict in the IATs. She said it reminded her of a school:
"Angella Mairs was the headmistress, Rosemarie Kozinos was the head
girl. There were also other head girls [the senior practitioners]
and we the social workers were the children." Ms Arthurworrey stated
there was a clear division of the team into camps. "The basis of
the split was the headmistress and the head girls against the social
workers ... It was very difficult to rebel among the schoolgirls
because we were regarded as children who should be seen and not
heard." Others, including Ms Bradley, agreed.
|
|
6.20
|
I heard different and often conflicting views expressed about Ms
Mairs's management style. Ms Arthurworrey and Valerie Robertson,
another social worker in IAT B, both considered Ms Mairs a powerful
and assertive manager with a reputation for being a bit of a bully.
However, Ms Robertson said she felt more comfortable in her social
work role once Ms Mairs took over as manager of the combined IAT
in November 1999, because she received more and clearer direction.
Ms Kozinos, on the other hand, found her an approachable manager
and Mr Almeida described her as hard working and loyal.
|
|
6.21
|
Whether or not Ms Mairs's management style verged on the bullying,
the evidence suggested that she was a tough, if controlling and
autocratic, manager whose reputation was known and valued by Haringey's
senior management team and whose skills were considered necessary
to run an efficient duty system. Mr Duncan confirmed that twice
in the past three or four years Haringey had got itself into a crisis
in the management of its duty teams, once in the NTDO and more recently
in Hornsey. On both occasions Haringey called on Ms Mairs to pull
it out of a tight spot, because she was clear and set up safe, strong
systems. According to Mr Duncan, that was one of the things that
Ms Mairs was good at. He described her style as "controlling, she
wants that team run in her way". In his opinion Ms Mairs would not
be everyone's favourite manager, but she may come out on top as
being the manager that gives the closest and clearest instructions
on what to do. Certainly her management style was to have an influence
on relationships between the NTDO IATs and those external agencies
that could and should have played a critical role in Haringey's
child protection system.
|
|
6.22
|
Relations with health colleagues were, on the whole, reasonable
but not without their difficulties. At the time Victoria was admitted
to the North Middlesex Hospital, Haringey had no social work presence
at the hospital, which raised concerns for hospital staff over gaps
in the service provided to Haringey patients. Dr Mary Rossiter,
consultant paediatrician at the North Middlesex Hospital, said that
prior to Victoria's case there had been occasions when Haringey
Social Services had not fully appreciated the paediatric team's
concerns or fully respected her views about cases. She felt there
were occasions when Haringey Social Services had not reacted properly
to her expressions of concern about children that she believed might
be the victims of deliberate harm. She said, "It was more that we
did not have a good working relationship. I really felt that I had
not been able to get through to them to explain my concerns." Dr
Rossiter felt social workers were not appreciating her point in
more complicated cases. When asked whether race made any difference
to the way social workers responded to her concerns, she replied,
"Maybe some social workers felt they knew more about black children
than I did." The minutes of a meeting between hospital social workers
and the North Middlesex Hospital paediatric consultants on 11 February
1998 concluded, "There are a lot of problems with North Tottenham
District Office and referring to them (which is done by the clinical
staff in some circumstances). This causes negative feelings about
social services in general which can be unjustified." It was not
a problem that Ann Graham, manager with responsibility for liaison
between Haringey Social Services and the North Middlesex Hospital,
or more importantly the ACPC on which Dr Rossiter sat, ever properly
addressed.
|
|
6.23
|
Tensions also existed between Haringey Social Services and the
police. Ms Arthurworrey described a general feeling of hostility
towards the police and other agencies, which stemmed from Ms Mairs's
view that, "Social services knew best ... we worked the hardest
and we knew our procedures. There was just very little consultation."
This was not Ms Graham's impression, but this may only serve to
highlight the disparity in perception between those on the ground
and those operating one step removed. Detective Sergeant Michael
Cooper-Bland of the Haringey Child Protection Team summed up relations
as a bit like "the curate's egg, partly good and partly bad". He
thought that on an individual basis, social worker to police officer,
there were many examples of good working relationships. Conversely
there were examples of poor working relationships and "in a very
few cases, downright rudeness".
|
|
6.24
|
Evidence emerged that the police felt pressurised about their role
within child protection inquiries. There were differences of opinion
on how cases should proceed, despite the existence of a protocol
for inquiries between the police and social services. The police
felt social services blocked or frustrated steps that the police
wanted to take. Sergeant Alan Hodges did not believe that the work
carried out in Victoria's case in July and November 1999, could
be said to have been an independent, thorough investigation by the
police: "I believe in Haringey the working practices there were
difficult for the police officers.
|
|
6.25
|
In a letter to Highgate police staff dated 8 March 2000, Detective
Chief Inspector Philip Wheeler mentioned the "difficulty of working
with what seems to be an 'aggressive' social services unit". In
a report of the same date, DCI Wheeler stated that Haringey Social
Services "seems to have its own particular culture and ways of working
within the child protection framework. It seems that they are extremely
powerful within the protection network and some social workers work
hard to actually prevent police involvement". Detective Inspector
David Howard said that some of the working relationships were difficult,
but relationships had to be maintained and difficulties overcome
to prevent a possible total breakdown. Once again the ACPC appeared
to have done little to broker good relations between its partner
agencies.
|
|
Paragraphs: 6.1 - 6.12
| 6.13 - 6.17 | 6.18 - 6.25
| 6.26 - 6.37 | 6.38 - 6.49
| 6.50 - 6.57 | 6.58 - 6.59
| 6.60 - 6.71 | 6.72 - 6.79
| 6.80 - 6.94 | 6.95 - 6.108
| 6.109 - 6.120 | 6.121 -
6.129 | 6.130 - 6.140 | 6.141
- 6.149 | 6.150 - 6.158 | 6.159
- 6.171
|
|
|
|
6.26
|
In contrast to Ms Mairs, the main issues arising out of Ms Baptiste's
management of IAT B were her lack of availability and her incompetency
as a team manager. Ms Baptiste worked two and a half days a week
from the end of 1998, following her return from maternity leave,
until the summer of 1999. In July 1999, before Victoria's referral
to Haringey, the members of IAT B raised a number of persistent
and serious concerns with Mr Duncan about Ms Baptiste's management
of the team. In particular, the B team felt that Ms Baptiste did
not know her cases properly, and care planning suffered as a result
of this. Staff also informed Mr Duncan that it was hard to seek
Ms Baptiste's advice on cases, given the uncertainty about when
she would be in the office.
|
|
6.27
|
As front-line manager of the B team and Ms Arthurworrey's immediate
supervisor, the extent to which Ms Baptiste's managerial competency
fell short of the mark and was known to be deficient, or ought to
have been known to be such by her managers, is of critical importance
and deserves careful consideration.
|
|
6.28
|
Ms Baptiste had been temporarily promoted by Haringey as a team
manager for at least four and half years. This was not a satisfactory
situation but was not unusual according to Joe Heatley, Mr Duncan's
predecessor as commissioning manager. He claimed that acting-up
managers were not uncommon in the late 1990s. Indeed, most managerial
posts were filled that way. He believed this was partly due to the
general shortage of experienced social workers at that time.
|
|
6.29
|
While there will always be a need for staff to be temporarily promoted
to fill unforeseen vacancies, directors of social services must
ensure that such arrangements are subject to routine review at no
later than six-monthly intervals, and the reasons for continuation
or termination should be recorded on the appropriate personnel file.
Therefore, I make the following recommendation:
|
|
|
Recommendation
|
|
|
When staff are temporarily promoted to fill vacancies, directors
of social services must subject such arrangements to six-monthly
reviews and record the outcome.
|
|
6.30
|
Prior to joining IAT B, Ms Baptiste had moved to one of the long-term
children and families' teams as an acting team manager. Dawn Green
(née Cardis), a child protection adviser for the NTDO, recalled
Ms Baptiste as being a chaotic manager with lots of files and unallocated
cases on her desk. She said Ms Baptiste "presented as not focused
and chaotic. She seemed less competent than other managers".
|
|
|
|
6.31
|
Mr Heatley, manager for children's services, was equally concerned
about Ms Baptiste's lack of management and this came to a head in
connection with an under-performing social worker in the children
and families' team who was known to this Inquiry as Ms B. Not only
had Ms Baptiste failed to pick up Ms B's poor performance, she had
failed to respond when asked to deal with it. Ms Wilson was fully
aware of the situation and an independent human resources consultant,
Alister Prince, was asked to prepare a report into the matter.
|
|
6.32
|
Its terms of reference were extended to consider not only the performance
of Ms B but also that of Ms Baptiste, her team manager, as well
as that of Mr Heatley because of his handling of the whole affair.
Although the report was commissioned in early 1998, the 15-page
report was not finally received by Haringey Social Services until
March 2001. That was some 21 months after Ms Baptiste joined IAT
B as its manager after returning from maternity leave. Given the
scope of the report, in particular its focus on the performance
of both a first and second tier manager, by any standard this was
an unacceptably long delay. Significantly, no decision was made
to pursue the findings of the report with any of the individuals
concerned.
|
|
6.33
|
Although Ms Baptiste failed to co-operate with Mr Prince's report,
it is clear from the evidence given by others including Ms B, a
new inexperienced social worker, that supervision with Ms Baptiste
closely mirrored the later observations of Ms Arthurworrey and others
about their supervision experience with Ms Baptiste in the IAT B.
Ms B said that she was an unsupportive and unfocused supervisor
and that she would spend supervision sessions talking about feeling
oppressed by a sexist and racist department. Ms B said she "felt
at sea".
|
|
6.34
|
Mr Prince's report contained a number of other, relevant observations,
namely:
|
|
•
|
Ms Baptiste had had management responsibility for one of Ms B's
cases for in excess of two years and was not aware that the social
worker had made only three visits in that time. Mr Prince concluded
that Ms B was a problem for Ms Baptiste to manage and consequently
a number of children and their families failed to receive a service.
Indeed Ms B had presented problems as a social worker from the outset
and these had not been vigorously addressed. As with Ms B's caseload,
they were allowed to drift. Mr Prince found that even a cursory
view of Ms B's files "from her earliest involvement in a case evidences
little or no social work input of any meaning, simply gaps exist".
It is a comment that could apply equally well to Victoria's file.
|
|
•
|
Ms B subsequently transferred to Ms Mairs's IAT and under vigorous
management her performance as a social worker turned around. Her
new practice manager, Ms Kozinos, "was very positive about her abilities".
|
|
•
|
In the face of a near revolt by Ms Baptiste's old children and
families' team, she was transferred on return from maternity leave
to IAT B team in the NTDO in 1998, but still in an acting-up capacity.
Mr Prince was highly critical of the "ostrich like" management response
in this regard, and suggested that no consideration was given to
returning Ms Baptiste to her substantive grade as a senior practitioner.
He argued that the corporate response was in effect to avoid a difficult
decision rather than to take positive action. "This lack of positive
action meant ... unacceptable 'supervision' of the C&F team
by Ms Baptiste and the potential passing on of that particular problem
to duty, investigation and assessment workers." It was a telling
conclusion.
|
|
6.35
|
The validity of Mr Prince's conclusions was called into question
by Haringey. In particular I was told that any subsequent improvements
in Ms B's performance were not sustained. Also that it was only
one worker from the children and families' team, and not the whole
team, who threatened to leave in the summer of 1998 if Ms Baptiste
returned to manage that team. Nonetheless, I am firmly of the view
that enough was known in 1997, or ought to have been known, about
Ms Baptiste's management style for alarm bells to be ringing.
|
|
6.36
|
According to Mr Duncan, Ms Baptiste had recognised the difficulties
she had had with the children and families' team and it was she
who requested a transfer to the IAT on her return from maternity
leave in August 1998. Ms Wilson and Mr Duncan agreed the transfer.
According to Mr Duncan, the thinking was to wipe the slate clean
and let Ms Mairs, who was considered a strong manager and who had
earlier been Ms Baptiste's line manager in another social work team,
act as her mentor.
|
|
6.37
|
If this had been the managerial intention, it certainly rendered
invalid any notion that the managers of the two IATs in 1999 carried
equal responsibility for the running of the teams. Indeed, the overwhelming
impression from the evidence of the social workers in Ms Baptiste's
team was that Ms Mairs was very much in control. Ms Mairs was equally
clear that it was not her understanding that she had any mentoring
role for Ms Baptiste. Certainly, no such support was offered by
her. Nor was any additional support given to Ms Mairs to take on
this task.
|
|
Paragraphs: 6.1 - 6.12
| 6.13 - 6.17 | 6.18 - 6.25
| 6.26 - 6.37 | 6.38 - 6.49
| 6.50 - 6.57 | 6.58 - 6.59
| 6.60 - 6.71 | 6.72 - 6.79
| 6.80 - 6.94 | 6.95 - 6.108
| 6.109 - 6.120 | 6.121 -
6.129 | 6.130 - 6.140 | 6.141
- 6.149 | 6.150 - 6.158 | 6.159
- 6.171
|
|
|
|
6.38
|
The tensions that had featured during Ms Baptiste's time in the
children and families' team began to resurface in IAT B. As a result,
according to Ms Baptiste, she found it hard to engage some social
workers, Ms Arthurworrey included, in the regular supervision so
fundamental to good practice. Although Ms Arthurworrey has denied
ever refusing supervision when it was offered, there clearly was
an issue about the quality and timeliness of the supervision that
was provided in Ms Baptiste's team. This was confirmed by the director
of social services at the time, Mary Richardson.
|
|
6.39
|
Ms Arthurworrey understood she would get supervision every two
to three weeks, "but this never happened". In practice she received
supervision about once every seven weeks. "When I asked about drawing
up a supervision contract Carole [Baptiste] told me that I was responsible
for doing that." Ms Arthurworrey said she experienced serious problems
in arranging supervision sessions with Ms Baptiste because of her
continued unavailability. Often Ms Baptiste would cancel or rearrange
sessions or simply not appear without an explanation.
|
|
6.40
|
Of equal concern, Ms Arthurworrey said she found supervision with
Ms Baptiste frustrating because, more often than not, they would
start discussing cases and then Ms Baptiste would go off on a tangent.
Ms Arthurworrey stated that Ms Baptiste often talked about her experiences
as a black woman and her relationship with God. The result was that
they would not have time to finish discussing the cases. Ms Arthurworrey
said she just tried to manage. Generally it was Ms Baptiste's practice
to agree with whatever suggestions Ms Arthurworrey put in front
of her. Ms Arthurworrey found this disturbing in the sense that
it led her to question Ms Baptiste's knowledge base.
|
|
6.41
|
Two other social workers in Ms Baptiste's team gave evidence as
to the irregularity and variable quality of her supervision and
complained that she referred to her religious beliefs and gave religious
guidance during supervision sessions. However, her senior practitioner
Mr Almeida was unaware of any complaints as to the content of Ms
Baptiste's supervision sessions, as was Mr Duncan. Ms Baptiste denied
using supervision sessions to talk about her own personal religious
beliefs saying that any talk of religion "was definitely relevant
to the casework". However, she admitted mentioning her religious
beliefs during the course of her work because during the period
when she was dealing with Victoria's case Ms Baptiste had started
attending the Rahema church.
|
|
6.42
|
The extent to which supervision sessions, when they occurred, were
preoccupied with talk about religion or matters unrelated to the
casework in hand has been difficult to gauge some two years after
the event. As pointed out by Haringey council, the record of the
meeting with Mr Duncan in July 1999 confined itself to a discussion
of Ms Baptiste's poor timekeeping, lack of availability for supervision,
poor case management and case allocation. This, together with the
assertion by Mr Duncan that he knew nothing of the complaints about
the quality of Ms Baptiste's supervision, may suggest that the experience
of Ms Arthurworrey and others was not universally shared by other
members of the team.
|
|
6.43
|
One outcome of the July meeting was that Ms Baptiste agreed to
work full time from July 1999 and it was hoped that this would ease
the problem of availability. But, as the restructuring interviews
took place throughout the autumn of 1999 and Ms Baptiste's job looked
increasingly insecure, her timekeeping became even more erratic.
I shall return to the restructuring interviews later at paragraph
6.124.
|
|
6.44
|
Ms Arthurworrey recalled, "Some days she was in the office, most
days she was not [and] she did not record her movements in the movement
book." Cases would appear on social workers' desks without any guidance
from Ms Baptiste about the issues. When she was in the office, Ms
Baptiste was not readily available, which became problematic when
cases required an urgent response. Ms Arthurworrey said she felt
unsupported and isolated at Haringey.
|
|
|
|
6.45
|
Complaints from IAT B about the lack of any formal allocation system
for new cases met with little response. Managers ultimately had
discretion as to who was given which cases - a discretion that should
have systematically taken into account a social worker's experience
and capacity for taking on more work. Typically, cases were just
'plonked' on social workers' desks without prior knowledge, often
with very little consideration to a social worker's experience,
current commitments or workload. There would be no conversation
between manager and social worker as to what work needed to be done
on a case. Peter Lewington, assistant branch secretary of Haringey
UNISON, stated, "Team managers seemed to be under pressure to get
cases allocated and it seemed as if their main priority was just
to get a worker's name against a case."
|
|
6.46
|
Once again, Ms Wilson said she was not aware that cases were allocated
without the team manager reading the case beforehand or that cases
were just left on social workers' desks. Ms Richardson, however,
accepted that case allocation was not done in the most rational
way and that this may have had an impact on Ms Arthurworrey at the
time.
|
|
6.47
|
Following the July 1999 meeting, a new system of case allocation
was introduced. Social workers were expected to attend weekly meetings
so that cases could be allocated to them involving issues in which
they had a particular interest. The experiment was extremely short-lived.
Ms Arthurworrey recalled, "One case allocation meeting chaired by
Carole [Baptiste] was held in July or August 1999 and this appeared
to work quite well. The second meeting was due to be chaired by
Carole but was never held because Carole arrived at work late ...
and the following week we were informed that the case allocation
meetings had been scrapped because there was 'no commitment from
the social workers'." Ms Baptiste blamed the social workers for
failing to attend and said, "Eventually we reverted to the old system
of allocation, as there was simply insufficient commitment to the
new system." The problem remained unsolved.
|
|
6.48
|
When Ms Baptiste was not available, Ms Mairs, Mr Almeida and Mr
Duncan would provide guidance and supervision to social workers
in IAT B. This put additional strain on Ms Mairs and Mr Duncan.
Ms Mairs stated that the quality and depth of support she was able
to provide would have been less than what would have been available
had there been a manager there full time.
|
|
6.49
|
Mr Duncan said he had serious doubts about Ms Baptiste's availability
to manage a team after July 1999. Mr Almeida felt that Ms Baptiste
could be a capable manager but at the time there were outside factors
that affected her capability to a degree. Even more worryingly,
Ms Wilson acknowledged that Ms Baptiste "was one of our weaker managers.
She was not the weakest".
|
|
Paragraphs: 6.1 - 6.12
| 6.13 - 6.17 | 6.18 - 6.25
| 6.26 - 6.37 | 6.38 - 6.49
| 6.50 - 6.57 | 6.58 - 6.59
| 6.60 - 6.71 | 6.72 - 6.79
| 6.80 - 6.94 | 6.95 - 6.108
| 6.109 - 6.120 | 6.121 -
6.129 | 6.130 - 6.140 | 6.141
- 6.149 | 6.150 - 6.158 | 6.159
- 6.171
|
|
|
|
6.50
|
At interview in September 1999, Ms Baptiste was deemed unappointable.
According to Ms Wilson, "[her] practice responses were not inappropriate
and her presentation and performance was just about adequate. In
one or two areas she achieved higher marks than other managers.
However, she appeared to have little confidence." Ms Wilson admitted,
however, in her statement to Mr Monaghan as part of Haringey's own
internal inquiry that she became very concerned about Ms Baptiste's
performance at interview and said she did not feel that she had
a "management grip". Ms Baptiste was subsequently moved from front-line
services to Quality Protects funded project work in November 1999.
She was formally suspended on 15 February 2000 and made redundant
on 25 February (the very day of Victoria's death), though she had
been absent on sick leave from 20 December 1999.
|
|
6.51
|
Ms Baptiste's suspension was entirely unrelated to her handling
of Victoria's case or to her work in Haringey. However, the issue
for this Inquiry is whether the deterioration in Ms Baptiste's mental
health culminating in her suspension was one that had been developing
in the preceding months and, more particularly, while Ms Baptiste
was the team manager responsible for Victoria's case. If so, did
it manifest itself in ways that were or should have been noticeable
to Ms Baptiste's managers? The evidence on this is far from clear.
|
|
6.52
|
Mr Duncan said that he thought Ms Baptiste's mental state was entirely
stable throughout 1999. Further, Mr Duncan stated that he saw Ms
Baptiste more than any other manager and he saw no mental or physical
symptoms in her. "No more so than any of the other managers." Ms
Baptiste was asked whether she was treated or diagnosed with any
mental disorder prior to January 2000. Ms Baptiste stated, "not
that I am aware of, no". Ms Baptiste advised that she had not been
to a doctor about a mental disorder before January 2000 and nobody
had diagnosed her as suffering from any mental disorder before January
2000.
|
|
6.53
|
Ms Baptiste stated that she did suffer memory losses during the
period August to December 1999 and had discussed this with her manager,
Mr Duncan. Ms Baptiste recalled "not being able to conceptualise
things … I was not able to visualise things … I remember
that I found it very difficult to do simple calculations and particularly
leading up to the restructuring where it was said that there was
going to be … a mathematical exercise … I was really
struggling with numbers." Ms Baptiste confirmed that this was around
summer 1999. Ms Baptiste spoke to Mr Duncan informally about how
she was finding it difficult to remember things and to remember
how to do things.
|
|
6.54
|
Asked whether her illness in January came out of the blue, Ms Baptiste
said that, "probably in hindsight … I am probably able to
say that there was a lot of forgetfulness, absentmindedness, not
remembering things, but not being aware that I was not remembering
things, which was something that I had mentioned to my manager but
it was not something that was taken particularly seriously." Ms
Baptiste stated that it was difficult to say whether these early
signs were affecting her competence as a team manager during the
period from July to November 1999. She confirmed, however, that
there was nothing that led her to suspect she might be suffering
from any form of mental disorder before January 2000 nor did she
report her difficulties to her GP. "I thought at the time it was
just because of the additional pressures of what was going on …
I did not think it was out of the ordinary.
|
|
6.55
|
Whatever Ms Baptiste's precise mental state may have been during
the second half of 1999, it seems clear to me that her managers,
in particular Ms Wilson and Mr Duncan, knew enough about her weakness
as a manager by the time she left to go on maternity leave in November
1997 to at least seriously question the wisdom of putting her in
charge of a pressured investigation and assessment team.
|
|
6.56
|
Indeed, not only were the additional supports entirely absent for
Ms Baptiste, but the restructuring process that was to occupy the
time of managers throughout so much of 1999 actually limited the
capacity of Ms Baptiste's manager to do his job properly.
|
|
6.57
|
Mr Duncan now believes that he may not have dealt sufficiently
rigorously with the concerns raised by staff at the July 1999 meeting.
In his closing submission he said, "I clearly should have taken
a more controlling approach to Carole and her team." As a temporarily
promoted manager himself - Mr Duncan was acting commissioning manager
for the NTDO from April 1998 to September 1999 - his substantive
grade remained that of team manager. As part of the restructuring
process, Mr Duncan was expected to compete for both positions -
in effect putting him in direct competition with Ms Baptiste, at
least for the team manager post. This, he said, may have caused
him to take his eye off the ball and led him to feel disempowered
in supervising Ms Baptiste from March 1999. While I accept Mr Duncan's
evidence as to how he felt at the time, I am of the view that a
stronger manager would not have let their acting-up status interfere
with the way they did their job. The net effect was that there was
no adequate supervision of Ms Baptiste's practice and her supervision
at all times.
|
|
Paragraphs: 6.1 - 6.12
| 6.13 - 6.17 | 6.18 - 6.25
| 6.26 - 6.37 | 6.38 - 6.49
| 6.50 - 6.57 | 6.58 - 6.59
| 6.60 - 6.71 | 6.72 - 6.79
| 6.80 - 6.94 | 6.95 - 6.108
| 6.109 - 6.120 | 6.121 -
6.129 | 6.130 - 6.140 | 6.141
- 6.149 | 6.150 - 6.158 | 6.159
- 6.171
|
|
|
|
6.58
|
This was particularly significant because, at the time, social
workers in the NTDO and their first-line managers were simply not
following local guidance, and senior managers either knew and condoned
this or remained blissfully unaware of its consequence.
|
|
6.59
|
Among the several sets of guidance that IATs were subject to, were
the following:
|
|
|
|
•
|
These were rewritten in 1997 and outlined the duties and responsibilities
of social workers undertaking investigative and assessment work.
The introduction states, "It is expected that these will be followed
by all staff involved in child protection investigations.
|
|
|
|
•
|
These were devised by Ms Mairs in June 1998 and covered "the overall
framework for the provision of a Duty Children and Families Service
for the North Tottenham District Office [and] work in conjunction
with existing procedures". These procedures were intended to operate
as a pocketbook enabling social workers to be clear about their
duties at a glance. Ms Arthurworrey was aware of the Duty Investigation
and Assessment Procedures, which she said influenced her practice.
But according to Ms Bradley, "There was a practice manual and other
procedures available to social workers. However, social workers
were never directed to it and practices developed which were separate
to the practice manual. There was a lot of confusion about what
the relevant procedures were.
|
|
|
|
•
|
In addition, there was a handbook prepared by the Haringey ACPC,
dated June 1997, outlining each agency's role in the child protection
process. These provided a guide to inter-agency procedures and a
working tool for professionals involved with children. Ms Arthurworrey,
however, had never heard of the ACPC handbook. Likewise, Ms Kozinos
said that she had no idea that there were ACPC child protection
guidelines to assist her. Ms Mairs said that she had seen the ACPC
guidance but she did not think they had much relevance to the day-to-day
operation in Haringey. Asked how she expected her team to be able
to take into account the ACPC guidelines if she was not familiar
with them, she replied that she could not answer. Ms Mairs stated
that the guidelines were not something her team would use.
|
|
•
|
Not for the first time, senior managers were to express surprise
at what they learned during the Inquiry's evidence stage. Speaking
about the ACPC guidelines, Ms Richardson said, "I find it difficult
to believe that people were not aware of them. They were widely
circulated and available in area offices." Ms Richardson said she
would expect them to use the guidelines in relation to the inter-agency
work that was going on. Ms Wilson advised that copies of the ACPC
handbook were available although they were not given out to individual
social workers. Further, Ms Wilson said that in January 1999 she
"personally spent time in Tottenham and at a large group meeting
... went over each of the relevant plans, documents and procedures
which were available to staff, confirmed their existence, accessibility
and staff familiarity with them and in relation to procedures and
their obligations in law. Managers and social workers concerned
in the Inquiry were all members of staff at this time and participated
in preparation and review of the services policies and procedures".
Ms Wilson said that she was satisfied that the guidelines were available:
"I was assured that staff knew they were available. I had feedback
through the child protection adviser on reinforcement of access
to those guidelines." Ms Wilson said she was very surprised to hear
that Ms Kozinos had never even seen a copy of the ACPC guidelines
because Ms Wilson had personally seen it on the shelf in that office.
While Ms Wilson may well have had grounds for being impressed by
the availability of the ACPC guidelines, it is less clear that she
had any grounds for being impressed as to their use.
|
|
|
|
•
|
Both Ms Kozinos and Ms Mairs said they had limited familiarity
with the Case Recording Practice Guidelines, dated January
1998, and that they were not followed because they "did not have
the appropriate resource to enable us to follow it." The truth of
that statement was all too visible in Victoria's case and more generally
as to merit repeated criticism in Social Services Inspectorate (SSI)
inspections and the Joint Review of 1999. But senior managers had
a different slant on the problem and one that, if correct, needs
to be addressed across the social work profession as a whole. Ms
Wilson observed, "We had some staff who, although qualified as social
workers, did not always appear to achieve that level of literacy
on paper." Ms Richardson commented that there was "resistance from
some staff in Haringey about using the written word at all".
|
|
|
|
•
|
More astonishing still was the admission by Ms Kozinos that they
did not follow the supervision policy of Haringey Social Services.
Specifically, she claimed that the supervision policy was regarded
as having been superseded by the custom and practice in Haringey
of not reading the case files. The tragic consequence of this was
that nobody in Haringey - not even Ms Arthurworrey - ever read Victoria's
case file in its entirety.
|
|
|
Ms Mairs said that while there was a written policy that managers
should read files, it was simply not practicable to read every file
unless there were concerns about the competence of the social worker.
There was a lack of resources to do this and no system in place
to facilitate it. Ms Mairs agreed that proper supervision necessitated
the reading of case files, if not routinely then at least periodically,
and she accepted that it was a rather hopeless system if managers
did not look at the files to test the way in which social workers
were going about their work.
|
|
|
Mr Duncan knew that managers were not systematically reviewing
files, but he claimed he did not know that Ms Mairs was not reading
them at the crucial points of supervision. Ms Mairs disputed this,
stating that Mr Duncan was aware that managers were not reading
files before supervision because it was discussed at team management
meetings.
|
|
|
Ms Wilson acknowledged that a manager could not participate fully
in supervision unless they had read the file: "I think files were
an intricate part of good supervision management." Once again, Ms
Wilson was surprised to learn that Ms Mairs's team did not read
files or adhere to the supervision policy during 1999. Ms Wilson
stated she knew as a certainty that other parts of north Tottenham
used the policy and did not accept that was the general practice
in the NTDO. I am left questioning just how she could be so certain
in the face of the evidence from Duty Investigation and Assessment
Team (DIAT) witnesses and the clear failings in practice in Victoria's
case. Therefore, I make the following recommendation:
|
|
|
Recommendation
|
|
|
Directors of social services must ensure that the work of staff
working directly with children is regularly supervised. This must
include the supervisor reading, reviewing and signing the case file
at regular intervals.
|
|
Paragraphs: 6.1 - 6.12
| 6.13 - 6.17 | 6.18 - 6.25
| 6.26 - 6.37 | 6.38 - 6.49
| 6.50 - 6.57 | 6.58 - 6.59
| 6.60 - 6.71 | 6.72 - 6.79
| 6.80 - 6.94 | 6.95 - 6.108
| 6.109 - 6.120 | 6.121 -
6.129 | 6.130 - 6.140 | 6.141
- 6.149 | 6.150 - 6.158 | 6.159
- 6.171
|
|
|
|
6.60
|
If local guidance was not routinely being followed in 1999 - and
I have no doubt that had it been, the standard of some of the work
done in Victoria's case would have been raised substantially - the
child protection advisers (CPAs) ought to have provided a necessary
and effective safety net. As part of the child protection, quality
and review section of children and families' services, they reported
direct to Ms Graham and worked independently of the children and
families' teams. Petra Kitchman was one of two CPAs that covered
the NTDO and had a room in that office, which she used for two days
each week.
|
|
6.61
|
Typically, social workers or team managers would invite CPAs to
give consultations and advice. CPAs had no case responsibility and
would not offer advice in a case unless asked to do so, despite
Child Protection Guidelines stating that all work in relation
to child protection must be carried out in consultation with CPAs.
|
|
6.62
|
It was Ms Wilson's "clear expectation" that "access to a child
protection adviser was the right of every social worker who was
concerned on a case". It was also her expectation that advice offered
by a CPA would be followed, though Ms Kitchman acknowledged that
CPAs would not necessarily know whether that was the case or not.
Where there was any conflict over the advice offered, it was for
the team manager and CPA to resolve, and if necessary, refer the
matter up through their respective line managers.
|
|
6.63
|
Ms Arthurworrey's understanding of the role of CPAs was less clear-cut.
She acknowledged they were not routinely used in all child protection
cases and believed they were only used at the specific direction
of team managers. In Ms Arthurworrey's experience, a team manager
would involve a CPA if there were issues that could not be resolved
in supervision. While Ms Arthurworrey had used CPAs in the past,
she did not make regular use of them and she did not initiate contact
with Ms Kitchman in Victoria's case. Ms Arthurworrey understood
her manager was responsible for her cases and she felt she "needed
to get directions from her manager so that she could work in a logical
way". This was not a view shared by Ms Baptiste or Ms Mairs.
|
|
6.64
|
Any confusion as to the role of the CPA appeared to extend to what
they did when they were consulted. Ms Kitchman advised that she
did not have a quality control role in relation to casework, although
she acknowledged there was an element of quality assurance in relation
to undertaking audits and chairing case conferences. Ms Kitchman
said that it was not part of her responsibilities to monitor and
evaluate the work of a social worker who approached her for advice
or to ensure that they were dealing with the case properly, unless
obvious concerns were noted.
|
|
6.65
|
Ms Wilson disagreed. She said CPAs "were an independent audit of
good practice". She was quite clear that CPAs had a role in supervising
the quality of the work on those cases with which they become involved.
In particular, she considered CPAs "had an individual responsibility
and accountability in relation to cases and that the service as
a whole had a formalised quality assurance role in relation to good
practice". CPAs had a "responsibility to determine what was good
practice on the case in giving advice. [Ms Wilson] would not expect
them to dip in and out unless they were satisfied that the way they
had left the position was one of safety".
|
|
6.66
|
Ms Mairs believed there were no politics in using a CPA. Yet Ms
Wilson observed that there was opposition to CPA involvement among
a number of team managers. CPAs and team managers worked at the
same operational level, but Ms Wilson was philosophical about this,
stating, "It was something that we recognised as being inherent
in the role and that needed to be strongly managed." Those tensions
are "built into the role if you have an inspector, but that does
not mean you should not have it and that it is not a very important
aspect of monitoring practice". According to Ms Wilson, the fact
that some team managers were undermining CPAs and that this was
causing tension was not a continuous problem. There were individual
issues that arose where team managers took a different perspective
from a CPA, which was resolved in 95 per cent of the cases, but
which needed to be confronted in a small minority of cases.
|
|
6.67
|
If the CPAs' role within Haringey Social Services was less than
clearly defined or understood, the position was considerably worse
in relation to outside agencies.
|
|
6.68
|
Ms Kitchman was also the link worker with the North Middlesex Hospital.
Besides a general duty to liaise with other agencies, there were
no established procedures or written documentation setting out what
Ms Kitchman's role in relation to the North Middlesex Hospital was
to be. As a result, Ms Kitchman thought her role as a link worker
to the North Middlesex Hospital was rather tenuous, but believed
in practice it amounted to attending liaison meetings at the North
Middlesex Hospital with Dr Rossiter, Enfield Social Services and
the North Middlesex Hospital social work team manager once every
two months. Ms Kitchman saw her relationship with Dr Rossiter as
involving liaison over specific cases, for example, at planning
meetings.
|
|
6.69
|
Dr Rossiter said she saw Ms Kitchman as the appropriate person
in social services with whom she should liaise and to whom she should
report concerns. However, Ms Kitchman said she did not see herself
as the sole point of contact, nor did she believe that referrals
from external agencies should be made to CPAs, in effect bypassing
the district offices.
|
|
6.70
|
Ms Mairs thought differently. She advised that CPAs were there
as consultants to the public. If agencies wanted to make a referral,
they could bypass the district and go straight to the CPAs, but
it was important that the CPAs inform the district of that. If a
CPA received information on a case that was already in a social
work team, Ms Mairs would expect the CPA to discuss it with the
social worker and the team manager.
|
|
6.71
|
Ms Green, another CPA, viewed her role as both intra and inter-departmental.
Ms Green believed CPAs offered a resource to everybody, including
the general public. Anybody could phone up about a child protection
concern, including other agencies. Outside agencies, for example
paediatricians, would contact the CPAs for advice on child protection
issues or because they were concerned a case they had referred to
social services was not progressing. If external agencies were frustrated
with trying to work things out with social services, CPAs were a
safety net and were seen as a centralised team of people who would
intervene, hear the case, and make a decision about the best way
forward. Sadly no such constructive action was forthcoming when
Dr Rossiter sought to involve Ms Kitchman in Victoria's case, nor
was it ever likely to be if managers were relying on the flawed
and misunderstood guidelines and protocols operating between CPAs
and DIAT social workers and CPAs and the North Middlesex Hospital.
Therefore, I make the following recommendation:
|
|
|
Recommendation
|
|
|
Directors of social services must ensure that the roles and responsibilities
of child protection advisers (and those employed in similar posts)
are clearly understood by all those working within children's services.
|
|
Paragraphs: 6.1 - 6.12
| 6.13 - 6.17 | 6.18 - 6.25
| 6.26 - 6.37 | 6.38 - 6.49
| 6.50 - 6.57 | 6.58 - 6.59
| 6.60 - 6.71 | 6.72 - 6.79
| 6.80 - 6.94 | 6.95 - 6.108
| 6.109 - 6.120 | 6.121 -
6.129 | 6.130 - 6.140 | 6.141
- 6.149 | 6.150 - 6.158 | 6.159
- 6.171
|
|
|
|
6.72
|
Haringey's management information system provided managers with
very limited help with keeping them up to date with what was going
on in their teams in 1999. Its client index system, originally created
as a management tool, was later adapted for team managers and service
managers to manage caseloads but had yet to achieve its purpose
by the time Victoria arrived in Haringey.
|
|
6.73
|
Mr Duncan said that in 1999 the information on the system was often
inaccurate. But he accepted that was the fault of the people putting
information into the system rather than with the system itself.
His business plan for the NTDO, dated February 1999, stated, "Among
other things, inaccurate statistics make performance targets hard
to set and reach, and plans hard to develop." Dinos Kousoulou, deputy
director of housing and social services, who was responsible for
the management information system across the directorate, said that
he was not aware of this at the time. However, the Joint Review
into Haringey in 1999 noted, "The authority is aware that its current
client index system is not able to support its service planning
and business planning arrangements." Mr Kousoulou could not explain
this inconsistency:
|
|
|
"Certainly if there were these levels of problems then yes
I should have been made aware, and if it was to do with the system
itself, the IT system rather than the information that was meant
to be put into it, then clearly that was my responsibility ... It
was for managers like Dave Duncan to make sure that front-line staff
used the system effectively that was there. If it was a problem
with the actual technology then that should have been brought to
my attention."
|
|
6.74
|
Ms Mairs was frustrated with the system and told the Inquiry that
she did not rely on the client index system because it was always
difficult getting accurate records from it and she had always used
a manual system. According to her, there were monthly printouts
informing managers what cases the workers had, but she said 9 out
of 10 times these were not the cases that were allocated to them,
or cases that were closed were still on the system. She thought
there were various reasons why the system was not working in terms
of the input: "It is a problem that Haringey has had for years and
still has." In response, Mr Kousoulou said he was surprised and
concerned that Ms Mairs had abandoned the client index system altogether
during 1999 and kept some manual system of her own.
|
|
6.75
|
Ms Wilson said she thought the system was improving in 1999 and
said, "It was coming into its own as it were in the autumn." Despite
Ms Mairs's independent stand, Ms Wilson said she took the view that
the client index system was no longer an optional extra: "I took
a very firm and clear line that whatever the good bits or the bad
bits about the system, it was the one we must use and we must get
it as accurate as possible." Ms Richardson thought that, by the
time she left Haringey, the client index system was still in a non-user
friendly state but it could provide most of the information they
had needed up to that point. Mr Kousoulou accepted, however, that
the improvements that were put in place at the end of 1999 did not
resolve all the difficulties, and that by April/May 2000 Haringey
still had a system that was producing inaccurate results and was
unable to support service planning.
|
|
|
|
6.76
|
One performance measure intrinsic to basic, safe, childcare practice
and which, if accurate, would have provided Haringey with an instant
gauge of the pressures facing its DIATs in 1999 related to its unallocated
children's cases.
|
|
6.77
|
In May 1999, Mr Duncan reported that in the NTDO there were 61
unallocated cases and in the Hornsey office there were 48, making
a total of 109 unallocated cases for which Haringey had responsibility
at the time. The Joint Review from its field work in early 1999
found little evidence of unallocated cases in both district offices,
although there were reports of managers holding responsibility for
unallocated cases. Ms Wilson stated that it was policy for team
managers to assume responsibility for unallocated cases as and when
the occasion demanded it, and to delegate work on those cases to
social workers where it was appropriate in light of their workloads.
|
|
6.78
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The state of play on unallocated cases in May 1999 apparently was
not known about at the top of office, nor were members apparently
kept informed. Gina Adamou was lead member of social services at
the time and she thought that the children's service was in good
shape. However, Councillor Adamou said she had not seen Mr Duncan's
report and she was not informed of this situation: "In May 1999
I just came in after a lapse of two years as a lead member of social
services and, no, I could honestly say that I was not told at the
time of this [nor did I see] this Report, but there are reports
that never come to members."
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6.79
|
Chief executive, Mr Singh, said that the information around unallocated
cases was something that was routinely collected through the performance
management framework. Had there been a problem he would have picked
it up. It was Mr Singh's understanding that unallocated cases was
not an issue at that time, further casting doubt on the value of
the performance management framework he relied on.
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Paragraphs: 6.1 - 6.12
| 6.13 - 6.17 | 6.18 - 6.25
| 6.26 - 6.37 | 6.38 - 6.49
| 6.50 - 6.57 | 6.58 - 6.59
| 6.60 - 6.71 | 6.72 - 6.79
| 6.80 - 6.94 | 6.95 - 6.108
| 6.109 - 6.120 | 6.121 -
6.129 | 6.130 - 6.140 | 6.141
- 6.149 | 6.150 - 6.158 | 6.159
- 6.171
|
|
|
|
6.80
|
Remedying an unreliable and inaccurate management information system
was clearly an essential prerequisite to sound business planning
for Haringey, particularly in the face of persistent and severe
financial pressures. In 1999, these were directly linked to its
decision to write off over a 10-year period a sizeable debt expended
on the redevelopment of Alexandra Palace, high levels of homelessness
and numbers of asylum seekers coupled with pressure from the Government
to protect and increase education funding.
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6.81
|
In fact, education had all but taken centre political stage in
Haringey in 1999, following a devastating OFSTED review of Haringey's
education services, which "completely condemned" the local education
authority and suggested the whole of the local education authority
function should be externalised.
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6.82
|
As a result, and bowing to Government pressure, by the year 2000/2001
councillors agreed to 'passport' the entire education standard spending
assessment (SSA) figure to its education services. It is not for
me to judge the merits of Haringey's financial deliberations between
its spending departments except to observe that children's services
fared badly by comparison. For the years 1997/1998 to 2001/2002,
Haringey council spent substantially less than the sum allocated
in the SSA for children's social services. In 1998/1999 the gap
was approximately £10m, declining thereafter not because of any
significant increase in Haringey's spending on children's services,
but because of changes in the way the Government estimated children's
services SSA across the board. This led to a reduction in Haringey's
own children's services assessment figure of just under £8m. The
cut was sufficient to prompt Haringey to make complaints to Government
ministers about its effect.
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6.83
|
In the evidence of its senior managers, and in their closing submissions,
Haringey council was at pains to point out that in the years 1997
to 2000 it did not consider the SSA as a valid assessment of an
authority's need to spend, nor that it was a Government instruction
to spend at that level. The SSA, it was said, is no more than a
formula used by Government to distribute the total national spend
on the basis of relative need (allowing for differences in population
profiles), which can then be topped up by local authorities from
council tax. Its limitations have been recognised by Government,
not least the fact that it cannot take account of all the pressures
facing a local authority. For example, the SSA formula took no account
of the £7m a year Haringey had to spend on its statutory duty to
homeless families. Accordingly, the fact that Haringey council spent
considerably less than its SSA for the period 1997 to 2000 does
not, in the council's view, indicate what priority Haringey council
accorded children's services nor does it reveal how well resourced
Haringey's children's services were compared with its needs.
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6.84
|
I disagree. While the SSA may not be capable of encompassing all
the cost pressures facing a local authority at any one time, it
is unlikely to have substantially underestimated these, and certainly
not to the extent of £10m for services to children and families.
Arguably elements of the SSA should represent no more than the starting
points in council budget deliberations, and any departures from
these should be justified on the basis of local intelligence about
population needs. In my view, any alternative approach to determining
children's services budgets has to be at least as good as that offered
by the SSA.
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6.85
|
Haringey council claims it had such an alternative approach. The
process involved the council's senior social services officers providing
information to elected members about local need and local service
requirements and ensuring members fully understood the council's
statutory responsibilities. To do this, officers held discussions
and had extensive contact with service users, other stakeholders
in the borough locally, and other agencies, for example, the health
service. In Haringey's view, this "local knowledge and discretion"
provided a more sophisticated view of need and was therefore a better
method than simply following the product of a national formula.
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6.86
|
It would seem that neither the Joint Review of 1999 nor the SSI
inspection of children's services in June 2000 agreed. The SSI found
that the children and families' services were "poorly resourced
in comparison to its equivalent group of councils ... We concluded
that the service was underfunded." The SSI commented, "Unless the
[children and families'] service is appropriately resourced a difficult
situation can only get worse." The Joint Review had also recognised
the funding of children and families' services as an issue.
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6.87
|
The 1999/2000 budgetary process was also affected by the publication,
in the summer of 1998, of the first Comprehensive Spending Review
(CSR), which set the national local government spending totals for
the period 1999/2000 to 2001/2002.
|
|
6.88
|
At the time, Haringey council had one of the highest council tax
rates in London. In the face of an election manifesto pledge in
May 1998 to keep the rate of increases in council tax below the
rate of inflation, Haringey council had all but ruled out council
tax increases as an extra source of revenue. In any event, the capping
regime in place at the time imposed its own level of restraint.
|
|
6.89
|
Instead, Haringey council set a three-year savings target of £26m.
In setting savings targets for individual service areas, Haringey
council allocated a 'high, medium, low' prioritisation to services.
The children's service received a high-priority rating, meaning
it should be protected as far as possible.
|
|
6.90
|
According to leader of the council, George Meehan, elected members
relied on social services officers to advise them on what the need
was and the amount of money to spend. The Inquiry heard conflicting
evidence as to whether senior social services officers advised members
that Haringey's statutory obligations to children would not be capable
of being fulfilled within the budgets set. Councillor Craig Turton
recalled that councillors were "consistently advised by senior Haringey
Social Services staff" that "The financial allocation made to children's
services and to child protection was barely adequate, and unless
significant year on year increases were made to the budget, the
quality of services provided would inevitably suffer a significant
deterioration." However, Councillor Turton acknowledged that these
concerns were not recorded in minutes of meetings.
|
|
6.91
|
Haringey council rejected the suggestion that senior officers informed
members that the proposed level of spending meant that the council's
statutory duties towards children could not be met or were at dangerous
levels. Ms Richardson confirmed that she "attempted to get ... the
highest level of protection possible" in the 1999/2000 budget for
children's services. According to Ms Richardson, the amount of saving
in the whole of children's services in proportionate terms was better
than the percentage taken out of other services and "the most vulnerable
parts of this service we gave the maximum amount of protection to,
internally". She stated that while priority was given, she did not
feel happy because services were stretched. However, "The reality
was that the service was treated better than other services."
|
|
6.92
|
Mr Singh told the Inquiry that while there were expressions of
concern about the general tightness of budgets, none of the three
directors of social services in post during his tenure advised him
that the budgets were insufficient to enable Haringey council to
discharge its statutory responsibility in the delivery of children's
services. Mr Singh told the Inquiry that if this risk had been drawn
to his attention, there would have been some interventions. Likewise,
Councillor Meehan advised that if the director had said children's
services needed more money, he has no doubt that the council would
have provided more money.
|
|
6.93
|
Based on the evidence before me, I accept Haringey council's contention
that there was no clear and explicit advice from its senior managers
to spend more money on children's services in order to avoid putting
at risk Haringey's proper discharge of its statutory duties and
avert potential tragedy.
|
|
6.94
|
I do not, however, accept its conclusion that "There is not a shred
of evidence that the alleged lack of funding of the children's services
had any impact on the way in which Victoria's case was handled ...
There was no facility to which she might have been referred to which
she was not referred because of lack of funds." Victoria died because
those responsible for her care adopted poor practice standards.
These were allowed to persist in the absence of effective supervision
and monitoring. Corners were cut and resources were fully stretched.
There is evidence in plenty to support this. An easing of the financial
pressures facing Haringey's children's services could only have
had a positive impact on the environment in which Ms Arthurworrey
was working in 1999.
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Paragraphs: |
