Child Protection Failings UK: The Need For Reform

One of our primary aims is reform of the child protection system in the UK.  If there is any doubt that this is neccesary, i urge you to have a look at this BRIEF history of child protection failings in the UK (it’s a very small part of the picture – but alot of the data is protected).

Reform of Child Protection Services last occurred following Lord Lamings recommendations as a result of a Public Inquiry into Victoria Climbies death, a few streets away and less than 10 years before Baby Peter Connelly was to die so horrifically. Knowing that Peter was visited over 60 times by various professionals before his death, it is clear the system is still not effectively protecting children.

We must be prepared to take a deep, honest look at the child protection system, and make real and lasting changes that will protect children like Victoria and Peter in the future. No more can we accept false promises, lip service, cover-ups and white-washes.

Most of us love our kids and would do anything to protect them from any kind of harm. But sadly, there are people who do not. Between 1 and 4 children die every 10 days in the UK as a result of child cruelty. Shamefully, this has not changed in 30 years. Child abuse is very REAL and likely to be happening no more than a few miles of your home. It is only by luck of birth that you are not part of that awful statistic.

Voiceless, innocent, and defenceless children are suffering and dying, and we have not become more effective at protecting them since the 1970’s. Everyone is responsible for protecting and caring for these kids, since their own carers abuse them. Not only are we socially, morally, and ethically responsible, but protecting children benefits everyone. If the cycle of abuse can be broken, then abused children that might once have become ‘lost’ are more likely to become constructive members of the community as adults.

Here, we have compiled the reasons why we believe reform of the child protection system is something the government really must consider. We have tried to take the most important points raised from child protection cases and Serious Case Reviews and organise the information so it is as easy-to-follow as we can make it.

History of Abuse and Protection Cases in UK:

1945: Dennis O’Neil, 13, was beaten to death by his foster father, Reginald Gough, at Bank Farm, Shropshire. He weighed just 4 stone, as he had been starved for months. A Home Office inquiry identified a string of failures by the staff and agencies involved in the case. There had been confusion between the two local authorities responsible for the boy’s foster placement, conflicting reports by childcare staff about his well-being, staff shortages and miscommunication. Sadly, this is a story that is all to familiar, even today, over 50 years later.

1956Toddler Holdsworth was 2 when he died after being systematically tortured by his mother.

1967 18-month old Michael Buckingham was murdered by his father.

1973, agencies were again criticised because Maria Colwell, seven, died in Brighton after being starved and beaten by her stepfather, William Kepple, despite over 50 visits to the family before her death. Parallels to the Baby Peter case in 2007 do not need to be pointed out.

1984: Jasmine Beckford was 4 when she died. She was in the care of Brent social services for two-and-a-half years before she died, after Beckford was convicted of assaulting her younger sister. She was seen by a social worker only once in 10 months. The same year, 21-month-old Tyra Henry died after being battered and bitten by her father, Andrew Neil, while in local authority care, because authorities were ‘too trusting’ of Neil.

1984 also, Heidi Koseda starved to death in a locked room, after a senior inspector for the NSPCC failed to investigate her well being, despite being allocated her case. After her death, he tried to cover up his mistakes by inventing a fictitious account of visiting her.

1986 Kimberley Carlile, 4, was starved and beaten to death in Greenwich by her stepfather, Nigel Hall, and her mother. An inquiry found that her death was avoidable and concluded that key social work and health staff in Greenwich failed to apply the necessary skill, judgement and care in her case.

1987, 16 month old ‘at-risk’ Doreen Mason died of neglect after her mother, Christine Mason, and her boyfriend, Roy Aston, bruised, burnt and broke her leg then failed to have her injuries treated. A report said her social worker was inexperienced and given no proper training or supervision, and that Southwark social services department suffered from a “siege mentality” and “destructive mistrust” between senior managers.

1991: 20-month old Martin Nicoll is killed by his step father.

1992: Leanne White, 3, was beaten to death by her stepfather Colin Sleate. An inquiry concluded that her death could have been prevented if Nottinghamshire social services had responded properly to reports from her grandmother and neighbours that she was at risk. Demi-Leigh Mahon was failed in much the same way by Child protection Services in 2008.

1993: Tiny John Gray, just 21-months old, suffered more than 200 injuries before he died, murdered by his mothers lover. His father said he had reported to the police in Fife, Scotland, where he lived, that his son was being injured by his wife’s lover, but that police said they could take no action as the offences were committed in England.

1994: Rikki Neave, 6, was killed by his drug-addict mother after she had asked a succession of social workers to take the boy off her hands and told one she would kill Rikki if they did not do something. A report by the social services inspectorate three years later said fault primarily lay with senior management in Cambridgeshire social services department.

1997: Lauren Creed was 5 when she was murdered by her mothers boyfriend, despite her plight being reported to civilian and RAF police, and social workers. A Serious Case Review found opportunities were missed to save Lauren, and all agencies involved in her case accepted charges that they had failed to keep adequate records, failed to communicate and failed to hold a case conference.

1999: Chelsea Brown was 2 when she died. A social worker had visited 27 times in the 10 weeks before Chelsea’s’ death. She took Chelsea to a paediatrician who said that six out of nine areas of bruising “had no plausible explanation” and at least one was deliberately inflicted. These findings should have triggered police involvement and a multi-agency case conference under Derbyshire county council’s procedures, but neither happened.

Beautiful Victoria Before Abuse

2000: Victoria Climbié, 8, died after months of horrific neglect and abuse, despite at least 12 chances for the agencies involved in her protection to have saved her, resulting in a Public Inquiry into Child Protection in 2001. The Government’s response to Lord Laming’s inquiry into the Climbie murder began with ‘Every Child Matters‘, a green paper issued in 2003. It said Victoria’s death had highlighted longstanding problems.  The ‘common threads’ linking the failure to prevent hers and other child murders were ‘poor coordination (between different services); a failure to share information; the absence of anyone with a strong sense of accountability; and frontline workers trying to cope with staff vacancies, poor management and a lack of effective training’. These failings, the paper said, were going to be put right, yet we are hearing

Beautiful Victoria Just Before Her Death

EXACTLY the same problems still, today. Peter still died in a very similar way, in the same place.

2000: Lauren Wright was 6 when she was killed by her stepmother. Norfolk social services department has admitted it made serious mistakes and missed chances to save Lauren. An inquiry found that inter-agency coordination was “ineffective” and social workers had not acted with “due urgency”. In 2009, a lack of urgency was found to be one of the reasons why Peter was failed so massively.

2001: Caleb Ness was 11 weeks old when he was shaken to death by his father  in Edinburgh. An investigation ruled that the tragedy in Edinburgh was avoidable and found “fault at almost every level in every agency involved”.

2001: Ashley Chadburn sipped from a bottle of methadone as his mother, Rachel Hipkiss smoked heroin in her home. An independent report into the case accused social services of being “too tolerant of such serious drugs misuse“. In a report by Roger Thompson, a former director of the NSPCC, 26 recommendations are aimed at preventing a repeat. “There was not, in my view, a full and proper assessment of the mother’s parenting capacity,” he said.

2002: Perrin Barlow was nine months old when he died in July in a Plymouth city flat. The SCR into his death revealed there was a “fundamental failure” to protect him from harm. Nigel Meadows, the coroner involved in the case, lost a High Court battle for a full jury inquest into the death. He said the European Convention on Human Rights demanded that an inquest jury consider whether social workers were to blame.

2002: Carla-Nicole Bone, 13 months, was killed by her mothers boyfriend in Aberdeenshire. After the case in Aberdeenshire, Carla-Nicole’s gran said she warned social workers 7 times that the baby was being abused.

2002: Ainlee Labonte, 2, was starved and tortured to death by her parents. An inquiry into her death found that the health and social workers who should have protected her failed to do so because they were paralysed with fear of her parents and also criticised the staff and agencies involved for poor communication and for failing to carry out a proper assessment of the risks facing Ainlee.

2002: Kennedy McFarlane was 3 when she was killed by her mothers’ kick-boxing boyfriend. Medics failed to tell social workers after Kennedy was admitted to hospital following an attack prior to her death. Afterwards, a senior doctor commented that the outcome ‘could have been very different’.

2003, Toni-Ann Byfield was shot in the back along with her crack addict father. A review into handeling of Toni-Ann’s protection critisised Birmingham City Council’s Social Care and Health Directorate, the National Immigration Service, and the Child and Family Courts Advisory and Support Service (CAFCASS) for failing in their professionalism and practice. The review highlighted the ‘need for professionals to maintain a thoroughly watchful and diligent stance in respect of their safeguarding obligations to the children and young people in their charge’. This sounds remarkably similar, again, to the SCR into Peters death.

2003: Chloe Thomas was 14 weeks old when she died with 40 broken bones. Chloe had been placed on an “at risk” register by health workers in the weeks before her death. Health adviser Anne Powell said there had been “concerns” about the baby, who appeared distressed. A child protection conference was held before Chloe’s death in which a “great deal of concern” was displayed by health professionals. Yet no action was taken, and within weeks, Chloe was dead.

2003: Deraye Lewis was beaten to death by his mothers’ boyfriend, Nicholas Halling, in Milton Keynes. He had been tortured for at least a year up to his death. Halling was known to social services because he had been involved with a family where the children were observed to be terrified… social services and the police in Bedfordshire had decided in 2002 that dog handlers should be used if the children needed to be removed and that the police should always be present during visits. Police records had him marked as dangerous and he had already been to prison numerous times.

Yet, when social workers first visited Deraye in July 2004, alerted by neighbours that Halling was physically and racially abusing him, they accepted Donna’s (mother) assurances that everything was fine and closed the file. The social workers were told of escalating abuse on three further occasions, and when they visited saw that Deraye was bruised, and once – like Baby P – had an untreated dog bite. The SCR says they were told by the neighbours that Halling ‘had trained his dog to attack Deraye‘. But ‘the community paediatrician decided, with little evidence, his injuries were not deliberate,’ and again the case was closed.

In September 2004, Donna made a statement to police, saying Halling had attacked her when she tried to stop him beating her son. But it wasn’t passed on to other agencies, and nothing was done to protect them. The SCR reveals that many opportunities to save Deraye were missed.

2004: Lois Lazenby was 2 when she was tortured and killed by her mother and her mother’s boyfriend. Before her death social workers visited the house following reports from a tradesman working nearby that Daniel Bishop (BF)had smacked the toddler. There was also a history of failing to keep appointments or deliberately keeping Lois away from social workers at times when she was obviously in pain.

2004: A three-month-old boy died on October 21 in Doncaster, after being found unconscious while sharing a bed with his alcoholic mother and an older sibling. A SCR concluded that the death was a “tragic accident” but found failings in the way the family had been dealt with and noted that “referral thresholds” were too high..

2004: Jasmine Gayler was beaten to death by her mother and her mothers boyfriend aged just 3 years. She was known to Social Services who failed to spot signs of abuse.

Baby Aaron Gilbert <3

2005: Aaron Gilbert An anonymous caller complained about the way Aaron Gilbert was being treated 8 days before the 13-month-old was killed by his mother’s partner, but a report found that Swansea social services had failed to follow these complaints up properly, and a social worker was suspended. Aaron paid for this mistake with his life.

2006: A seven-month-old girl died on May 18 in Doncaster after concerns were repeatedly raised that her severely depressed mother was drunk while looking after her.

2006: Jack Mallinder was killed by his mother, weeks after he was taken out of foster care and returned to her.

• 2006: Neo Craig was 10 weeks old when his crack-addicted parents killed him. Despite being on the “at risk” register, social workers failed to detect injuries on a visit two months before Neo’s death because he was covered in baby powder. A post-mortem test showed that as well as his fatal injury he had suffered rib fractures and bruising and his head hair tested positive for cocaine. A serious case review by the Havering Safeguarding Children Board found Neo’s parents had tried to hide his injuries. The board said: “Neo’s home life was chaotic and his parents deliberately set out to deceive and confound the various child protection agencies in the lead-up to his death.” The same was said of Baby Peter’s mother…the lessons were clearly not learnt in time to save Peter.

2006: Baby Jack Taylor was 6 months old when he was abused and killed by his parents.

2007: 10-month-old baby died in December in Doncaster after a number of referrals to social services, including indications that he and an older sibling were at risk of harm from their 18-year-old mother and 16-year-old father. The SCR found that social workers were working “against the backdrop of unmanageable workloads” which led to a “chaotic and dangerous situationwithin the child protection team.

2007: Amaraye Bryan was killed by his father, Courtney Bryan, when he was 11 weeks old. The SCR into his deaths revealed that many opportunities to save him were missed by the agencies responsible for protecting him. His SCR reveals that his Bryan had assaulted two children almost the same age during previous relationships. One suffered severe brain damage and still needed full-time care when he was convicted of killing Amaraye. He had also been suspected of seriously injuring two other children, one aged two, the other three.

2007: Hylene Essilfie was murdered by her father. A SCR into her death revealed no action was taken by the police or the social services after Hylene’s mother claimed her husband was violent and had made threats to kill her and her unborn baby. Both agencies missed multiple warning signs like this. The SCR discloses that if the police had consulted their own records they would have found details of ‘six previous incidents or episodes involving alleged domestic violence by Mr Essilfie with a discernible pattern including serious assaults on young, pregnant women’. It adds ‘there should have been a clearer focus by police and children’s services on the child‘, although it concludes (strangely?) that Hylene Essilfie’s death was not preventable.

2007: 18 month old Sean Denton was killed by his mother, who had already served time for manslaughter. Despite a history of violence and drug abuse within the family, Sean was taken off the ‘at-risk’ register when he was a few months old. Mother and baby were being monitored by the Metropolitan Police, London Probation, Barnet NHS Primary Care Trust, Barnet and Chase Farm Hospitals NHS Trust, Barnet, Enfield and Haringey Mental Health, London Borough of Barnet and Barnet Homes and Barnet Children’s Services. A SCR exposed several opportunities to save Sean’s life were missed.

2007: Joseph Kompus died aged 3 months old after weeks of abuse at the hands of his mother. Joseph had never been seen by social services but he did have contact with health workers during his short life, according to an official report into his death. A SCR found that opportunities were missed which could have led to Joseph receiving protection. The report said: ‘The pieces of the puzzle were not put together in an effort to establish the story of this child’s life and the expectations of his care. ‘There is a lack of systematic collection of information, analysis and recommendation. Expected standards were not met.‘ The report called for a series of actions from Waltham Forest doctors and hospital staff to improve child protection in the borough.

2007:despite being visited by many professionals from multiple agencies

Beautiful Peter, Days Before He Was Murdered.

(police, NHS, SS) Baby Peter Connelly died an agonising and lonely death in Haringey. The first SCR (which said Peters death was not preventable!) was considered invalid as the author of that report was a former employee and colleague of the director of children’s services in Haringey, thus the investigation was not independent. A second SCR finds serious failings from ALL agencies involved in Peters protection. The second, independent SCR found that Peters death COULD AND SHOULD have been prevented. After public outcry, Haringey failed a new Ofsted inspection, despite passing well a little while AFTER Peters death. Ofsted maintain that this was because Haringey manipulated data, which goes to show how much of Ofsted inspection was based on paperwork and not observing real social workers doing their best to protect children in danger. The government ask Lord Laming to review Child Protection following his recommendations after the Victoria Climbie Inquiry in 2002.

2007: 16 month old Amy Howson was killed by her father after agencies missed three key opportunities to protect her. Doncaster children’s services’ duty and assessment team failed to carry out an initial assessment on Amy after South Yorkshire Police referred on domestic violence concerns in late January 2007, the SCR found. This would have led to a child protection plan being produced for her and her older brother, known as Child C. Neither Doncaster’s youth inclusion support service nor Child C’s school recognised or responded to concerns about the father’s “aggressive” behaviour in the home, and failed to inform the duty and assessment team. Serious Case Review concluded Doncaster Primary Care Trust’s health visiting services’ “narrow focus” on Amy’s physical health meant they failed to see the need for a more “challenging and thorough assessment”.

2007: Alisha Allen was killed by her father when she was just 5 months old. A review into Alisha’s death exposed a ‘catalogue of failings’ and missed opportunities by authorities that had removed Alisha from the ‘at-risk’ register, including: Senior social workers failed to attend a vital conference into her protection, a doctor failed to report a bruise on her forehead, the abusive past of Alisha’s father was known but not investigated and Sunderland Royal Hospital discharged her after treatment for weight loss despite concerns about her welfare.

2007: Ruby Spink was killed by her mother boyfriend in. Ruby was on the ‘at-risk’ register and had been treated for broken ribs and fractures to her legs. Her killer had been ‘barred’ from coming near her before her death, but her mother did not follow this. Over the course of several weeks before her death, Ruby was taken to a GP, a paediatrician and an orthopaedic surgeon. All of these professionals diagnosed her injuries as accidental.

2008: Sanam Navsarka was 2 when she was tortured and killed by her mother and her mothers’ partner.

2008:  Paul and Jay Ross were both murdered by their father.

2008: 11 week old Alfie Goddard was killed by his father. The review by Doncaster Safeguarding Children Board found there were “numerous indicators” to show Alfie and his sibling were vulnerable and the family was in need, but ten agencies, including Doncaster PCT and children’s social care, had failed to take these account. Agencies “acted in isolation” and inter-agency working and communication were “largely inadequate”, the SCR found. Staff shortages in children’s social care meant social workers failed to carry out an “acceptable” duty and assessment service when contacted about the family.

2008: Brandon Muir, 23 months, was savagely attacked by Robert Cunningham, the boyfriend of his drug addict prostitute mother, Heather Boyd, in Dundee. Brandon died slowly and in agony. The SCR revealed the council knew Brandon was living in chaos. There had been 70 complaints about anti-social behaviour at Boyd’s flat in just two years. The review stated that: kids at risk of abuse or neglect in Dundee were not spotted or helped in time, risks facing children were not assessed quickly enough, bosses failed to give social workers a clear idea of how to do their jobs and bad parents were often allowed to carry on severely neglecting their children.

The report is the latest in a long line of calls for improvements to child protection in Scotland. But despite repeated promises to improve the system, children continue to die. Government inspectors looked at 18 key performance areas in Dundee and ruled that 9 were weak or unsatisfactory. They were: operational planning; policies and procedures; vision, values and aims; leadership and direction; leadership of change; meeting children’s needs; spotting and assessing risks; effectiveness of planning and responding to concerns. Six other “indicators” were classed as merely satisfactory and only three were described as good.

After the report was published, children’s minister Adam Ingram called for urgent improvements to services in Dundee. But Labour leader Iain Gray demanded a nationwide inquiry into child protection. He insisted: “This is not a localised issue but a national one. “We were told after the death of Brandon Muir that changes would be made. I have no confidence that is happening.”

2009: 7 year old Khyra Ishaq was starved to death by her mother in Birmingham. Her siblings were seriously malnourished and neglected. An investigation into her death is ongoing, and there have been calls again for a full Public Inquiry, after 7 similar deaths in Birmingham and 8 in Doncaster.

Ashley Shaw was 10 weeks old when he died this year in Doncaster. An 18 year old man has been arrested, and Doncaster authorities have started a SCR. Investigation into Ashleys death continues.

2009: A baby is severely injured by her mother. A SCR states that authorities missed opportunities’ to ensure the welfare of a fostered baby and she was handed back to her birth mother, who then inflicted life-threatening injuries on her. The decision about the girl’s care was based on “a hopeful, rather than a realistic, view about her mother’s ability to be her sole carer”When the five-month-old infant was examined at hospital two months after she was returned to her mother, it was found that she had suffered a broken right arm some four to six weeks earlier and had suffered retinal haemorrhaging in the previous 24 hours. There was also bruising to her face, legs, right arm and buttock.

2010: Laura Wilson, 17 is murdered and thrown in a canal after being exploited and abused by sex gangs. She was murdered after revealing her secret to abusers’ family members. Authorities in Rotherham had known she was at risk from exploitation from gangs, up to 6 years before her muder, but had tried to hide this fact. Laura had been referred to a child exploitation project just three months after her 11th birthday. She had been groomed by gangs and given drugs and alcohol from the age of 13.

2011: Tyler Whelan was 5 when he was kicked so severely by his step father that his abdomenem ruptured and he died slowly. Although his mother lied to protect her boyfriend (as with Peter, lessons learned?) There were a few instances where concerns should have been raised; hospital visists a few too many times, and concerns raised from teachers. The SCR concludes it is not possible to determine if Tyler’s death was preventable, but Malcolm Newsam, Executive Director of Children’s Services, said: ‘There were certainly missed opportunities when intervention should have been more rigorous.”

These examples are just a tiny handful of child abuse cases that have proved fatal in the past 70 years. It really is a drop in the ocean. There are many, many more that we have not documented here or do not know about. In addition, this ‘history’ does not include cases where a child has been injured (often horrifically) or sexually abused, and does not account for emotional abuse. Then there are the many cases of abuse that go unnoticed and unreported forever.

Number of Serious Case Reviews since The Childrens Act (THAT WE KNOW OF):

2004: 37

2005: 36



Because of secrecy surrounding these issues (why?) we do not have an exact figure. Some authorities refuse to release this information to the public (e.g. Birmingham)If we had this information, undoubtedly these figures would be much higherSome estimates have been as high as 228 SCRs since the government introduced the Childrens Act 5 years ago.

Facts from the NSPCC:

• On average, every week in England and Wales one to two children are killed at the hands of another person

36% of all rapes recorded by the police are committed against children under 16 years of age

25% of children experienced one or more forms of physical violence during childhood. This includes being hit with an implement, being hit with a fist or kicked, shaken, thrown or knocked down, beaten up, choked, burned or scalded on purpose, or threatened with a knife or gun. Of this 25% of children, the majority had experienced ‘some degree of physical abuse’ by parents or carers

7% of children experienced serious physical abuse at the hands of their parents or carers during childhood.

6% of children experienced frequent and severe emotional maltreatment during childhood.3

6% of children experienced serious absence of care at home during childhood.

72% of sexually abused children did not tell anyone about the abuse at the time. 27% told someone later. Around a third (31 per cent) still had not told anyone about their experience(s) by early adulthood

Infants aged under one are more at risk of being killed at the hands of another person than any age group of child under 18 in England and Wales

While the number of child homicides fluctuates each year, the overall child homicide rate in England and Wales has remained broadly similar since the 1970s.

• The National Commission of Inquiry into the Prevention of Child Abuse estimated that the cost of child abuse to statutory and voluntary agencies is £1 billion per year in the UK. Most of this is spent dealing with the consequences of abuse rather than its prevention. The total cost of abuse far exceeds this estimate. Individuals and families bear most of the consequences, sometimes for the rest of their lives at an incalculable cost.

For these reasons, please support the Against Child Abuse movement in every way you can. I hate adding to this list :(

~ A.A.A

One comment

  1. Similar problems in U.S.

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