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Barnsley Safeguarding Children Board

Serious Case Review

Concerning P children

Overview Report

25 August 2015

P Children Overview Report 25 August 2015

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Table of Contents Page 1. Introduction

3

2. Scope and Terms of Reference of the Review

3

3. Contributors to the Review and Methodology

4

4. Summary of Family Circumstances

6

5. Summary of Agency Involvement and Key Events

6

6. Analysis

18

7. Conclusions

38

8. Learning from the Review

40

Appendices Appendix 1: References

Appendix 2: Abbreviations Used 43 44


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1. Introduction 1.1 This Serious Case Review (SCR) was commissioned following the tragic deaths

of two children, P1 and P2, following a house fire at their father’s home. The children’s father (FP) also died in the fire. P2 and his father died on the day of the fire whilst P1 survived for five days before succumbing to his injuries. Inquests have been held in connection of all three deaths and have found that whilst the children were playing in the attic, one fire was set on the ground floor and 14 on the first floor. Entrances to the property had been barricaded to inhibit escape and petrol was used as an accelerant. The coroner recorded verdicts of unlawful killing in respect of both children and suicide in respect of their father. The coroner made it clear that there was no knowledge by a public authority of any identifiable risk of such an event taking place and that none of the agencies involved with the family had fundamentally failed in their duty to the family. This review has reached the same conclusion, although it has also found areas of practice which could have been improved and where lessons can be learned.

1.2 The review was commissioned in compliance with regulation 5(1) (e) and 5(2) (a)

& (b) (ii) of The Local Safeguarding Children Boards (LSCBs) Regulations 2006 which came into effect on 1 April 2006. Regulation 5 sets out the functions of Local Safeguarding Children Boards including the requirement for them to undertake reviews of serious cases in specified circumstances.

1.3 Working Together to Safeguard Children 2013, which was in force when this

review was commissioned, states that an SCR must be undertaken when abuse or neglect of a child is known or suspected and either (i) the child has died or (ii) the child has been seriously injured. In the case of (ii) an SCR has to be undertaken unless it is clear that there are no concerns about inter-agency working.

1.4 In accordance with Chapter 4 of Working Together to Safeguard Children 2013,

the purpose of this SCR is: To look at what happened in this case, why, and what action will be taken to

learn from the SCR findings? For such action to result in lasting improvements to the services which

safeguard and promote the welfare of children and help protect them from harm.

To ensure that there is transparency about the issues arising from the SCR and the actions that LSCB partner agencies are taking in response to them, including sharing the final report of the SCR with the public.

Consequently this report is not intended to be a judicial opinion or to apportion blame but to consider, with the benefit of hindsight, the above three points.

2. Scope and Terms of Reference of the Review 2.1 The timeframe for this SCR is from 22 January 2014, when the children’s mother

(MP) contacted P1’s school and stated that she and her husband had separated, to 27 October 2014 when P1 died. Organisations were also asked to provide brief relevant background information which pre-dated this time period. Where appropriate such information is outlined within the analysis section of this report.


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2.2 The key lines of enquiry were identified as follows: 1. The extent, to which the children’s wishes and feelings were heard,

considered and acted upon in relation to contact with their father. 2. The appropriateness of the contact arrangements that were in place and

whether other arrangements could or should have been made. 3. The response to any allegations of physical abuse made against the

father, including those made by younger child P2 to his school in June and September 2014. Consider whether anything else could or should have been done.

4. The response to any allegations about the care of the children, including that made by the father to Children’s Social Care in June 2014.

5. The referral of father to IAPT and the response when he did not attend the appointment, including information sharing.

6. The response to any allegations of domestic violence including the complaint made to the Police on 26 June 2014. Was a referral made to Stronger Families? If so, how was it dealt with; if not, should a referral have been made?

7. The circumstances which led to CAFCASS, not Children’s Social Care, writing the S7 court report and the appropriateness of this.

8. Agencies’ knowledge of father’s alleged ‘breakdown’ in 2013 and how this was addressed by agencies when working with the family in 2014.

9. Agencies’ knowledge of possible Domestic Abuse within the family and how this was addressed.

10. Determine whether the policies, procedures and practice expectations of the agencies were followed during this period and identify any shortfalls.

11. The quality of information sharing within and between agencies and whether there were any missed opportunities to share information that may have prompted agencies to intervene differently.

3. Contributors to the Review and Methodology 3.1 The Lead Reviewer for this SCR is Peter Ward who has a background in social

care and has worked in management and front line social work. Mr Ward is qualified to degree level in social work and has a post-graduate diploma in management studies. He is now the Director of Arrow Social Care Consultancy Limited and, as such, undertakes investigations and other consultancy work on an independent basis. Since 2005 he has been involved in approximately 20 Serious Case Reviews.

3.2 In accordance with the guidance issued in Chapter 4 of Working Together to

Safeguard Children 2013, the Lead Reviewer is independent of Barnsley Safeguarding Children Board and the organisations involved in the review.

3.3 The Chairperson for this SCR is Bob Dyson who is the Independent Chair of

Barnsley Safeguarding Children Board. A SCR Panel was convened which consisted of the following people: Independent Chair, Barnsley Safeguarding Children Board (Chair) Head of Service, Cafcass Head of Children and Family Social Care, Barnsley Metropolitan Council Public Health Specialist Nurse Head of Safeguarding, Children and Young People’s Social Care, Barnsley

Metropolitan Council


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Designated Nurse Safeguarding Children/Looked After Children, NHS Barnsley Clinical Commissioning Group (CCG)

Named Doctor for Safeguarding, Barnsley CCG Named Nurse, Safeguarding Children, South West Yorkshire Partnership

NHS Foundation Trust Public Protection Unit Manager, South Yorkshire Police Interim Barnsley Safeguarding Children Board Manager

The Lead Reviewer attended all meetings of the SCR Panel. 3.4 Organisations which had been involved with the family during the relevant time

period provided detailed chronologies of their involvement and these have been integrated into one combined chronology which has been used to assist with the writing of this Overview Report. These organisations have also undertaken Individual Management Reviews (IMRs) in which they have analysed their agency’s involvement with particular consideration of the key lines of enquiry listed above. IMR authors have identified key learning and made recommendations to ensure that necessary changes are made to reflect the lessons learned. They have sought to establish not only what decisions were made and action taken but also the reasons why.

3.5 IMRs were provided by the following organisations:

Barnsley Metropolitan Borough Council Children’s Social Care Barnsley Metropolitan Borough Council Education Services Cafcass NHS Barnsley CCG South West Yorkshire Partnership NHS Foundation Trust South Yorkshire Police

3.6 The Lead Reviewer made an application to court for access to documents

relevant to MP’s application for a Child Arrangements Order and Prohibited Steps Order. MP consented to the Lead Reviewer’s application and an order was made giving the Lead Reviewer access. This enabled a clearer understanding of the information provided within the application and the orders made by the court.

3.7 Royal Manchester Children’s Hospital commissioned an investigation into the

immediate circumstances of P1’s death on 27 October 2014 whilst he was a patient in the hospital. P1 died five days after the house fire in which he sustained significant burns and four days after he was admitted to Royal Manchester Children’s Hospital. The Incident Investigation carried out by the hospital considered care provided to P1 on the day of his death; it related solely to services provided by the hospital and has no bearing on the services provided by any agency involved in this Serious Case Reviewer. The Lead Reviewer has had an opportunity to read the report of this investigation and notes the learning from the review and the recommendations made. The Chair of Barnsley Safeguarding Children Board has ensured that the Chair of Manchester Safeguarding Children Board is aware of the investigation and the recommendations made.

3.8 Working Together to Safeguard Children 2013 states that “families, including

surviving children, should be invited to contribute to reviews.” MP accepted an offer to contribute to this review and the Lead Reviewer met with her so that she


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could explain the sequence of events from her perspective and express her views of the services that she and her family had received during the period covered by this Serious Case Review. MP was also able to clarify some issues that were unclear within the IMRs. Information provided by MP has been incorporated within sections 4, 5 and 6 of this report.

3.9 Following completion of the first draft of the Overview Report a ‘Learning Event’

was held. This was led by the Lead Reviewer and involved staff who had worked directly with the family as well as managers from the agencies. The purpose of the Learning Event was to ensure the accuracy of the timeline and to gain a greater understanding of how things appeared when agencies were working with the family and how and why decisions were made and actions taken.

4. Summary of Family Circumstances 4.1 P1 and P2 were 12 and nine years of age respectively at the time of their deaths.

They were the only children of FP and MP, a recently divorced couple. The family was white British.

4.2 In January 2014 MP left the family home, taking both boys to live with her at her

mother’s home. However they only stayed away over the weekend and then returned to the family home where they remained until April 2014 when they left again and the separation between the parents became permanent. Following the separation contact between the children and their father was initially arranged by the parents on an informal basis.

4.3 On 4 June 2014, P2 made an allegation to his teacher of physical abuse against

his father, which related to an incident that had taken place a few months previously and for which there were no visible signs of injury. Following this allegation, subsequent difficulties with contact and a domestic incident, MP made an application to court for a Child Arrangements Order and Prohibited Steps Order. She specifically applied for an Order confirming that P1 and P2 should live with her and that FP should not have any contact until Children’s Social Care had assessed the situation and also an Order preventing FP from removing the children from her care or the care of any other person charged with their care. The application was made on 2 July 2014 and an urgent hearing took place in court on 9 July 2014 at which an interim order was made, with the agreement of both parents, that FP should have contact twice each week with one session lasting three hours and the other two.

4.4 At the time of the tragic incident which resulted in the deaths of P1 and P2 they

were still living with their mother and maternal grandmother at the grandmother’s home. Court proceedings to determine contact arrangements had not been concluded but interim arrangements remained in place for contact twice each week, although an adjustment was made to the pickup point.

5. Summary of Agency Involvement and Key Events 5.1 Brief Summary of Agency Involvement – by Agency

Barnsley Metropolitan Borough Council Children’s Social Care


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5.1.1 Children’s Social Care first became aware of the family on 4 June 2014 when the headteacher from P2’s school phoned as a result of a disclosure made by P2 that his father had previously hurt him. A duty social worker (SW1) spoke to both MP and FP by phone that day and an assessment was carried out later that month. The last involvement by Children’s Social Care was a phone conversation between another social worker (SW2) and a family court advisor (FCA1) from Cafcass on 30 July 2014.

Barnsley Metropolitan Borough Council Education Services

5.1.2 Throughout the period covered by this review P1 attended a local high school and P2 a local primary school. P1 had previously been at the primary school that P2 attended and MP was a governor at the same primary school. On 4 June 2014 the headteacher of the primary school informed Children’s Social Care of an allegation made by P2 that his father had hurt him some time previously.

Cafcass

5.1.3 Cafcass is the Children and Family Court Advisory and Support Service which was established in 2001 as an independent non-departmental public body. One of Cafcass’ functions is to safeguard and promote the welfare of children and young people in a range of family proceedings. In this case Cafcass’ role related to MP’s application, made on 2 July 2014, for a Child Arrangements Order and Prohibited Steps Order. Cafcass first became aware of the family on 3 July 2014 when MP’s application was received by the Central Intake Team. Their active involvement commenced immediately following an urgent court hearing on 9 July 2014 and continued for the remainder of the children’s lives.

Barnsley CCG

5.1.4 CCGs are NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England. The IMR provided by Barnsley CCG to this review considered the GP services provided to this family. All family members were registered with the same GP Practice throughout the period covered by the review.

South West Yorkshire Partnership NHS Foundation Trust (SWYPFT)

5.1.5 SWYPFT provides a range of community health care services within the Barnsley area. Prior to the period covered by this review P1 was in receipt of Podiatry1 services and this continued into the period covered by this review. In total P1 was seen six times by the Podiatry service between 2011 and 9 January 2014. He did not attend an appointment on 29 January 2014 and was discharged from the Podiatry service in accordance with the SWYPFT ‘Did Not Attend policy’. A request for a new appointment was made in March 2014 and he attended appointments in April and September 2014.

5.1.6 Also in April 2014 P1 was referred to Change for Life2 due to concerns about his

weight. He attended four out of five scheduled sessions.

1 Podiatry is a medical speciality dealing with assessment, diagnosis and treatment of the foot, lower limb and

associated structures. It also treats conditions of the foot, assesses gait and joint function in order to prescribe orthotics to assist with walking and running problems. 2 Change for Life was a free 5 week programme for children and their families that provided fun activities to

educate parents and children about the value of living healthy lifestyles.


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5.1.7 In July 2014 FP referred himself, on the advice of his GP, to Improving Access to

Psychological Therapies (IAPT)3 but did not attend the appointment that was offered.

5.1.8 Neither P2 nor MP received any services from SWYPFT during the period

covered by this review.

South Yorkshire Police 5.1.9 Historical records show that South Yorkshire Police had had one contact with the

family prior to the period covered by this review. This was in 2011 when FP assaulted a male neighbour in connection with a boundary dispute. FP received a caution for this offence.

5.1.10 Within the period covered by this review South Yorkshire Police were contacted

on two occasions prior to the house fire on 22 October 2014. The first of these was on 18 June 2014 and the second was on 26 June 2014. Details of these contacts are provided within the timeline below.

5.2 Timeline of Agency Involvement and Key Events

22 January 2014 – 3 June 2014 5.2.1 On 22 January 2014 MP informed staff at the high school that she had left her

husband, taking the children with her. Support was provided to P1 by the Learning Mentor (LM1) for his year group. P1 did not engage with formal arrangements for support so an informal arrangement was made and P1 was encouraged to talk to the Learning Mentor if he felt the need. The school did not observe any change in P1’s personality following the separation of his parents and there was no apparent impact on his well being or academic progress. Although the school had been informed of the parent’s separation in January 2014 there is no indication that they were aware of the reconciliation a few days later or the subsequent separation in April 2014.

5.2.2 There is no evidence in the records to suggest that either parent had any

communication with the primary school about their marital problems during the period between 22 January and 3 June 2014.

5.2.3 P1 had an appointment with the Podiatry service on 29 January 2014 but did not

attend, which was unusual as he normally attended appointments. He was discharged from the service in accordance with the SWYPFT ‘Did Not Attend policy’. A request for a new appointment was made in March 2014 and he attended appointments in April and September 2014.

5.2.4 On 24 February 2014 P2 was taken to the GP Practice with a scald on his arm

which was reportedly caused by a coffee spill. The practice nurse dressed his arm.

3 IAPT is an NHS programme which is being rolled out nationally. It offers services for treating people with

depression and anxiety disorders.


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5.2.5 In March 2014 FP and MP attended a parents’ meeting together at the high school and spoke with LM1 who observed that FP was the dominant partner and his wife did not make any real contribution to the discussion. The parents were living together at this time. Also in March, MP attended the GP Practice as she was experiencing stress due to her marriage breaking up. She was referred for counselling.

5.2.6 On 16 April 2014 P1 saw the GP about his weight as his parents were concerned

that he was overweight. As a result of this consultation the GP referred P1 to Change for Life on 21 May 2014.

5.2.7 In late April 2014 FP arrived at the high school unannounced and asked to speak

to LM1 about P1. However as the discussion progressed FP spoke about himself rather than his son. The parents may have separated again by the time of this incident.

4 June 2014 – 22 October 2014

5.2.8 On 4 June 2014, P2 was tearful in school. He reported that his parents had

separated and he said he was anxious about going to his father’s home that day as his father was verbally and physically abusive. He said that his father had previously dragged him along by the throat during a holiday. As a result of this statement, the school contacted MP who agreed to collect P2 early from school and not allow him to go to his father’s that evening as had been planned. The headteacher contacted Children’s Social Care to inform them of the allegation made by P2. He then contacted FP to inform him of the allegation and the action he had taken, including his contact with Children’s Social Care. On the same day MP informed LM1 by phone of the allegation made by P2 and told her that P1 should not leave school with his father that day. LM1 spoke to P1 who said that he was not scared of his father.

5.2.9 Upon receipt of the allegation a management decision was made within

Children’s Social Care that a social worker should undertake a brief assessment to explore the current concerns and ascertain what support, if any, was required by the family. SW1, the duty social worker, spoke to the headteacher to gather further information and then spoke to MP, P2 and FP by phone. These contacts all occurred during the afternoon of 4 June 2014.

5.2.10 During these contacts it was established that MP and FP had separated and that

the children were living with their mother and having contact with their father but that the level of contact was currently a matter of dispute. MP described her husband as a bully who had been aggressive towards her and verbally abused her in front of the children and had a Police Caution for pushing a neighbour. With regard to the specific allegation made by P2 that day, MP agreed that it had happened some time previously when they were on holiday but she did not think it had happened quite as P2 described it. MP told the Lead Reviewer that the holiday had taken place in February 2014. P2 told SW1 that his father had shouted at him for not eating the crusts of his toast, grabbed him, slammed him into a chair and punched him in the stomach. FP denied any rough handling except for one incident on holiday when he had physically stopped P2 going down the wrong route on a ski run. FP also told SW1 that both boys had eating disorders with one being overweight and one underweight.


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5.2.11 During the initial contact the social worker made it clear to MP that Children’s

Social Care could not make decisions about contact and it was for MP to decide whether or not to allow the children to see their father. The social worker felt confident in MP’s ability to make an appropriate decision and act upon it.

5.2.12 As a result of the information gathered by SW1 the team manager decided that a

children and young person’s assessment was required to explore the current concerns and any support needs P1 and P2 might have. The manager considered that (Child Protection) enquiries were not required at this stage but was clear that this decision would be reviewed if information emerged that suggested Section 47 enquiries were required. A referral was made for allocation to a social worker within the Assessment Team.

5.2.13 On 5 June 2014 SW1 contacted MP to confirm that an assessment would take

place; she reiterated that it was for MP to decide about contact. That same day MP contacted both schools; telling LM1, at the high school, that Children’s Social Care were involved as a result of the allegation made by P2 and telling the primary school that she was collecting Child P2 at the end of the school day and that Children’s Social Care had recommended that FP should not have any contact. The headteacher of the primary school contacted Children’s Social Care who clarified that they had not made any recommendation regarding collection from school as they were not in a position to do this. They confirmed that MP would have to decide what was in P2’s best interests.

5.2.14 Four days later P1 told LM1 that his brother was scared of their father and did not

want to go to his house. LM1 reassured P1 that support was available for him if he needed it.

5.2.15 Also in June 2014 LM1 had a handover meeting with LM2 as P1 was changing

school year. LM1 told her colleague that when she had met FP in April 2014 she had felt uncomfortable with him; she advised LM2 not to meet with him alone. LM1 had not recorded this view at the time and neither had she shared it with anyone else in the school.

5.2.16 During the final month or so before the school finished for the summer holiday in

July 2014 LM2 had contact with P1 two or three times each week, on an informal basis. This routine continued when P1 returned to school in September. P1 did not raise any concerns about home life during these contacts.

5.2.17 On 16 June 2014 P1 attended the first of the Change for Life sessions; in total

attending four of the five sessions on the programme. For children to attend the session a parent also has to attend and both parents’ names have been placed on the attendance sheet. No concerns were raised during the course and a post course questionnaire completed and signed by MP indicated that the programme had been a positive experience with positive outcomes for P1.

5.2.18 Also on 16 June 2014 FP phoned the Social Work Team to enquire as to what

was happening with regard to the proposed assessment. He spoke to SW3 who was on duty and said that both of the children had eating disorders with P1 being overweight and P2 underweight. FP suggested that MP was not addressing these issues.


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5.2.19 On 17 June 2014 the referral was allocated to SW2 who was on leave until the

following week. 5.2.20 Police records state that at 14:59 hours on 18 June 2014, South Yorkshire Police

were contacted by the maternal grandmother who stated that FP was due to have the children that evening. The grandmother expressed concern that there may be issues when her daughter went to collect the children, as she believed that their father would not allow the children to return with their mother. This was dealt with by the Police call handler who advised that the family speak to a solicitor; the call handler also gave the grandmother the telephone number for the Child Support Agency. The incident number was given to the Grandmother and she was told to re-contact the Police should there be any issues later in the evening.

5.2.21 Children’s Social Care records for the same afternoon (18 June 2014) state that

MP phoned Children’s Social Care and explained that FP had been to where the children were and had taken them and some clothes even though he was not supposed to have any contact. MP said that she had informed the Police who were ‘sorting it’ but had advised her to ring Children’s Social Care. She asked for a social worker to phone her back. The duty social worker tried to phone back at 16:40 hours and the phone was answered by P1 who said his mother was not available. MP phoned back later and spoke to the duty social worker. She told the duty social worker that she had been letting FP have contact and the boys were with him now although they had not wanted to go. The duty social worker explained that SW2 would discuss contact when she carried out the assessment but contact issues could only really be resolved by the courts. MP said that she felt bullied by FP around contact and agreed to it when she did not want to.

5.2.22 MP told the Lead Reviewer that she agreed that the children could go to their

father’s home for contact after school on18 June 2014 but could not stay overnight. P1 was off school that day and FP walked into the maternal grandmother’s house whilst MP was at work and “frogmarched” P1 out of the house taking his school uniform with him. The maternal grandmother phoned the Police about this. Because FP had taken P1’s school uniform, MP deduced that he intended to keep the boys overnight so she phoned the Police and said she was worried that he was abducting them. The Police said that she should wait until after 8.00 pm as this was the time P1 and P2 were meant to be brought back to her. If they were not returned she could phone the Police again and they would go to FP’s house to get them. MP told the Lead Reviewer that the children were not returned that evening but she decided not to phone the Police again as she did not want the children to experience the stress of the Police coming to the house and FP had indicated that he would not be at the house anyway.

5.2.23 On 23 June 2014, FP met with the headteacher at the primary school. The

headteacher tried to reassure FP that the welfare of P2 was of paramount importance and that the school would continue to monitor his general well-being. The headteacher also undertook to enquire of Children’s Social Care the timing of the assessment. The headteacher found that FP primarily wanted to discuss his divorce, which was not appropriate. FP took with him a document which he left with the headteacher. The headteacher looked at this document and found that it was not relevant to the circumstances but was about FP trying to


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undermine his wife. The headteacher decided not to read it in detail and it was collected shortly afterwards by FP. Four days before this meeting, FP had sent a letter of complaint to the Chair of Governors in which he had complained about the headteacher having contacted Children’s Social Care and about MP in her role as a school governor. Both complaints were investigated but neither was upheld.

5.2.24 SW2 returned from annual leave on 24 June 2014 and was phoned that same

day by FP who wanted the assessment to be undertaken as quickly as possible because of difficulties he was having with MP regarding contact. FP was reassured that he would be contacted as part of the assessment.

5.2.25 Two days after his meeting with FP, the headteacher from the primary school

contacted Children’s Social Care and was informed that the social worker was going to visit MP and the children that day.

5.2.26 SW2’s visit to MP and the children on 25 June 2014 was the only occasion that

anyone from Children’s Social Care met directly with them. SW2 spoke to MP and also had a lengthy discussion with the two children together. During the discussion both children said that their father emotionally abused them and that they were scared of him. They referred to him kicking them and P2 described him as ‘pure nasty’. They described a number of incidents to illustrate what they were saying and said that their father behaved like this mainly when their mother was not around. They did not disclose any recent occasions when their father had hurt them and SW2 was of the view that the main focus of their concern was that they were spending equal time with each parent and this was emotionally tiring for them. They also said that they did want to continue to see their father although P2 stated that he did not want to be there at meal times or to stay overnight. SW2 addressed the concerns raised by FP about P1 being overweight and P2 being underweight. MP told the social worker that FP used to make P1 get on the scales and would tell him that “nobody likes a fat boy”. P2 himself told the social worker that he did not want to have tea at his father’s home because his father put him under pressure to eat things that he did not like. In the analysis of the visit SW2 wrote “It is clear that the boys do want a level of contact with their dad but they do want to be listened to and have the situation managed where they know they will be returning back to their mother’s care everyday’.”

5.2.27 At the end of the visit MP told SW2 that she would stop FP from having contact

with the children and would seek an emergency Residence Order. MP has told the Lead Reviewer that SW2 advised her “off the record” that she should stop the children from seeing their father and it is written in the Children’s Social Care IMR that SW2 advised MP following the visit that there should be no contact with FP.

5.2.28 During the course of this Serious Case Review SW2 has reported that she spent

some time with the children trying to understand the context of what they were saying and she also spoke to MP. The incident that P2 had talked about at school had occurred in February 2014 and MP described it somewhat differently to how it was described by P2. The other allegations of physical abuse related to earlier incidents. The social worker did not believe that it was unsafe for the children to have contact with their father but did believe that spending half their time with him was not meeting their needs. Consequently her view was that the


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most pressing issue for the children at the time of the assessment was the emotional impact of their time being spread equally between the parents. Because of this, SW2 was satisfied that MP’s decision to initiate Private Law Proceedings was reasonable and she did not believe that there was any need for Children’s Social Care to initiate Section 47 enquiries.

5.2.29 SW2 carried out her visit to MP and the children on the evening of 25 June 2014.

There is no record of her discussing the outcome with her manager but SW2 and her team manager have stated that they had a discussion the following day and that Section 17 was the appropriate level of assessment and there was no need to initiate Section 47 enquiries.

5.2.30 On 26 June 2014 SW2 telephoned P2’s school to up-date them after the visit to

the home the previous day. This was the last contact between Children’s Social Care and the primary school until 15 August 2014 when a letter was sent to school informing them of the outcome of the Children’s Social Care assessment, the involvement of Cafcass in assessing the situation and the end of Children’s Social Care involvement. Also on 26 June 2014, MP’s solicitor informed Children’s Social Care that MP was going to seek an Emergency Residence Order and had been advised to collect the children from school that day rather than let them go for contact with FP as had been planned.

5.2.31 At 16:12 hours on 26 June 2014, South Yorkshire Police were called to a report

of a Domestic Abuse incident taking place. The maternal grandmother reported that FP had attended her home and had thrown MP’s belongings onto the garden. The grandmother reported that FP had made a number of threats towards MP and had then left the address. She confirmed that her daughter and the children were safe and well. The grandmother told call handlers that FP had threatened MP in the past and been violent to her in the bedroom. She added that FP was unhappy about being informed he could not see the children, had made verbal threats and potentially caused damage to property.

5.2.32 The incident was graded as priority which means that Police Officers should

respond within one hour. In the event the attending officers arrived at the grandmother’s home at approximately 17:30 hours and spoke with MP. P1 and P2 were present initially but were sent out of the room by MP as she spoke with officers. The officers did not note any concerns for the children at that time.

5.2.33 MP told the police officers that she believed her husband’s actions had been in

response to the fact that she had collected the children from school early in order to prevent him collecting them. She went on to say that she had taken this course of action following a disclosure made to school by Child P2 who had indicated that his father had physically abused him some months earlier. She advised the police officers that Children’s Social Care had applied for an emergency order to prevent FP having contact whilst an investigation/assessment was carried out but this had not yet been granted and therefore she had removed the children from school early.

5.2.34 MP stated that she had not been assaulted during this incident and no damage

had been caused but FP had made a threat towards her. Initially she thought this was a threat to harm her physically but afterwards she interpreted it differently. She also indicated that FP had sent her a text message in which he said ’bye’.


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She was concerned about his mental state and that this may indicate that he intended to cause harm to himself, although she confirmed that he had not previously attempted self-harm. She also reported to officers that FP had sent text messages to a relative of hers who was terminally ill.

5.2.35 MP indicated to the police officers that FP had been controlling and manipulative

prior to their separation and the contact restrictions would have frustrated him. Police officers considered that FP’s behaviour in sending texts to MP’s relatives and in asking them to bring MP to the family home demonstrated his controlling nature.

5.2.36 Officers undertook the Domestic Abuse, Stalking and Honour Based Violence

(DASH) risk assessment with MP. This involves asking 37 standard questions about the current situation, children/dependents, domestic violence history, the abuser and stalking. MP admitted to feeling unsettled and said that FP had been controlling and she had suffered emotional abuse from time to time in the past. She also told officers that she believed that FP had hurt the children in the past but she did not disclose that he had been physically violent to her or that he had said things of a sexual nature that had made her feel bad or hurt her.

5.2.37 Following their attendance at the grandmother’s home the officers visited FP at

his home address, where they spoke with him through an open upstairs window. He refused to allow them access and asked them to bring his wife to the address. The officers indicated that this was not an option and he asked them to leave. The officers noted that he was upset and they overheard him speaking with a third party on the phone. They subsequently made contact with a close friend of FP who confirmed that he had spoken to him and although he was upset regarding restrictions to his contact with the children, he had not made any mention of self-harm.

5.2.38 The attending officers identified that the incident did amount to a Domestic Abuse

incident as per the definition and subsequently submitted a Domestic Abuse report form. The submitting officer completed the suggested initial risk level as ‘standard’ but added that the incident had occurred as a result of child contact issues and that the risk factors may change depending upon the access restrictions to his children. Following the submission of the Domestic Abuse report form the incident was risk assessed by one of the centrally based risk assessors and the risk considered to be standard.

5.2.39 A record was made on the Police incident system, that domestic abuse had taken

place between MP and FP at this address. Referrals were made to Children’s Social Care and Stronger Families and Domestic Abuse leaflets were sent to the mother of the children identifying and providing contact details for other agencies that can offer support. Although MP told the officers that she suspected that FP had previously hurt the children they believed she was referring to the report of abuse made to school and the catalyst for this incident. The officers were told that Children’s Social Care were aware of this previous report of abuse and they also knew that the Domestic Abuse report form from this current incident would be shared with Children’s Social Care. Consequently they did not consider the submission of an additional Child Protection referral form to be necessary.


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5.2.40 On 27 June 2014 FP contacted Children’s Social Care and spoke to SW2 who tried to arrange to meet with him. However FP would not agree to meet at any of the venues suggested by SW2 and SW2 was not prepared to meet him at his home due to concerns expressed about his behaviour. On the same day SW2 informed the GP of Children’s Social Care involvement and the reason for it. The GP practice reported that there were no health concerns about either child. SW2 did not ask for information about the health of either parent and the GP did not provide any such information.

5.2.41 On 1 July 2014 Children’s Social Care received the domestic abuse notification

relating to the incident that had taken place five days earlier at the maternal grandmother’s home. Because the family were already allocated to a social worker in the Assessment Team the details went directly to the Assessment Team and Stronger Families were not involved. This is standard practice where a case is already open within Children’s Social Care.

5.2.42 On 3 July 2014 SW2 was contacted by the solicitors for both parents and advised

that a court date had been set for 9 July 2014 for an emergency hearing in respect of MP’s application for a Child Arrangements Order and Prohibited Steps Order. SW2 provided MP’s solicitor with information about the interview with the children and updated FP’s solicitor regarding Children’s Social Care involvement.

5.2.43 MP’s application to court was received by Cafcass on 3 July 2014 and this was

the start of Cafcass involvement with the family. The application was screened the following day by Family Court Advisor (FCA)2 and allocated to FCA1. Numerous concerns were made about FP including allegations of him being bullying, controlling and verbally threatening and abusive to the children and MP. Also that he had physically chastised the children who were scared of him. The application included a statement that on 26 June 2014 FP had told MP “he had nothing to live for and intended to commit suicide” and a statement that FP had previously told MP that “he can understand fathers killing their children”. It also included a statement that FP was a “very controlling man” and MP was “afraid of his actions” and did not trust him “not to take the children from school or remove them from her care”.

5.2.44 Also on 4 July 2014 FP attended the GP Practice reporting low mood since his

wife had left him, taking the children with her. He told the GP that he had had thoughts of hurting himself but that he would not do this and no longer had any suicidal thoughts. The GP prescribed Mitrazapine and gave FP the phone number to refer himself to IAPT, s service provided by SWYPFT. FP contacted IAPT and was offered an appointment for 8 August 2014 but he did not attend (see Key Line of Enquiry 5).

5.2.45 Level one police checks were received by Cafcass on 6 July 2014 and screened

by FCA3. The police check showed that FP had received a caution for assault occasioning actual bodily harm on 4 October 2011.

5.2.46 MP’s application was heard at court in an urgent hearing held on 9 July 2014 and

an interim order was made that FP should have contact twice each week with one session lasting three hours and the other two. A further hearing was scheduled for 30 July 2014. In line with usual practice, no-one from either Cafcass or Children’s Social Care was present at this hearing. Cafcass do not


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attend urgent hearings and their role commenced once the hearing had concluded. SW2’s record of her discussion with the children on 25 June 2014 was provided to the court at the urgent hearing. This included allegations of abuse, the children’s fear of their father and their statements that they wanted contact to continue. Information provided to this review by MP is that she herself was not in the courtroom when contact was agreed but that she had been advised by her legal representative that the court was unlikely to agree to father having no contact, which is what she had requested, and because of this she accepted the proposal of contact twice each week.

5.2.47 Later that same day FCA1 carried out safeguarding interviews with both parents

by phone. This was the first direct contact that anyone from Cafcass had with any member of the family. Cafcass guidance states that the purpose of safeguarding interviews is to “... ascertain and gather information in relation to risks to children who are subject of the court application.” The recording of the interview with FP, which is a summary of the main points discussed, confirms that he denied that he felt suicidal and also denied having assaulted the children, instead blaming MP for the breakdown of the marriage. FP told FCA1 that he himself had been abused when he was a child. There is no indication that the allegations made by MP about her husband’s behaviour were discussed. The recording of the interview with MP suggests that it was more focussed on the impact of FP’s behaviour on the children, particularly P2. There is no indication that there was any exploration of suggestions within MP’s application that FP was controlling and that she might have suffered domestic abuse from him.

5.2.48 After the court hearing, MP sent the high school a letter in which she provided

information about the contact arrangements determined by the court. She also informed the school that the children could contact FP anytime and that he would be invited to any relevant school event.

5.2.49 On 14 July 2014 Cafcass received a safeguarding check from Children’s Social

Care which outlined Children’s Social Care’s involvement and provided contact details for the social worker who was involved.

5.2.50 On 16 July 2014 SW2 visited FP at home accompanied by a colleague, SW4. A

joint visit was considered necessary due to FP’s perceived volatility. SW2 had tried to undertake this visit previously as part of her assessment but FP had not responded to her requests for contact. By the time the visit was carried out court proceedings had commenced and SW2 was of the opinion that contact between Children’s Social Care and FP would not affect the outcome. SW2 told FP that her involvement was now at an end but that there would be a court hearing which would consider reports written either by Children’s Social Care or Cafcass. SW2 felt that FP had his own agenda during this meeting and did not really listen to anything she said. At one point he mentioned having been abused as a child but he did not elaborate upon this. This was the last involvement that Children’s Social Care had with the family apart from a telephone call between SW2 and FCA1 from Cafcass two weeks later.

5.2.51 On 25 July 2014 FCA1 filed his safeguarding letter for the court to consider on 30

July. He recommended that the court should order a Section 7 report to address the issue of contact between the children and their father. He further recommended that this report should be written by Cafcass. He did not


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recommend that contact be suspended whilst this report was being prepared. FCA1 was a worker who was allowed to complete and file reports without management oversight (a ‘self filer’) and therefore the safeguarding letter was submitted to court without being seen by a manager. In order to be designated as a self filer, Cafcass officers should have provided evidence of consistently good practice and they are subject to a minimum of one quality assured report each quarter in order to maintain that designation.

5.2.52 FCA1 attended the hearing on 30 July 2014 and was accompanied by his service

manager (SM1) who had only recently commenced this post and was familiarising herself with the staff. During the hearing FP requested additional contact with the children, including overnight stays. FCA1 was asked to speak with both parents individually and report back to the court. SM1 was present whilst FCA1 interviewed FP and at one point FP went to put his hands on her to demonstrate how he physically engaged with P2. SM1 felt uncomfortable with this and asked him not to touch her but nothing else about his behaviour struck her as unusual. At the end of the hearing it was ordered that contact should remain at the same level as previously although an adjustment was made to the pickup point. In accordance with FCA1’s recommendation, Cafcass was ordered to prepare a Section 7 report which was to be filed on 6 November 2014 with a further hearing listed for 13 November 2014.

5.2.53 After the court hearing FCA1 prepared the case for transfer to the Work After

First Hearing team. As part of the transfer process FCA1 phoned SW2 for what was the first direct communication between Cafcass and Children’s Social Care in respect of this family. Cafcass records state that this contact occurred on the day of the court hearing whilst Children’s Social Care records have it occurring the following day. The Cafcass record of this conversation includes an undertaking from FCA1 to record something in relation to FP’s mental health. FCA1 believes that this relates to an observation that FP was a bit ‘odd’.

5.2.54 On 6 August 2014 the case was allocated to FCA4, within the Cafcass Work

After First Hearing team. FCA4 wrote a detailed case plan which included an intention to speak to SW2 by 2 September 2014 to seek additional information prior to talking to other parties. Following this she intended to talk to both children to ascertain their wishes and feelings and to interview the parents separately. FCA4 identified the need to seek clarification on FP’s mental health and also to discuss domestic violence.

5.2.55 On 3 September 2014 P2 returned to school after the summer holiday; he was

upset about arrangements for contact with his father and repeated the disclosure he had made previously. He was given support and reassurance by school staff but information was not shared with any other agency or with MP. P2 was not observed to be upset again after his day.

5.2.56 By 22 September 2014 FCA4 had not carried out any further actions relating to

the Section 7 report and she amended her case plan with 29 September 2014 as the new target date for speaking to SW2. In the event FCA4 never spoke to SW2; she explained that this was because she had seen a detailed recording of FCA1’s conversation with SW2 which covered the questions she had wanted to ask.


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5.2.57 In late September 2014 someone from Cafcass left a message at the high school requesting that LM2 phone back. LM2 tried, unsuccessfully, to speak to the Cafcass officer, leaving messages on both the mobile and landline numbers that had been provided but she did not hear from Cafcass again.

5.2.58 On 6 October 2014 FCA4 met with MP. FCA4 indicated in her case record that

she had intended to meet with MP again before completing the Section 7 report. 5.2.59 On 16 October 2014, FCA4 was due to meet with P2 and with the headteacher of

the primary school. In the event FCA4 was late arriving which meant that, although she met with P2 she was unable to meet with the headteacher. She recorded that she found P2 to be chatty and he appeared confident. He shared details of abusive experiences he had suffered at the hands of his father, many relating to food. P2 also told FCA4 that he only wanted to see his father once each week for three hours, not the current arrangement of twice per week. He took the opportunity to write a letter to the judge specifying his wish.

5.2.60 On 17 October 2014 the headteacher from the primary school contacted FCA4

for feedback about her meeting with P2. The headteacher told FCA4 that female staff at the school did not like to see FP alone although the headteacher could not clarify exactly what the concerns were.

5.2.61 On 20 October 2014 FCA4 met with FP. She was aware of the report that he

had told his wife that he “understood why fathers kill their children”. As a result of this she asked him questions in relation to hurting or harming his children and he was adamant that he would never do such a thing. This was a difficult interview for FCA4 who found it difficult to keep FP’s focus on the relevant issues. During the interview FCA4 asked FP how he would feel about spending less time with P2. FCA4 was unhappy with this and responded that he did not know how he could spend less time than at present. FCA4 brought the meeting to a close because she felt that FP was becoming “agitated and unreasonable” and was speaking over her; she suggested a follow up meeting. FP did not want the interview to end and barred the door while he expressed his view that Cafcass believed his ex-wife and sons rather than him.

5.2.62 After the interview FCA4 sent an email to her manager in which she described

FP as agitated, unreasonable, intimidating, controlling and aggressive. She further told her manager that she would not see FP again on her own, either inside or outside the office.

5.2.63 On 22 October 2014 FCA4 contacted MP. Records show that the primary

purpose of this phone call was for FCA4 to make an arrangement to see P1 and it was agreed that she would do so at the Cafcass office on 28 October 2014. FCA4 had tried to contact the high school to make an arrangement to see P1 there but FCA4 and relevant school staff had not managed to speak to one another and the following week was the half term holiday. During this conversation MP told FCA4 that the children were going to their father’s for contact that evening. The Cafcass record shows that FCA4 responded by asking MP to note their mood when they returned home. FCA4 has explained that this would be a usual question to ask a parent in such circumstances and it was not prompted by any concern or particular issue.


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6. Analysis 6.1 Key Line of Enquiry 1

The extent, to which the children’s wishes and feelings were heard, considered and acted upon in relation to contact with their father.

6.1.1 During Children’s Social Care’s initial involvement with the family on 4 and 5

June 2014 there was no direct contact with P1 and P2 and therefore no opportunity for the social worker to hear, at first hand, their wishes and feelings regarding contact. It is recorded that MP told the social worker that she wanted to stop contact and the children did not want to go. Also that SW1 advised MP that Children’s Social Care could not make decisions about contact and the decision was hers. MP told SW1 that the children would have a say in whether or not they saw their father.

6.1.2 On 25 June 2014, SW2 had a lengthy discussion with the children who

expressed concern about their father but both indicated that they did want to have some contact with him. Notwithstanding this, MP told SW2 that she would stop contact and apply for a court order in order to demonstrate that they were safe. MP reiterated that the children’s views would be taken into account regarding contact in the future.

6.1.3 During the urgent hearing on 9 July 2014 the court had sight of SW2’s record of

her discussion with P1 and P2 on 25 June 2014. In this both children stated that they did want to have contact with their father. This record was one of the factors considered by the court when making the decision regarding interim contact.

6.1.4 Cafcass does not have direct contact with children during the Work to First

Hearing stage of their involvement and therefore FCA1 did not have an opportunity to directly hear P1 and P2’s view regarding contact. FCA1 did, however, have access to the recording made by SW2 following her discussion with the children on 25 June 2014. Although they had told SW2 that they wanted to see their father they also expressed some fear of him and alleged that there had been occasions when he had physically and emotionally abused them. It was FCA1’s belief that they were distressed by contact and he reported this in his letter to the court.

6.1.5 Seeking the wishes and feelings of children is a key part of the Work After First

Hearing stage of Cafcass involvement. In this case FCA4 met with P2 to seek his wishes and feelings and found that despite his anxieties about his father he did want to have some contact with him. FCA4 made an appointment to meet P1 on 28 October 2014 to explore his wishes and feelings before writing her report which was due to be submitted to court on 6 November 2014. However the house fire occurred on 22 October 2014 and therefore this meeting never took place.

6.1.6 It is evident from the above that attention was paid to the children’s wishes and

feelings regarding contact throughout the involvement that Children’s Social Care and Cafcass had with the family. Additionally, MP told the social worker that she intended to pay attention to the children’s wishes and feelings. .

6.2 Key Line of Enquiry 2


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The appropriateness of the contact arrangements that were in place and whether other arrangements could or should have been made.

6.2.1 The contact arrangements that were in place at the time of the children’s deaths

were determined by the court at the First Hearing Dispute Resolution Appointment held on 30 July 2014 and were agreed by both parents. None of the agencies involved in this SCR had the authority to determine the contact arrangements between the children and their parents. This is a matter for the court and the decision making of the court is outside the scope of this Serious Case Review. Nevertheless, Cafcass had a role in advising the court regarding contact and there were occasions when Children’s Social Care was involved in discussions about contact. These occasions are considered below.

6.2.2 From the time of the parents’ separation until 4 June 2014 when P2 disclosed

physical abuse the contact arrangements were negotiated between the parents without intervention from any agency. In her application to court MP stated that FP would not accept that the children did not want to spend 50% of their time with him despite being told this by MP and the children.

6.2.3 Children’s Social Care’s stance throughout their involvement with the family was

that contact was a matter for the parents to determine and more specifically, that it was for MP to determine if and when the boys should see their father. As explained in paragraph 6.2.1, this approach was correct in the sense that where contact arrangements cannot be agreed between parents Children’s Social Care do not have the authority to determine the arrangements; instead it is for courts to do so. Furthermore it is not uncommon for children to have contact with a parent even when a Child Protection Plan is in place due to the risk of significant harm. However, if Children’s Social Care had grounds for concern that the children may be at risk of significant harm during contact, they could have undertaken Section 47 enquiries. This is considered further in relation to the allegations of physical abuse made by P2 on 4 June 2014 and by both children on 25 June 2014, in the response to KLE3 and it is concluded that it was reasonable of Children’s Social Care not to have initiated child protection procedures but to have allowed this to be resolved through the Private Law Proceedings that MP said she was going to initiate.

6.2.4 Following the urgent hearing at court on 9 July 2014, FCA1 from Cafcass advised

the court regarding contact arrangements on two occasions. The first of these was via a safeguarding letter to court when FCA1 recommended that the court order a Section 7 report. FCA1 had had the benefit of having seen MP’s application to court and was therefore privy to her concerns about her husband that had not been shared with SW2 on 25 June 2014 (see paragraph 6.3.7). However this review has found FCA1 did not identify the statement that FP had told his wife that he understood why fathers kill their children and consequently he did not discuss this with either parent and did not factor it into any of his analysis of the risks. In addition, there is no indication that domestic abuse or FP’s alleged controlling behaviour was discussed during the safeguarding call between FCA1 and MP on 9 July 2014. This review has found that FCA1 probably did not read the application in its entirety.


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6.2.5 FCA1 also incorrectly believed that the contact agreed by the court had been determined by the Local Authority although he had no information or evidence to support this belief.

6.2.6 It is impossible now to say what action would have been appropriate if FCA1 had

read the application to court more carefully and had addressed these issues with MP and FP. However it may have been appropriate for him to have considered recommending the suspension of contact pending the completion of the Section 7 report.

6.2.7 The second occasion when FCA1 advised the court regarding contact was on 30

July 2014 when FP sought an extension of contact to allow overnight stays and the court asked FCA1 to interview the parties and advise the court. During her interview MP told FCA1 that contact with FP was emotionally harmful to the children, that they returned from contact upset and that she was concerned that P2 might harm himself as a result of this. On advising the court FCA1 did not support FP’s request for increased contact including overnight stays but recommended that contact remain as per the original order. Given MP’s concerns FCA1 might have advised the court that Cafcass was engaging its S16A duty (see paragraph 6.2.8 below) and that the court may wish to suspend contact pending the provision by Cafcass of a risk assessment. Although it should be noted that SM1 observed the interview between FCA1 and MP and has stated that she does not recall the level of emotional harm being such that the S16A duty should have been invoked.

6.2.8 The Children and Adoption Act 2006 amended part ii, Section 16A of the

Children Act 1989, making it a duty for Officers of Cafcass to undertake a risk assessment whenever they have cause to suspect a child is at current risk of harm, and to provide that risk to the court. Cafcass guidance clarifies that this is a duty and that an FCA does not need the direction of the court to undertaken such an assessment. Furthermore the harm does not need to be at the level of significant harm for the Section 16A duty to be invoked.

6.2.9 There is a danger of hindsight bias when considering this issue with knowledge

of the tragic events that unfolded. There is no clear evidence that FCA1 should have recommended suspension of contact on either of the occasions that he advised the court regarding contact arrangements and this review goes no further than to say he could have considered recommending this. In addition it is important to note that, although the court order did not stop FP from having any contact with the children it did reduce the amount of contact and prevented overnight stays. Furthermore this was in line with the children’s expressed wishes and feelings and both MP and FP agreed to the outcome.

Assessment of risk

6.2.10 An issue to consider is whether sufficient consideration was paid to the possible risk to the children and whether there was information available to suggest that FP posed a risk to the children to the extent that Section 47 enquiries should have been undertaken. It is very difficult to make a judgement about this without being influenced by subsequent events but nevertheless, it is important to identify what evidence of risk was available to agencies at the time. The initial allegation made by P2 was that his father had previously hurt him by “dragging him by the throat”. MP had confirmed that an incident took place but said it had not been


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quite as P2 described it. During the discussion that SW2 had with the children on 25 June 2014 they both described times that they had been physically hurt by their father and both expressed their fear of him. In deciding whether or not to undertake Section 47 enquiries Children’s Social Care were mindful that the exact circumstances of the alleged incidents were unclear, they had happened some time ago and the children’s circumstances had changed as they were no longer living with their father. Given these factors, the allegations were not believed to indicate a risk of current significant harm.

6.2.11 On 26 June 2014 MP made the Police aware of her concern that her husband

might be suicidal and she repeated this in her application to court where she also referred to him telling her once that “he can understand fathers killing their children” and to him physically chastising the children and them being scared of him. It appears that Children’s Social Care were not made aware of these concerns and FCA1 did not pick up on some of the information within the application to court so it was not included in his safeguarding letter. There is evidence that FP was experiencing depression; he was prescribed anti-depressants by his GP and referred to IAPT. However this information was not shared with other agencies and therefore neither Cafcass nor Children’s Social Care were aware of it. In July 2014 FP was asked by both the GP and FCA1 whether he was experiencing any suicidal thoughts and on both occasions he said that he was not.

6.2.12 In September 2014 FP was asked directly by FCA4 whether he would harm the

children and he said no. However in July 2014 he had denied to FCA1 that he had previously harmed the children, a statement which was at odds with the allegations that had been made by P1 and P2 and which SW2 had considered to be credible.

6.2.13 It is important to acknowledge that the children were killed before Cafcass had

completed the Section 7 report or the court had made a final order regarding contact so it is impossible to know what would have been ordered. Furthermore the catastrophic events of 22 October 2014 could not have been predicted.

6.2.14 By taking the lives of his children and himself, FP joined a small group of people,

almost exclusively men, who have deliberately set out to kill their children. In ‘A Taxonomy of Male British Family Annihilators, 1980-2012’ Yardley, Wilson and Lynes consider 59 cases reported in newspapers of British men who murdered their children during the 33 year period in question. In 39 of the 59 cases (66.1%) family break-up was reported to be the primary motivation for the annihilation.

6.2.15 Yardley, Wilson and Lynes identify four sub categories of family annihilator but

conclude that they are all linked by “masculinity and the need to exert power and control in situations when the annihilator feels that his masculinity has, in some way, been threatened.” They do not identify any features that could help agencies predict whether an estranged father was likely to attack or kill their children and add that the vast majority would never dream of doing so. Consequently they state that children still should be given access to their fathers.



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The response to any allegations of physical abuse made against the father, including those made by younger child P2 to his school in June and September 2014. Consider whether anything else could or should have been done.

4 June 2014

6.3.1 The first allegation of physical abuse made against FP was on 4 June 2014 when P2 told his school teacher that his father had tried to choke him. The school’s response was to contact MP and Children’s Social Care. This was an appropriate response as steps were taken to ensure P2’s safety that day and to initiate further enquiries from the primary agency responsible for safeguarding.

6.3.2 Children’s Social Care responded promptly to the allegation with the duty social

worker speaking to MP, P2 and FP by phone on that day. The manager decided that it was not necessary to undertake Section 47 enquiries at that time but instead that a Children and Young People’s assessment should be carried out on a non-urgent basis. This was because the children were considered to be safe now that their mother had left her husband and the alleged incident had happened some time ago. In contributing to this Serious Case Review, Children’s Social Care comment that whilst they do not have the authority to determine contact, they may suggest restrictions on contact until an assessment is carried out in cases where a parent is struggling to recognise significant harm to a child. However Children’s Social Care considered MP to be a parent who was capable of protecting the children and not allowing contact if they did not want it.

6.3.3 Because Children’s Social Care decided not to undertake Section 47 enquiries

there was no strategy meeting with the Police and P2 was not asked to undergo a medical examination. Based on the information provided to this review, it is clear that the Police’s knowledge of the family at the time of the allegation was limited to one incident involving FP that had taken place three years previously. This incident did not involve FP or the children. It is unlikely that this incident would have been considered particularly significant in the context of the situation in early June 2014. Given P2’s description of the alleged incident and the fact that it was believed to have happened some months previously it was reasonable to take the view that a medical would be unlikely to find evidence of injuries resulting from the incident. It was conceivable that P2 may have other injuries but given his age and the readiness with which he had made his allegation it seems likely that, if he had sustained more recent injuries he would have disclosed these.

6.3.4 Considering the information that was available to Children’s Social Care at that

time, the decision not to initiate Section 47 enquiries can be justified. The children were no longer with their father and there was unlikely to be evidence to support the allegation as it had happened some time before.

25 June 2014

6.3.5 SW2’s visit to MP and the children is described in paragraphs 5.2.26 – 5.2.29 in the previous section of this report. As with many relationship breakdowns, MP and FP were in dispute with one another regarding the children and many such cases are resolved using Private Law Proceedings and without the Local Authority needing to seek orders to help safeguard the children.


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6.3.6 The question that needs to be considered is whether it was reasonable for

Children’s Social Care to allow future contact arrangements to be resolved through Private Law Proceedings or whether the children were at risk to the extent that warranted Children’s Social Care intervention to protect them.

6.3.7 In considering this issue it is important to be mindful of what information was

available to Children’s Social Care at the time and to avoid making judgements with the benefit of hindsight. The domestic incident of 26 June 2014, when FP sent MP a text in which he said “bye” (see paragraphs 5.2.30 – 5.2.39) had not taken place; FP had not been to the doctor to report that he was feeling depressed (see paragraph 5.2.44) and it appears that SW2 was not provided with some of the information that was subsequently included in MP’s application to court (see paragraph 5.2.43). In particular there is no evidence to suggest that SW2 had been told about FP having previously said that he understood fathers killing their children.

6.3.8 There was an apparent ambiguity between, on the one hand, the children’s

statements that they wished to have contact with their father and, on the other, their stated fear of him and their reports of him physically and emotionally abusing them. Nevertheless, although the allegations made by the children about their father’s behaviour should have given Children’s Social Care some cause for concern there was no evidence that the children would suffer significant harm by having short periods of contact with him and it was clear from MP’s comments and the information her solicitor provided to Children’s Social Care, that a court order would soon be made regarding contact. Consequently it seems reasonable for Children’s Social Care to take the view that contact should be resolved through Private Law Proceedings.

6.3.9 It is a matter of some concern that the records do not provide any evidence of

SW2 discussing her assessment with her manager. It appears that this was the result of the pressures of a busy duty and assessment team where discussions take place and decisions are made but not always recorded on file.

6.3.10 At the end of SW2’s visit to MP and the children there was a difference between

what P1 and P2 said they wanted to happen regarding contact with their father (for it to continue) and the action that MP said she was going to take (to not allow contact). Although SW2 has told this review that she did not think there was any reason why the children should not have some contact with their father she did advise MP, at that time, not to allow contact to take place.

6.3.11 MP told SW2 that she was going to apply for a court order regarding contact and

SW2 also knew that the children had expressed a wish for contact to continue. Consequently it should have been anticipated by Children’s Social Care that the court may make an Order which permitted contact. Nevertheless the evidence suggests that the social worker acted on the belief that contact would not continue.

September 2014

6.3.12 The allegation made by P2 in September 2014 was a repeat of the one he had

made in June 2014 and the school was aware that this was being dealt with. P2


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was not observed to be upset again. In the circumstances it was reasonable for the school to have dealt with this internally.


The response to any allegations about the care of the children, including that made by the father to Children’s Social Care in June 2014.

6.4.1 Concerns about FP’s behaviour towards and care of his children are addressed

throughout this report as it was these concerns that resulted in the involvement of Children’s Social Care and South Yorkshire Police, and MP’s response to these concerns that resulted in the court proceedings and involvement of Cafcass. However there were also occasions when FP raised concerns about MP’s care of the children.

6.4.2 Any concerns raised about the welfare of children must be taken seriously and

judged on their own merits. FP had opportunities to raise any concerns he had with Children’s Social Care and the only specific allegation he made was that MP was not addressing concerns relating to the weight of the children. This was addressed by Children’s Social Care and there were found to be no significant concerns. MP had taken P1 to the GP and he was attending Change for Life whilst P2 indicated that arguments about food were a primary source of tension between his father and himself. When SW2 contacted the GP on 27 June 2014 in the course of undertaking the assessment she was told that there were no concerns about the health of either child. There is however no indication on the records of either Children’s Social Care or the GP Practice to suggest that the social worker asked about these specific concerns.

6.4.3 The document which FP gave to the headteacher at the primary school does not

appear to have been a credible statement of concern that required further investigation (see paragraph 5.2.23).

6.4.4 FP’s comment to SW2 on 27 June 2014 that MP was emotionally abusing the

children needed to be considered within the context of MP having left him and taken the children with her and the fact that he wanted more contact than he was having. Furthermore, SW2 had spent a considerable period of time two days previously talking to the children about their wishes in respect of contact with their father.

6.4.5 Overall the responses to the allegations made by FP appear to have been

appropriate and no evidence was found to support them. 6.5 Key Line of Enquiry 5

The referral of father to IAPT and the response when he did not attend the appointment, including information sharing.

6.5.1 IAPT is an NHS programme which is being rolled out nationally. It offers services

for treating people with depression and anxiety disorders. Within Barnsley the IAPT programme is provided by SWYPFT. Individuals can self refer to the service and can also be referred by their GP. When a referral is deemed to be non-urgent it is routine practice for the GP to give the patient a number to self refer. FP visited the GP on 4 July 2014 and reported that he had left his wife “a couple of months ago” and had not seen his children for 18 days. He reported


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low mood and added that he had recently had thoughts of harming himself but he no longer had any suicidal thoughts and would never do it. The GP prescribed anti-depressants and gave FP the number of IAPT to refer himself, which he did. FP was given an appointment for 8 August 2014 but he did not attend. SWYPFT policy in relation to patient’s not attending IAPT appointments is to discharge the patient and write to the referrer to inform them of the non-attendance. In cases such as this one, where the GP has provided a patient with the number to refer him or herself, IAPT write to the GP to inform of the non attendance. According to SWYPFT, a letter was sent to advise FP’s GP that he had not attended IAPT. There is however no such letter on FP’s GP record and subsequent enquiries at the GP Practice have failed to find any evidence of the letter ever being received. The view of relevant professionals at the Learning Event was that even if this had been received it is unlikely that it would have been followed up. FP had self referred having disclosed depression but denied any suicidal tendencies and the GP was unaware of any information to suggest that FP was a risk to himself or others.

6.5.2 The agreed and established procedure by which IAPT should have informed the

GP that FP had not attended his appointment did not work although this review has not managed to establish where or why it broke down. In response SWYPFT have undertaken an audit to establish whether or not this is a common problem. 25 cases of non attendance at IAPT were selected at random and the patient’s GP practice was contacted to establish whether or not a letter had been received advising of the non-attendance. Responses were received from GP practices in respect of 19 of these cases; in 18 of them a letter had been received and in 16 cases the letter was received within five days of the missed appointment. In light of these findings the Serious Case Review Panel is reassured that there is not a consistent failure on the part of IAPT to inform GPs of non-attendance.

6.5.3 One week prior to FP visiting his GP, SW2 had contacted the GP practice and

made them aware of the reasons for Social Care involvement. There was no discussion about either parent and it was reported that there were no health concerns for either child. Historically, and in many ways appropriately, GPs have often been reluctant to share information about patients without the patients consent. Increasingly it is accepted in principle that where there are child protection concerns then GPs should share relevant information about parents even without consent.

6.5.4 Although SW2 did not ask the GP for information about MP and FP, Children’s

Social Care report that social workers and their managers are aware that they should do so and this practice is usually followed. The requirement to ask GPs about parents is detailed in the Assessment Framework used by Children’s Social Care in Barnsley and to emphasise this further, the relevant service manager has added a statement about the requirement to the Section 47 and Section 17 forms that are used.


The response to any allegations of domestic violence including the complaint made to the Police on 26 June 2014. Was a referral made to Stronger Families? If so, how was it dealt with; if not, should a referral have been made?


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6.6.1 Within the period covered by this review South Yorkshire Police were contacted on two occasions prior to the house fire on 22 October 2014. These were on 18 June 2014 and 26 June 2014 and details are provided in Section 5 of this report. The incident on 26 June 2014 was classified as a domestic incident but the incident on 18 June 2014 was not. This review has considered both incidents and whether they were handled appropriately.

Incident on 18 June 2014

6.6.2 There are a number of inconsistencies in the information provided to this review

regarding 18 June 2014. Based on the information recorded within the Police records there is nothing to indicate that this was a domestic incident that required a response. The maternal grandmother was given advice as to what action should be taken, including that she should phone again if there were further problems later in the evening. There is no evidence within the Police records that a complaint was made about FP going into the maternal grandmother’s home and ‘frogmarching’ P1 out of the house. There is also no record of MP phoning the Police that day, although MP told the author of this Overview Report that she did so.

6.6.3 The Children’s Social Care record of information provided by MP on 18 June

2014 suggests some coercion, at the very least, from FP in taking the children but it is also recorded that MP said that the Police were ‘sorting it’. Based on the information within the record there is no suggestion that Children’s Social Care should have taken action that evening. When SW2 met with the children on 25 June 2014, P1 described a recent occasion when his father had “barged” into his Grandmother’s house and made him leave with him. P1 said he was worried that he would not see his mother again. MP reported this incident to FCA4 when they met on 6 October 2014; she described it as the trigger for her making the application to court. During the visit to FP on 16 July 2014 SW2 raised an issue about him breaking into his mother’s house and the boys not talking to him. When asked about this in connection with this Serious Case Review, SW2 explained that this related to a conversation she had with MP on 25 June 2014. The conversation with MP is not recorded within the case record which is an omission. The Lead Reviewer has been unable to establish exactly what incident this refers to. However it seems to the Lead Reviewer that it may refer to the occasion on 18 June 2014 when FP went into MP’s mother’s (not his own mother’s) home and took P1 for contact.

6.6.4 One interesting point from the records is that the duty social worker recorded that

when she tried to phone MP the phone was answered by P1. However, the reason for MP’s call to Children’s Social Care was that FP had taken the children for contact when they did not want to go. Therefore neither child should have been in a position to answer the phone. A further inconsistency is that the Children’s Social Care record includes a statement that MP said that FP was not supposed to be having contact with the children whereas the information in the Police record and provided by MP to the Overview Author is that contact was supposed to be taking place.

6.6.5 The reason for these various inconsistencies and anomalies cannot be

ascertained by this review. It may be that the records from the Police and/or Children’s Social Care contain some inaccuracies or it may be that MP,


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understandably, has not clearly remembered the exact sequence of events and that her report to the Overview Author was not entirely accurate. She did not tell the Overview Author about her phone call to Children’s Social Care on 18 June 2014 and her memory may be that it was the Police she phoned.

6.6.6 However, leaving aside all the inconsistencies, it is agreed that the Police gave

advice that MP or her mother should phone again if the children were not returned from contact at the agreed time. Neither party did phone back and therefore the Police did not take any action. The Lead Reviewer and Serious Case Review Panel are of the view that this incident was dealt with appropriately by the Police. There was no evidence that domestic violence had taken place and no requirement for it to be reported as a domestic incident.

Incident on 26 June 2014

6.6.7 The initial grading of the incident as ‘priority’ was appropriate. It had been

confirmed that FP had left the address and that MP and the children were safe and well and therefore, the risk was not immediate. However actual attendance by the police officers was 18 minutes outside the target response time of one hour.

6.6.8 The police officers were correct to identify that this was a domestic abuse

incident. The risk assessment of standard was also appropriate as it was the first report of a domestic incident between FP and MP, the evidence at the time did not indicate a likelihood of serious harm and the positive responses to the DASH questions were minimal.

6.6.9 Police officers recorded that MP told them that Children’s Social Care had

applied for an emergency order to prevent FP having contact whilst an investigation/assessment was carried out. In fact Children’s Social Care were not taking any action in respect of contact but believed that MP was not going to allow it and assumed that the court would support her. It is not possible to know whether MP provided incorrect information to the Police or if the officers misunderstood what she said.

6.6.10 MP’s assertion that her husband had not been aggressive to her in the past was

inconsistent with the statement made by the grandmother when she contacted the Police to report the incident (see paragraph 5.2.31). It appears that officers did not explore this inconsistency or make reference to it in the domestic abuse referral that followed.

6.6.11 Because the family were already allocated to a social worker in the Assessment

Team the details went directly to the Assessment Team and Stronger Families were not involved. This is standard practice where a case is already open within Children’s Social Care and therefore it was an appropriate response.

6.6.12 The officers’ immediate response to the concerns expressed by MP that her

estranged husband might harm himself appears to have been appropriate in the circumstances. There is no indication that the referral to Children’s Social Care included any information about MP’s concerns that her husband might harm himself. In light of the ongoing issues around contact it would have been appropriate to share this information.


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6.6.13 The delay between the incident taking place and Children’s Social Care receiving

the notification from the Police was due to the case being risk assessed as standard. This is the lowest risk level and therefore it is afforded the lowest priority. If the Public Protection Unit (PPU) is under particular pressure it can take a few days before such notifications are forwarded to Children’s Social Care and where a case is already allocated to a social worker this presents a potential difficulty in that the social worker may have contact with family members after the incident has taken place but before the notification is received. On this occasion FP phoned SW2 the day after the incident but SW2 was unaware of it and therefore she was unable to factor the incident into her analysis of the phone conversation, which was a difficult one. Indeed even when she did become aware of the domestic incident she did not realise that the phone conversation had been the following morning.

6.6.14 It is reported that there is some uncertainty within Children’s Social Care as to

how social workers should be advised of Domestic Violence alerts when a case is already open to a social worker. The business support manager has confirmed that the approved way is to add a task to the TED system4 which puts a task on the worker’s ‘to do’ list to check the new information. However the view of SW2 is that some business support staff do this, others send an e-mail and others just add the detail to the file without any additional contact. A problem with this third approach is that the allocated social worker may remain unaware of the incident. Once a task is completed it does not remain on the record so there is no way of knowing which approach was followed on this occasion. However, there is no indication within the Children’s Social Care records that the incident was discussed with either parent and it is not referred to in the social work assessment.

6.6.15 Since this incident, capacity has been increased within the PPU risk assessment

team in recognition of an increase in the number of domestic abuse incident that the Police are responding to. Consequently the unit is not currently experiencing delays in forwarding information to Children’s Social Care about cases which had been risk assessed as standard . In addition there have been significant changes in the way domestic violence referrals are dealt with by Children’s Social Care. All domestic violence referrals from the Police now go through one screening process which is based with the Assessment Team. The Police colour code the referrals so that they are easier to identify as high, medium and standard and the screening team re-assess, in the light of additional information they are able to access, whether the original allocation made by the Police as a single agency is correct. High and medium level cases are routinely subject to either a section 47 or a child in need assessment whichever is appropriate and the standard cases are passed to the Stronger Families Teams for assessment at an early intervention level. Duplication of information which previously occurred when Children’s Social Care were notified by the Public Protection Unit and the Domestic Violence Team no longer happens as all information is sent to the same screening desk and linked. All notifications, whether high, medium or standard are screened on the day of receipt and where a case is already allocated the social worker will be notified of the incident by email that same day.

4 TED (Tribal Electronic Desktop) is the computerised recording system used by Barnsley Council Children’s

Social Care


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6.6.16 Children’s Social Care together with the Police, Health and Education will be

implementing a Multi-Agency Screening Hub approach from September 2015 which will address the need for a multi-agency initial assessment and the need to bring together information which may be held on a number of data-bases.

6.6.17 SW2’s (lack of) response to the domestic abuse notification suggests that it was

not regarded as particularly significant in the context of the case. It provided evidence of FP’s potential for aggressive behaviour and thereby confirmed Children’s Social Care’s existing opinion of him. Children’s Social Care’s belief at that time was that MP was going to stop the children from having contact with their father and it seems that the social worker believed that the court was going to support this stance. It is only with hindsight that the details entered on the DASH assessment assume greater significance.

6.6.18 No other allegations of domestic violence were made to any agency during the

period covered by this review. Key Line of Enquiry 9 considers whether any of the agencies had knowledge of possible Domestic Abuse within the family and how this was addressed.


The circumstances which led to CAFCASS, not Children’s Social Care, writing the S7 court report and the appropriateness of this.

6.7.1 When hearing private law applications, courts will sometimes request a Section 7

report to assist the court in making decisions relating to children. Such reports can be prepared by Children’s Social Care or by Cafcass and an agreement is in place between Cafcass and the Association of Directors of Children’s Services as to which service should be responsible for writing the report in given circumstances. Generally speaking Children’s Social Care should write the Section 7 report if they are involved with the family or have been within the past month. Cafcass should write the report where there has been no involvement from Children’s Social Care within the past month.

6.7.2 In the case of P1 and P2 it is written within Children’s Social Care records that

the decision that Cafcass should complete the Section 7 report was made during a telephone conversation between FCA1 and SW2 on 31 July 2014. SW2 explained that although the case was technically still open she had completed the assessment and her work with the family and was intending to close the case very soon. In the event the case was not closed by Children’s Social Care until 20 August 2014 although the last active involvement was on 16 July 2014. According to Cafcass records the safeguarding letter which was filed on 25 July 2014 recommended that the report should be written by Cafcass. FCA1 had not spoken to SW2 before writing the safeguarding letter but appears to have believed that the case was closed to Children’s Social Care.

6.7.3 It is evident that the court should have been advised to order Children’s Social

Care, not Cafcass, to prepare the Section 7 report in this case. Even if Children’s Social Care had closed the case by 31 July 2014 the service had been involved within the previous month and therefore would have been responsible for preparing the report. It is not clear why FCA1 agreed to write the report and the


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date of the safeguarding letter pre-dates the date when, according to the Children’s Social Care records, SW2 and FCA1had a conversation about this.

6.7.4 It is impossible to know what difference it would have made to subsequent events

if the Section 7 report had been prepared by Children’s Social Care rather than Cafcass. However nothing in the Children’s Social Care records suggests that there were particular concerns that the children should not have any contact with their father. Therefore there is no indication that Children’s Social Care would have taken steps to curtail contact at a time prior to the tragic events of 22 October 2014.


Agencies’ knowledge of father’s alleged ‘breakdown’ in 2013 and how this was addressed by agencies when working with the family in 2014.

6.8.1 FCA1 from Cafcass had a “safeguarding telephone call” with MP on 9 July 2014. During this call MP referred to her husband having “had something of a breakdown in 2013 and said that his life was not worth living.” No other agency involved with this Serious Case Review has found any information relating to FP’s mental health in 2013 and there is no indication that he spoke to his GP about his mental health in 2013. It would have been appropriate for FCA1 to have explored this issue further as this may have led to a better understanding of FP’s mental health and could have informed a risk assessment. FCA1 could have considered seeking a report from FP’s GP in relation to his mental health. It would also have been appropriate for this to have been discussed with FP during the Cafcass assessment but there is no indication that this was done.

6.8.2 When the Lead Reviewer asked MP about this issue she explained that it had not

been a breakdown but in 2013 FP told her that he had been abused when he was a child. MP had told him that he should report this to the Police but, as far as MP is aware, FP did not do so and did not talk to anyone else about this issue.

6.8.3 Other concerns regarding FP’s mental health 6.8.4 Although there is no evidence that FP had a breakdown in 2013, information was

available to some agencies that could have raised concern about his mental health and it is appropriate to consider what information was available and how it was addressed.

6.8.5 GP records show that in 1993 FP was referred to psychiatric services in the area

in which he was then living, due to depression and the following year was given a ‘Differential diagnosis’ of Borderline Personality Disorder, mixed affective episode and Cyclothymia.’ The named doctor for safeguarding within the Clinical Commissioning Group has advised the SCR Panel that the differential diagnosis is a professional technique to communicate the thought process of professionals and help to structure a treatment plan. The idea is to use this list to exclude or substantiate each diagnosis through investigation or continual monitoring. The monitoring in this case was passed back to the GP who could have referred back to this list with any future contacts. It is likely that FP would have been told that he seemed a little depressed and he would have been told to see his GP if he needed help in the future. Following the differential diagnosis, FP was


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prescribed anti-depressants and referred to a community psychiatric nurse but it is not known whether contact was made. There are no subsequent GP records relating to FP’s mental health until July 2014 (see Section 6.5).

6.8.6 None of the agencies involved with this Serious Case Review were aware of this

history for FP at the time they were working with him. However these events took place 21 years previously and it is the view of the SCR Panel that there is no reason why agencies should have been aware or should have factored these events into any assessment or decision making within the scope of this SCR.

6.8.7 The statement in MP’s application to court that FP told her on 26 June 2014 that

“he had nothing to live for and intended to commit suicide” differs from the Police record of the incident in which it is written that FP had sent a text to MP consisting of the single word “bye”. This latter statement is more ambiguous than the one reported in the application to court. Nevertheless the Police report goes on to state that MP was concerned about FP’s mental state and believed that the message may indicate that he intended to cause harm to himself. Therefore it is clear that there was concern, on the part of MP, that her husband may be feeling suicidal and she shared these fears with the Police and subsequently in her application to court.

6.8.8 In the application to court it was also written that both MP and Children’s Social

Care were “extremely concerned” about FP’s mental health. Records show that SW2 had spoken to MP and the children on 25 June 2014, the day before the incident in which FP had allegedly threatened to kill himself. There had been no communication between MP and Children’s Social Care since that date and, although Children’s Social Care knew that an incident of domestic violence had taken place, there is no evidence that they had been told by anyone about the concerns that FP might harm himself. There is also no indication in the information provided to this review by Children’s Social Care that they had particular concerns about FP’s mental health or that such concerns, if they existed, were shared with MP. In light of this statement being included within the application to court it would have been appropriate for FCA1 to have spoken to SW2 to ascertain what concerns she had. However, as is reported elsewhere in this report there was no contact between FCA1 and SW2 until either 30 or 31 July 2014 when FCA1 was preparing the case for transfer to the Work After the First Hearing Team. FCA1’s record of the phone conversation with SW2 on 30 or 31 July 2014 suggests that FCA1 had concerns about FP’s mental health although the nature of the concerns is unclear.

6.8.9 Notwithstanding the apparent inconsistencies between statements in the

application to court and information within Children’s Social Care and Police records it is evident that MP did have concerns about her husband’s mental health and the possibility that he may harm himself. It appears that FCA1 did talk to FP about the suggestions that he had threatened suicide as it is written that he denied he was suicidal. This is consistent with FP’s statement to the GP on 4 July 2014 that he did not feel suicidal.


Agencies’ knowledge of possible Domestic Abuse within the family and how this was addressed.


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6.9.1 Key Line of Enquiry 6 considered the response of agencies to incidents that occurred on 18 June 2014 and 26 June 2014. This Key Line of Enquiry considers whether agencies had other knowledge that may have led them to suspect domestic abuse.

6.9.2 Between June 2004 and September 2012 MP visited the GP in respect of four

bruising injuries. Two of the injuries were attributed to falls, one to being hit by a door and no explanation has been recorded for the other one. MP also attended the GP once in 2003 and twice in 2007 due to stress and/or low mood and during these appointments she made reference to issues with her husband. All of the appointments referred to above were with different GPs. There is no indication that any GP ever considered whether the injuries sustained by MP might be the result of domestic abuse. It was stated at the Learning Event that historically GPs have often not recorded negative responses to questions. Therefore it is possible that on one or more occasion a GP may have asked MP about possible domestic abuse but if she denied this no record would have been made of the question or the denial. GPs have been informed to record negative answers.

6.9.3 With hindsight there were occasions when health professionals might have been

inquisitive as the cause of the injuries sustained by MP. It is unclear whether any GP ever asked her about possible domestic violence but plausible explanations were provided for the injuries, they were spread over several years and were attended by different health professionals so no one person would have had a full picture of the injuries sustained by MP. Even at this stage, there is no evidence that any of the injuries were the result of domestic violence from FP to his wife.

6.9.4 There is no indication to suggest that MP ever disclosed that her husband had

hurt her physically. On two separate occasions health visitors specifically asked her whether she was the victim of domestic abuse and on both occasions she responded that she was not. In her application to court MP listed the types of abuse she had suffered as emotional and psychological and the types suffered by the children as physical, emotional and psychological. During this review she told the Lead Reviewer that her husband had been emotionally abusive and had thrown things at her but she added that he had never physically hurt her. By contrast, when SW2 spoke with the children on 25 June 2014, P2 made a clear statement that he had seen his father slap his mother and on 26 June 2014 the maternal grandmother told the Police call handler that FP had threatened MP in the past and been violent towards her in the bedroom. The records suggest that neither SW2 nor the Police officers who attended the domestic incident challenged MP when she denied that her husband had hurt her physically.


Determine whether the policies, procedures and practice expectations of the agencies were followed during this period and identify any shortfalls.

6.10.1 In various places through the analysis of the Key Lines of Enquiry reference is

made to policies, procedures and practice expectations and whether or not these were followed. This section of the analysis does not seek to repeat the detail of all those occasions. Furthermore, Key Line of Enquiry 11 addresses issues of communication between agencies and therefore policies, procedures and


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practice expectations specifically relating to communication will be addressed there rather than in this section.

Cafcass

6.10.2 Cafcass have identified that the work undertaken in this case fell below the expected standards in several ways. From the outset, when MP’s application to court was screened, important information was either not read or was overlooked with the result that FCA1 did not make the necessary enquiries to properly consider the possible implications for the children’s safety. Of particular note was MP’s report that her husband had previously told her that he ‘understood why fathers kill their children’ and this should have been explored with both parents. A more thorough reading of the application to court might have allowed FCA1 to ask appropriate questions which, in turn, would have enabled him to provide a more robust analysis in his safeguarding letter. Based on the information that was available to FCA1 it is reasonable to suggest that he could have considered recommending that contact be suspended whilst risks were further assessed. He could also have considered engaging Cafcass’s Section 16A duty and commissioning a level 2 enhanced police check in respect of FP.

6.10.3 The Cafcass information system relating to the quality assurance of reports does

not include evidence that FCA1’s work had been quality assured with the necessary frequency for him to retain his self filer status.

6.10.4 The Work After the First Hearing was not completed by the time of the children’s

deaths, however there is a concern that it relied too heavily on the Work To First Hearing. FCA4 should have contacted SW2 directly rather than relying on the limited case recordings from FCA1. FCA4 did not meet the Cafcass procedure in terms of how quickly case records were written. Because of this her records of discussions with P2, MP and FP were written after the fire.

6.10.5 Records show that this case was allocated to FCA4 on 6 August 2014 and her

first involvement with anyone from the family was two months later when she met with MP on 6 October 2014, one month before the Section 7 report was due to be submitted to court. MP expressed concern to the Lead Reviewer about this two month gap. The author of the Cafcass IMR has reported that whilst Cafcass is encouraging staff to complete work as early as possible it is not uncommon for work to be completed in the final four weeks of the 12 week period allowed by the courts and this is usually reasonable as long as the case has been screened for immediate risks that may require action. In this case FCA4 did screen the case and wrote a detailed case plan on 20 August 2014 and had other commitments that would have made it difficult to carry out this work sooner. There is no indication that she would not have filed her report within the necessary timescales. Nevertheless it is acknowledged by Cafcass that the delay in commencing this work was not ideal.

6.10.6 MP also expressed concern to the Lead Reviewer that FCA4 had shared too

much information with FP about P2’s wishes with regard to future contact. She believes that this made FP angry. It is however necessary for Cafcass to work with parents in a transparent way and FCA4 has stated that the discussion about future contact was framed within the context of building up contact and re-establishing FP’s relationships with the children and not as a final position. It is considered appropriate for FCA4 to have raised this with FP.


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Children’s Social Care

6.10.7 Following the team manager’s decision that a Section 17 assessment should be undertaken the case should have been allocated within three working days. In fact it was not allocated until 13 days after the initial contact and even then was allocated to a social worker who was on leave and therefore a further week passed before any work was carried out. It is reported that this delay is due to the high number of initial contacts being received by Children’s Social Care and an increase in the proportion of these becoming referrals. This pressure continues for Children’s Social Care. Having returned from leave SW2 contacted the family quickly and the assessment was completed and authorised by a manager within the 45 days allowed by the relevant statutory guidance ‘Working Together to Safeguard Children 2013’.

6.10.8 The Children’s Social Care case records relating to P1 and P2 do not include any

record of management supervision or decision making between the initial decision to refer for an assessment and the decision that Children’s Social Care involvement would cease. SW2 has stated that ad hoc discussions took place with the manager regarding the case and the lack of formal recorded supervision is attributed to the pressure on the service coupled with a view throughout the assessment that this was a straightforward case and not a high risk, high priority case such as would be addressed regularly in supervision. A written record should have been made of any discussion between SW2 and the team manager about the outcome of the assessment. This should have clearly stated the decision that was reportedly taken that Section 17 was the appropriate level of assessment and that there was no need to undertaken Section 47 enquiries. The only explanation that has been provided for this not being done is that the visit was made late in the day. However that does not explain why a discussion which reportedly took place the following day was not recorded.

6.10.9 Over recent years Children’s Social Care have experienced an increase in the

number of referrals being made to the service and this has made it more of a challenge to respond within an appropriate timescale. Children’s Social Care have temporarily appointed six extra staff to the Assessment Team to respond to the increased demand.

6.10.10 Some of the record keeping appears to have fallen below the expected standard.

For example there is little record of the discussion that SW2 had with MP after SW2 had seen the children on 25 June 2014 and the record of SW2’s conversation with FCA1 is described as “unclear”.

South Yorkshire Police

6.10.11 There was a brief delay in the Police attending the maternal grandmother’s home on 26 June 2014 following the report of FP throwing items into the garden. Officers should have been at the property within an hour of taking the phone call but in fact arrived after one hour and 18 minutes. However the incident itself was correctly identified and recorded in line with South Yorkshire Police policies, procedures and practice expectations. The risk assessment of this incident was correct and the appropriate referrals made to partner agencies.

Education


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6.10.12 The primary school responded appropriately on the day that P2 disclosed that his father had hurt him. The high school provided good support to P1 when they became aware that his parents had separated.

GP

6.10.13 There is no indication of any failure by the GP practice to follow policies, procedures or practice expectations although record keeping needs to be improved.

SWYPFT

6.10.14 SWYPFT had very limited contact with the family during the period covered by the review. Apart from the possible omission by IAPT to write to the GP regarding FP’s non attendance there is no indication that policies, procedures and practice expectations were not fulfilled.


The quality of information sharing within and between agencies and whether there were any missed opportunities to share information that may have prompted agencies to intervene differently.

6.11.1 This review has identified several occasions when agencies should have

contacted one another to share information. 6.11.2 Children’s Social Care did not speak to anyone at the high school which was

attended by P1 at any time during the Children’s Social Care involvement. Contact would have been appropriate in order to establish how P1 presented at school and whether the school had concerns about his well being. Contact would also have provided an opportunity for Children’s Social Care to ensure that the high school were aware of the allegations that had been made against FP and to ascertain what experience the school had of him. Consideration should have been given to contacting the high school on 4 June 2014 whilst SW1 was making the initial enquiries which led to the team manager deciding that it was not necessary to initiate Section 47 enquiries. Contact should certainly have taken place when SW2 was undertaking the assessment at the end of June 2014. SW2 has stated that she tried to contact P1’s school on one occasion and left a message. She acknowledges that this was not followed up and she came back to it at the end of her assessment but believed that by then she had the necessary information to complete the assessment. However she is now aware that this should have been followed up.

6.11.3 A previous Learning Lessons Review commissioned by Barnsley Safeguarding

Children Board in 2014 in respect of a different child found that in carrying out an assessment, Children’s Social Care did not communicate widely with other agencies involved with the family, including the school. Information was provided to that review that a framework for assessing the needs of children and young people had been introduced by Children’s Social Care in September 2013 which was clear about the importance of working with other agencies when undertaking assessments. Notwithstanding SW2’s assertion that she did try to phone P1’s school on one occasion, the absence of any communication between Children’s Social Care and P1’s school suggests that in this case, the framework was not followed.


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6.11.4 As it happens there is no evidence that the high school would have had significant information to contribute if contact had been made and it appears that such contact would not have led Children’s Social Care to intervene differently.

6.11.5 There was only one contact between Cafcass and Children’s Social Care during

the whole time Cafcass was involved and this took place when FCA1 was preparing the case for transfer to the Work After the First Hearing Team. The Children’s Social Care case record of this conversation consists of the transcript of an email which appears to have been sent by SW2 to confirm the outcome of the conversation. The author of the Children’s Social Care IMR states that the email is very unclear. It refers to contact between the children and their father but the actual contact arrangements are not specified. It appears that even after this conversation SW2 remained unclear as to whether or not the court had made an order for contact. The author of the Children’s Social Care IMR also comments that when Cafcass took over writing the Section 7 report it would have been useful for them to have had at least the transcripts of the interviews with the children, the assessment itself, the report of the Domestic Violence incident and the report of the interview with FP. However it is unclear form Children’s Social Care records how much information was transferred between SW2 and Cafcass at that time. The author of the Cafcass IMR states that the purpose of this phone conversation appears to have been to update the local authority on the progress of the case in court and that the conversation appears to have focused on FP and his presentation.

6.11.6 As has been stated elsewhere in this report, FCA4 wrote a case plan which

included an intention to contact SW2 but in the event she did not do so and has told the Cafcass IMR author that this was because FCA1’s record of his conversation with SW2 answered the questions she had. This view appears inconsistent with the IMR author’s description of FCA1’s record as brief and lacking any specific detail.

6.11.7 Leaving aside the quality of the record keeping of the discussion between FCA1

and SW2, there should have been more communication and information sharing between Cafcass and Children’s Social Care. Cafcass officers should have sought to find out exactly what involvement Children’s Social Care had had with the family and it would have been useful for them to have copies of records such as the interviews that Children’s Social Care had carried out with family members and the domestic abuse notification. FCA1 should have contacted Children’s Social Care prior to the telephone interviews with FP and MP and FCA4 should have contacted Children’s Social Care rather than relying on the records FCA1 had made of the conversation he did have with SW2. If Children’s Social Care’s decision not to intervene with regards to contact was based on a belief that the court was going to make a no contact order then it would have been appropriate for Children’s Social Care to contact Cafcass after the urgent hearing on 9 July 2014 to establish the outcome.

6.11.8 FCA4 met with P2 at school and attempted to arrange to meet P1 at the high

school. There was a breakdown in communication with FCA4 believing that the school did not return her call whilst LM2 states that she phoned both numbers that had been left but did not get a response. In addition to speaking to the children it was appropriate for FCA4 to speak to school staff to inform the Section 7 report. A planned meeting with the headteacher at the primary school did not


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take place due to FCA4 being late and no meeting was arranged at the high school. The fire occurred 15 days before the Section 7 report was due to be submitted so there was still some time for FCA4 to gather information but one week of that time was a school holiday.

6.11.9 The School Nursing Service was not involved at all with the family although there

were occasions when referral to the service may have been beneficial, such as when P2 made his allegation on 4 June 2014 and when concerns were expressed about the children’s weight. School nurses are lead professionals for health for school age children and it is important that other agencies recognise the role they can play in the multi-agency teams working with families. .

6.11.10 When SW2 phoned the GP Practice she did not talk to the GP about the

concerns that FP had raised about the children’s weight and did not seek any information about either parent. The General Medical Council recommends that where a child is considered to be at risk of harm then GPs should share information regarding the parents’ medical history. (see section 6.6)

6.11.11 As identified elsewhere in this report, IAPT should have informed the GP when

FP did not attend his appointment. IAPT records show that a letter was sent to the GP Practice but the letter does not appear on FP’s GP record. It is not known where this communication broke down but the audit undertaken by SWYPFT suggests that this is not a common problem that requires action.

7. Conclusions 7.1 The deliberate, devastating actions of FP on 22 October 2014 could not have

been predicted by anyone. Research suggests that such incidents are rare, that the vast majority of estranged father’s would not consider such actions and that there is no known way of identifying those who will do so. Historically there was no information regarding the family to cause concerns. Neither FP’s known offending history nor his mental health history was sufficient to make agencies believe that he posed a significant threat to himself or others. The coroner made it clear at the inquest into the children’s deaths that there was no knowledge by a public authority of any identifiable risk of such an event taking place and that none of the agencies involved with the family had fundamentally failed in their duty to the family.

7.2 The children told SW2 that they wanted contact to continue but their mother said

that she was not going to allow it. However during the urgent court hearing she agreed to contact taking place. Children’s Social Care believed that the children were not at risk of significant harm from their father and that there were no grounds undertake Section 47 enquiries. This review believes that to have been a reasonable decision considering the information available to Children’s Social Care at the time it was made. A record should have been made on the Children’s Social Care case files for these children evidencing that the team manager had agreed with this course of action.

7.3 In MP’s application to court and the discussion she had in court with FCA1, she

expressed concern about FP’s care of the children and the impact that contact was having on them. It appears that FCA1 had not read MP’s court application in its entirety and overlooked some of the concerns that she raised. In the light of


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the concerns raised by MP this review believes that Cafcass should have considered recommending that contact be suspended whilst assessments were ongoing. Such judgements are difficult to make at the time and it is considerably easier to criticise with the benefit of hindsight than it is to make the correct judgement at the time. This review does not conclude that contact should have been suspended but does conclude that this should have been considered.

7.4 Although the court made an order for contact the amount allowed was a

reduction in what had gone before, was in line with the children’s wishes and was made with the consent of both parents.

7.5 The primary school responded appropriately when P2 initially alleged that his

father had hurt him and Children’s Social Care responded in a timely fashion. There was then a delay before Children’s Social Care commenced an assessment, although it was completed within the required timescales, and there was an absence of supervision for the social worker. These shortfalls are attributed to the pressure of work and this case not being identified as high risk.

7.6 As with many Serious Case Reviews, this review has found examples of

agencies failing to communicate with each other as comprehensively as they should have done. Of particular note is the contact between Children’s Social Care and Cafcass, which was limited to one phone conversation between FCA1 and SW2 when FCA1 was preparing the case for transfer to the Work After the First Hearing Team. It is evident that Children’s Social Care and Cafcass had different information, to one another, about the family. By sharing this information both agencies would have had a better all round understanding of the family situation which may have led to different actions and recommendations.

7.7 This review has also found that communication between Children’s Social Care

and GPs needs to be improved. Where there are potential safeguarding concerns social workers need to feel empowered to ask GPs for information about parents. In this case there is no indication that better communication between Children’s Social Care and the GP Practice would have led Children’s Social Care to act in a different way. Children’s Social Care have now taken action to strengthen the message that when carrying out Section 17 and Section 47 assessments, social workers should ask GP’s about parents as well as their children (see section 6.5).

7.8 Children’s Social Care did not have any communication with the school attended

by P1. Such communication would have been appropriate both to make the school aware that an allegation had been made by P2 against his father and to gather information about P1 to inform the assessment that was carried out. In 2013 Children’s Social Care introduced a framework for assessing the needs of children which was clear about the importance of working with other agencies when assessing children. The absence of any contact with the high school suggests that this framework was not followed.

7.9 Information regarding the children was not shared with the School Nursing

Service although there were times when it would have been appropriate to do so. 7.10 South Yorkshire Police’s response to the incident of domestic violence on 26

June 2014 was appropriate and the incident was reported to Children’s Social


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Care and Stronger Families in line with existing procedures. Because the risk was appropriately assessed as standard there was a gap of a few days before it came to the attention of the allocated social worker. During this period the social worker had a conversation with FP but unfortunately did not know about the incident. There is no suggestion that this made any difference to the subsequent decision making in this case. Changes made since this incident should result in social workers being informed of domestic violence incidents connected to allocated cases in a timely manner.

7.11 The exact circumstances of the incident that occurred on 18 June 2014 have not

been established. However, based on the information that is available it appears that South Yorkshire Police acted appropriately by offering advice. Furthermore there is no evidence that domestic violence had taken place and no requirement for the incident to have been reported as a domestic incident.

7.12 There is no clear evidence of previous domestic violence within the relationship

between MP and FP. However there were occasions when MP visited the GP with injuries which could have raised concern about possible domestic violence. The GP records are insufficiently detailed to indicate whether or not any GP suspected domestic violence or asked MP about it. This review has been informed that GPs have been given advice in relation to record keeping; nevertheless a recommendation is made that training should be provided.

7.13 Although MP expressed concern about FP’s mental health there was little

evidence available to agencies to support this. Apart from the differential diagnosis made 21 years previously and about which the GP Practice was unaware, there was only one occasion when FP sought medical help in respect of mental health. This was on 4 July 2014 when he presented as having a low mood and stated that he had had thoughts of harming himself but no longer had these. Also in July 2014 FP told FCA1 that he did not feel suicidal. Nevertheless, in light of the information contained within MP’s court application FCA1 should have explored the issue of FP’s mental health more thoroughly than he did.

8. Learning from this Serious Case Review 8.1 Introduction 8.1.1 Since the death of P1 and P2, and whilst this review has been in process,

agencies involved in the review have learnt lessons and taken several actions in order to improve services. These actions are all relevant to this case although they have not all been undertaken as a direct result of the case. The first part of this section of the report describes the actions that have been taken. Notwithstanding these changes, this Serious Case Review has identified several further areas where improvements can be made and recommendations are made to bring about these improvements. These recommendations can be found at the end of this section.

8.2 Action Taken Since the Death of P1 and P2 8.2.1 SWYPFT have undertaken an audit of letters sent by IAPT to GP practices when

patients have failed to attend appointments (see paragraph 6.5.2)


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8.2.2 Children’s Social Care have taken action to strengthen the message that when

carrying out Section 17 and Section 47 assessments, social workers should ask GP’s about parents as well as their children (see paragraph 6.5.2)

8.2.3 Significant changes have been made to dealing with Domestic Abuse

notifications (see paragraphs 6.6.15 and 6.6.16). Children’s Social Care and the Police are continuing to work together to improve joint working and understanding between each other and progress will continue to be reviewed on a regular basis.

8.2.4 Capacity has been increased within the PPU risk assessment team in recognition

of an increase in the number of domestic abuse incidents that the Police are responding to (see paragraph 6.6.15).

8.2.5 Children’s Social Care have temporarily appointed six extra staff to the

Assessment Team to respond to an increase in the number of referrals being made to the service (see paragraph 6.10.9).

8.2.6 Cafcass have undertaken the following actions:

a. Senior Head of Service - Work to First Hearing (WTFH) has reviewed business processes in safe handling of court applications with specific attention to urgent applications to ensure compliance with Child Arrangements Programme (CAP).

b. Senior Head of Service (WTFH) has improved the operational effectiveness in WTFH to deliver safe outcomes through a range of interventions.

c. Senior Head of Service (WTFH) has improved the quality and consistency of assessment and analysis in Safeguarding letters

d. Senior Head of Service - Work After First Hearing (WAFH) has ensured that Private Law casework in WAFH is delivered effectively and with minimal delay.

e. Senior Head of Service (WAFH), through a range of workshops, has improved the quality and consistency of assessment and analysis in WAFH.

f. Senior Head of Service – Stakeholder Engagement continues to share learning raised by this review with the court and local authority stakeholders in relation to urgent hearings and the joint protocol in relation to the preparation of Section 7 reports.

g. National Service Director has reviewed and amended the processes in relation to staff self-filing status and ensure that guidance is being adhered to.

8.3 Recommendations 8.3. 1 In addition to the actions described above, which have already been completed,

the following recommendations are made:


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Barnsley NHS CCG 1. The Named Doctor for Safeguarding Children, NHS Barnsley CCG should

ensure that education sessions are arranged in order to improve the standard of General Practice Medical Records to ensure that appropriate information is recorded and transferred to the relevant people in an acceptable format. This to be achieved by end October 2015.

Children’s Social Care 2. The Head of Service should ensure that the framework for assessing the

needs of children and young people is fully implemented and embedded in practice and that social workers are consulting widely with other agencies when undertaking assessments.

3. The Head of Service should ensure that managers within Children’s Social

Care record, on a child’s file, important decisions such as whether an assessment is required under S17 or S47, and the rationale for the decision.

SWYPFT 4. For SWYPFT to be proactive in raising the awareness across the wider

partnership about the role of the school nursing services. This will take the format of a poster to be circulated via the intranet that can be circulated across the partnership


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Appendix 1: References Yardley E, Wilson D and Lynes A (2013); A Taxonomy of Male British Family Annihilators,

1980 – 2012 The Howard Journal of Criminal Justice.


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Appendix 2: Abbreviations Used CCG Clinical Commissioning Group FCA Family Court Advisor GP General Practitioner IAPT Improving Access to Psychological Therapies LM Learning Mentor PPU Public Protection Unit SW Social Worker SWYPFT South West Yorkshire Partnership NHS Foundation Trust TED Tribal Electronic Desktop

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