Case Review – Child O

I have been reading through the National Society for the Prevention of Cruelty to Children (NSPCC) Case Review Repository and, in doing so, stumbled through this one.

I cannot describe it, words fail me.


The NSPCC provides this definition on their website:

A serious case review (SCR) takes place after a child dies or is seriously injured and abuse or neglect is thought to be involved. It looks at lessons that can help prevent similar incidents from happening in the future.”

With this case, the timeline seems a bit off. Perhaps it’s a recording error. I don’t know.

I’ll be reviewing the chronology of the case then will look at the lessons learned, recommendations, etc, which have come out from the case.

A lot of this has been lifted straight from the Case Review itself, some has been rejigged to make easier to understand.


Death of 22-month-old Child O at the hands of their mother who also killed herself in summer 2014. A post-mortem concluded mother and child died of carbon monoxide poisoning. Parents were separated, and mother and Child O had since moved to a number of areas around the country.

A strong thread throughout the Case Review was their concerns that the significance of Child O’s father’s role was inadequately recognised and the allegations made by the mother were too easily accepted. As such they felt there was an inherent bias towards him as a father. The impact on Child O’s father and his family has been profound. Child O’s father had not seen his child since he was 5 months old and had no knowledge of his whereabouts for the remainder of his life. The mother of Child O would not allow any contact with the father’s family, meaning that they never met their first grandchild and nephew. Child O’s father was also faced with serious allegations from Child O’s mother which could have been life-changing, but these were ultimately identified by the police as unfounded.

The parents of Child O met in early 2012 in Southampton. Neither, at that point, had any previous involvement with safeguarding services. The mother of Child O had at some point prior to their meeting changed her name, but this was not then known to the father. The mother’s initial description to the father of her own family was that she had been brought up by her grandmother and had no contact with her parents for most of her life, which is now known not to be the case. The couple had only been in a relationship for a very short period when the mother told the father she was pregnant. This was not only an unplanned pregnancy but, unexpected, as the father states that he had been told by the mother that she was unable to conceive.

During her pregnancy the mother attended at her GP’s with a range of symptoms and in June 2012 she was referred by her GP to IAPT (Increased Access to Psychological Therapies) for stress related problems. No record has been provided as to whether the mother accessed this service.

Child O was born at North Hampshire Hospital in October 2012. Although the staff in the hospital noted that there was some evidence of maternal low mood, this was not highlighted as being unusual. However, the father’s experience gave him greater cause for concern, including the mother’s quite insistent refusal to allow anyone else to touch the baby. He was also concerned at the mother’s insistence on discharging herself the day she had given birth due to her dislike of hospitals but contrary to medical advice. Child O became ill with congenital pneumonia necessitating a return to hospital the following day and care in the neo-natal unit for a number of days.

The mother reported having no family of her own and would not allow father’s family to visit new-born Child O. The following day the Health Visitor spoke to the GP because of her concerns including that the father had visited her at her office, again very upset. He stated that he increasingly felt he did not really know the mother and that she had been dishonest about a number of things, including her relationship with her family. The mother became increasingly paranoid and over-protective of the child. A couple of days after the father’s visit to the Health Visitor, the mother contacted the health visiting service to cancel her next appointment as she was planning to leave the area. This was subsequently flagged.

A second health visitor met with the mother and noted that the mother’s mood was low, but she had no concerns about her care of Child O. The mother presented as distressed about the ending of the relationship with the father, but stated that he was not abusive or controlling, simply that he did not understand how she felt. The mother was recommended to see the GP and was prescribed a low dose anti-depressant.

The following day the father made a referral to Hampshire Children Services, raising concerns about mother’s mental health. Children’s Services made enquiries with the first Health Visitor and recorded that mother had post-natal depression, had been abandoned by her father as a child, but had ‘good family support’ in place. A duty Social Worker telephoned the mother who stated she would be moving to Devon the next day and did not want the father to know her new address. The mother later phoned Devon Children’s Services unhappy that they had become involved and stating that the father had been abusive to her.

A similar conversation took place with the Devon Health Visitor (DHV), who noted that the mother had ‘fled’ domestic abuse but had also said that this had never been physical. A referral was made by the DHV to unspecified ‘domestic violence services’. Child O’s mother again denied any post-natal depression and stated she was not on any medication. Nevertheless, information that the mother was prescribed with antidepressants whilst in Hampshire was recorded within the Devon health visiting records.

In mid-November the mother phoned the police following what she described as a ‘heated argument’ with the father, who had then left the house. Police attended, spoke to both parents and recorded no offences. It was agreed that the parents would stay in separate rooms until Mother was able to move out in the next couple of days. A DASH risk assessment was undertaken and concluded there was a standard risk, the details were passed to Victim Support and a Child at Risk form was sent to Children’s Social Care as a matter of routine.

Several attempts at mediation were made but, they all failed due to the mother’s unwillingness to be near the father. This was not because of any risk to the mother but, her own preference. Following the failed attempt at mediation Child O’s father made an application to the Family Court under private law to resolve the dispute between them. During this period the mother contacted her GP asking for Child O’s name to be changed by removing the father’s surname. It would appear that this was actioned by the GP (which they’re not supposed to do).

Whilst living in Devon, Child O’s mother contacted the police on 3 occasions with allegations about the father. On the first occasion she stated that he had called her pretending to be from a doctor’s surgery in order to obtain information. She also said he had contacted the surgery claiming to be from the hospital. There was no evidence to support this allegation. This was recorded by the police as a ‘non crime domestic incident’ and a DASH assessment undertaken, which identified it as ‘standard risk’. On the second occasion she reported receiving an abusive letter from his parents. The Police Officer did review the letter and did not consider the letter to be threatening or offensive and again recorded this as a non-crime domestic incident on the basis of what the mother had told them. Lastly in April 2013 the mother reported that during a contact meeting the father had made a threat to her life and had also sent her a sympathy card. Again this was recorded as a non-crime domestic incident, but given that the mother appeared to be very frightened, the DASH risk assessment on this occasion was recorded as medium (remember this!). The Police Officer spoke to the father who was noted to be polite and understanding, but denied the allegations. The father reported to this Review that the officer had told him he had not actually seen the sympathy card and felt frustrated at what therefore appeared to him to be an unquestioning acceptance of the mother’s allegations.

[In other words: if she seems upset, he’s guilty – irrespective of evidence. I wonder, how many of my viewers have been there!? How many know, quite intimately, what I’m talking about!?]

In late summer of 2013 father applied to the Family Proceedings Court in Torquay under private law proceedings. He had not had any contact with Child O since March 2013. The first Family Court hearing was in late September 2013. CAFCASS had forwarded the outcome of their safeguarding checks to the court. The father attended the hearing, but the mother did not. The mother did not attend any of the subsequent hearings at the Family Court.

At the end of October 2013 Child O’s father contacted Devon Police to report that Child O and mother were missing. This followed the return of court papers, sent to the mother, which had been marked that she was no longer at that address. The father had also been concerned as a result of previous comments that the mother had made suggesting she might move to Spain. During the autumn the mother missed appointments with the Health Visitor, including taking Child O for their 1st year assessment in November 2013.

The Police immediately initiated a Missing Person enquiry in relation to Child O and mother, assessing the case as Medium Risk. They spoke to maternal grandfather who said that he had not seen his daughter and grandchild for two months since they moved to Spain, but did provide an e-mail address. Mother subsequently contacted them to state that she and the child were safe and well, but she refused to tell them where they were living.

In early December Devon police identified that Child O and Mother were living at an address in Norfolk. Contact was made by Devon with Norfolk Police who agreed to visit in order to undertake a ‘safe and well’ check, which took place first thing the following morning. Two officers attended, they saw both Child O and mother and concluded that there were no immediate concerns regarding Child O’s welfare. Child O was described as clean, cheerful and engaging and the home environment was immaculate. Child O’s mother was very unhappy about having been traced and was not willing to provide any details in order for a Risk Assessment to be undertaken nor to provide a contact phone number. She was advised that she should inform maternal grandfather or her solicitor if she intended to leave the country. Later that day maternal grandfather contacted Devon and Cornwall police asking for a further visit from the police in Norfolk as Mother wished to make a statement regarding a history of sexual and physical abuse and attempts to kill.

The mother made serious allegations of domestic violence and rape against father. She also alleged that he had in the past told her of a sexual relationship with a young person which, because of the nature of his employment, would need to be investigated by the local authority in Southampton. The mother also said that she was in fear of her life as the father had threatened to kill her if she ‘took Child O from him’. Mother was not willing to make a formal statement in relation to any of the allegations.

The mother and Child O left this address sometime in January 2014 and moved to a house owned by her father’s family in Lancashire. On 13th August 2014 Child O and mother were found in the garage of the house in Lancashire. They had died of carbon monoxide poisoning.


The role that the father was able to play in his child’s life was manipulated by the mother, who, we can see with hindsight, worked over an extended period to exclude him from Child O’s life. That she was able to do this so effectively appears, to some degree, to have been unwittingly supported by professional assumptions and attitudes about the father’s role and it appears that her actions were rarely actively challenged.

SCRs and research more widely have also highlighted the failure to recognise that fathers can bring positive resources to their children’s lives. Child O’s separation from their father was fundamentally a result of the actions of their mother and maternal grandfather. However, what Child O’s experience again reflects is the often subtle mindset within health and social care which can view the mother, who is generally the day to day carer, as having more ‘rights’ and significance in the child’s life and involvement with the father as ‘optional or undesirable’. As such, it could again be argued that the mother’s perspective effectively determined the actions of professionals. The mother was absent and yet completely in control up until the very final weeks of Child O’s life.

Child O’s mother made a number of allegations of domestic abuse to a range of services, initially asserting that there were no issues of domestic abuse, later describing low level conflict and emotional abuse and specifically stating that the abuse was never physical, but developing over time into very serious allegations. The evidence in this case is that professionals generally worked to established practice guidelines regarding listening to, respecting, recording and offering support when approached by the mother. Health services routinely asked the mother about domestic abuse and followed up any information the mother supplied which might suggest cause for concern. Advice and information was provided to the mother about support services.

For the family, the impression was given, whether or not it reflected what professionals actually thought, that the father had already been judged. What resulted was a perception of bias, in the words of Child O’s paternal grandmother: “they just put him in this box: he was a man, he had to be violent and he was none of those things.”

Although the father’s distress at being contacted by the police about false allegations is entirely understandable, reasonable judgements were made about the absence of criminal offences and no action was taken other than ‘giving words of advice’, which in itself understandably added to the father’s sense of frustration. Nevertheless, it is difficult to avoid the conclusion that services had not given serious consideration to the possibility that the allegations might be malicious and therefore whether this might lead them to take different actions or consider the potential implications for Child O. Illustrative examples include:

  • The language of agency records effectively shifts from allegation to presumed fact, such as recordings that the mother has ‘fled’ domestic abuse.
  • The use of the words ‘disclosures’, rather than ‘allegations’ in many records, which subtly reflects an acceptance of what the service has been told.
  • Decisions by health and social care services not to pass on information about Child O in response to the mother’s wishes.

One particular example of the way current systems to assess domestic abuse can have unintended consequences and could impact unhelpfully on professionals’ judgement is the use of risk assessment tools. Police officers appropriately used the CAADA DASH RIC, a tool which is used nationally to identify risk in relation to domestic abuse. The risk factors that form the basis of the assessment are statistically evidentially sound. However, what the assessment does not explicitly recognise is that the actual information provided to the assessor may not itself be based on objective evidence. On one occasion the risk assessment identified 9 high risk factors, moving the risk assessment from standard to medium risk. However, each one of those risk factors was totally reliant on self-reporting by the mother and therefore open to manipulation.

(This is where it gets good.)

This review and others has highlighted the requirement for this agency to consider the current levels of knowledge and understanding among front line staff including supervisors around the DASH risk assessment process. Women’s Aid has been commissioned to carry out a gap analysis in respect of training requirements. Findings from this work will inform the development and commissioning of DASH training for police officers.

Moving away from DV but staying in the same vein as a father’s role in his child’s life, we see other concerns. At other points in Child O’s life there is some evidence that processes and routine practice tended to assume that the mother, who had immediate care of Child O, was ‘the parent’. Examples of this include the acceptance by the GP of the Mother’s decision to remove the father’s surname from Child O’s surname. A parent can only change a child’s name legally with the agreement of everyone with parental responsibility or with a court order. The implications of removing the father’s name did not appear to be recognised and there is no evidence that this was questioned or challenged. After the move to Devon, there is no evidence of attempts being made by the health visiting service to actively contact or involve the father. The need for training and support of Health Visitors in this regard has been identified nationally as an area for development. Evidence from research supports the view that improvements to practice can be achieved. Also, in February 2014 in response to a solicitor’s letter the GP surgery were only willing to confirm that Child O was registered with them and the date they had seen the child, as the mother had requested that no information should be given about the child to Child O’s father. Child O’s father had Parental Responsibility and this had been confirmed by the Health Visitor, which raises a question as to why he was not considered to be entitled to full information about his child.

The father felt that he and his family were frequently not taken seriously enough by professionals and believes this was a result of his role as a father. In particular he described a poor experience of CAFCASS’ involvement. He did not feel listened to or properly consulted, for example he specifically told the Children’s Guardian that Mother was not at the address in Devon, and was left highly frustrated that letters continued to be sent to this address, which, it appears, was the only address held by the court, and therefore by CAFCASS, at that time. He felt the Children’s Guardian was at times dismissive of his concerns and that he was given minimal opportunity to speak to the officer either before or during court hearings, including not receiving responses to his phone messages. The Children’s Guardian has been interviewed by CAFCASS as part of this Review and “believes … was sympathetic to the situation and was clear with the father about their role”. The degree of the mismatch between the father’s description of his experience and the CAFCASS officer’s perception is striking, but ultimately it is not something about which this report can make a judgement.

What is undisputed is that the Children’s Guardian made a decision not to interview the father while undertaking the Section 7 report for the Court and it is evident that this has impacted significantly not least on the perception of fairness, irrespective of the rationale. It cannot be concluded that if there had been a meeting with the father it would have changed the outcome for Child O, but it might have shifted the perception of the case and, for example, led to a stronger advice to the court about the need for an urgent response.

CAFCASS have acknowledged that a more ‘cautious’ approach would have been to meet the father earlier in the process. CAFCASS practice standards do not define whether or how parties should be interviewed, this is a matter for professional judgement. The CAFCASS report identifies that the Children’s Guardian had developed a mindset about Child O’s case, as one of a ‘mother not seeking to be found as she did not want her child to have a relationship with their father’. It concludes that she had not been robust enough in her planning.

In response to questions about whether there might be anything further to learn about the organisation’s approach to working with fathers, CAFCASS has provided information from two National Audits of practice (April 2013 and November 2014) and the Ofsted National Inspection (April 2014). This latter report concluded that CAFCASS ‘consistently worked well with families to ensure children are safe’. None of these audits identified poor practice in relation to working with fathers and CAFCASS as a result feels satisfied that attitudes to fathers are not a cause of concern within their practice nationally. This Review has therefore sought further information about the specific context in which the Children’s Guardian was working in order to better understand how such practice decisions are made. However, the information provided was unable to answer the key question as to why the Children’s Guardian adopted a particular approach. On this basis the Review cannot share CAFCASS’ confidence that it can exclude the possibility that an individual or cultural response to fathers’ roles may have impacted on the management of this case.

(Yeah, fuck you CAFCASS! Now we know why they refused to sign off this report.)

The role of fathers is an all too familiar an issue in SCRs1 frequently in relation to fathers who seem to be ‘invisible’ or may be threatening or dangerous. SCRs and research more widely have also highlighted the failure to recognise that fathers can bring positive resources to their children’s lives. Child O’s separation from their father was fundamentally a result of the actions of their mother and maternal grandfather. However, what Child O’s experience again reflects is the often subtle mindset within health and social care which can view the mother, who is generally the day to day carer, as having more ‘rights’ and significance in the child’s life and involvement with the father as ‘optional or undesirable’.

There are plenty more recommendations in the Case Review. I could read them all out but, I shan’t. Instead, I shall link to the source and Case Review below.

Source & Case Review.

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