Viewers/readers/listeners may recall my previous case (Child O) which featured a paranoid mother who fled the country with the child (International Child Abduction) and was of such a state she refused to let doctors touch her baby after she’d given birth. Well, this case is on another level! Thankfully, it does not end in a fatality but, not for lack of trying!!!
“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.”
I’ll be reviewing the chronology of the case then will look at what the CR has to say about the events that took place. A lot of this has been lifted straight from the Case Review itself, I have moved & reordered some of it to aid presentation. Obviously, they re-iterate the same series of events but, from different perspectives. I’ve tried to organise it as best I can. I will also look less at the failures of the system and more at the course of events.
Child AB, a junior school child*, was born 4 weeks prematurely and nursed on a Special Care Baby Unit for 1 week prior to being discharged home care of parents. The family home was in an area of low deprivation with good and mostly privately owned housing stock. The child attended two Early Years Pre-school establishments, prior to starting school. Child AB’s mother (hereinafter referred to as mother) was the main contact point for school and was fully supported by her husband. Nursery Practitioners advised the family had a secure and stable family life. The child was popular, happy, confident, sociable, and maintained positive relationships with staff and other children. The child made positive, excellent academic progress and enjoyed good health.
* The Junior age range (Key Stage 2) is from age 7 to 11.
In November 2013, the maternal grandparents noticed their daughter was not quite herself. This was thought to be due to several stressful events she had experienced including; workplace bullying and witnessing a car accident.
In March 2014, Child AB’s father (hereinafter referred to as father) became increasingly concerned for his wife’s welfare, encouraging her to seek medical support.
In April 2014, the mother presented to NHS Primary Care General Practitioner Services with increased symptoms of mental illness. The mother complained of anxiety, stress and sleeping difficulties due to pressure at work. She did not disclose thoughts of self-harm or intentions to take her own life and declined a same day appointment. She was seen three days later by a General Practitioner, presenting with work related anxiety rather than depression. Medication was prescribed and a referral for practice based counselling was completed. One week later the mother attended the Practice presenting with increased symptoms including depression and low mood. The medication regime was amended. There was still no discussion regarding intentions to self-harm or intentions to harm others despite the emergence of depressive symptoms.
During a triage telephone conversation 8 days later, the mother disclosed thoughts of serious self-harm. She was promptly seen by a General Practitioner to assess whether an urgent specialist mental health consultation was required. She then provided a different perspective to the attending General Practitioner than she had done during the triage conversation. She reported that the medication had begun to help her and stated her thoughts were more about not wanting to wake up than serious self-harm. Unusually the maternal grandmother had two separate communications with the surgery around this time, on consecutive days, without her daughter’s consent, asking if an urgent referral could be made to a private healthcare establishment that offered Mental Health Services. The maternal grandmother said she would re-contact the surgery following further discussion with her daughter but the issue did not progress.
In May 2014, the child’s mother began counselling sessions, 6 weeks after the initial referral.
In June, a risk assessment was undertaken during a counselling session, it was noted she had a low mood however there were no risk factors identified. The assessment omitted to include risk to others.
Despite evidence from national serious case reviews there was no consideration of the impact of potential risk to the child because of the mother’s mental health. The risks of extended suicide by including others was not an apparent consideration. The mother also completed a patient health questionnaire (PHQ-9), a tested and reliable tool used to detect depression and the score was high. She had identified thoughts of “being better off dead or wanting to hurt herself every day”. The practice did not review the PHQ-9 document or compare its content with the findings of the day’s earlier counselling session. The contrast in the two communications may have encouraged further exploration and the high risk identified.
In June 2014, the child attended General Practice with a 6-night history of night terrors. There are many complex interrelating factors that may cause night terrors however the General Practitioner review did not provide any definitive conclusion as to the significance for the child.
In July 2014, following an incident of self-harm the mother was found by her step-daughter, and was immediately taken to hospital by Ambulance Services. Later that day, the child disclosed to the half-sister, that the mother had attempted to seriously harm the child that morning on two occasions. The mother had initially attempted to suffocate the child, who had struggled so she had stopped. Later she attempted strangulation by placing her hands around her child’s throat. The father was told about the incident and informed the nursing staff caring for his wife. The nursing staff made a Child Protection referral.
Children who experience such life-threatening assaults are known to be at higher risk of developing post-traumatic stress disorder and other health consequences. Therefore, the long-term outcome on the child’s emotional wellbeing combined with the enforced separation from the mother, who was a main caregiver, will need to remain a consideration for all universal services who remain in contact with the family.
In August 2014, the mother was voluntarily admitted to Mental Health Services In-Patient Facilities. During August 2014, following the initial referral, the Constabulary commenced a criminal investigation, stating the mother would not be arrested until her discharge from hospital and the charge against her would be attempted murder. Her solicitor was notified. This was the right course of action to support her ill-health at the time and in accordance with legislation (Section 23 Of the Criminal Procedure and Investigation Act 1996). Constabulary bail conditions were arranged, including a condition that contact arrangements with the child should be managed by Children’s Social Care.
The day after admission, Mental Health Services described Child AB as a “protective factor” for the mother. This term is sometimes used in Mental Health Services meaning that a mentally ill vulnerable adult is less likely to take a child’s or other person’s life if they are securely attached. However, it can be misunderstood and in cases when a vulnerable adult has started to seriously self-harm or attempt suicide the child as a protective factor is negated and the risk may become that filicide-suicide is planned.
On the third day, the reviewing Consultant Psychiatrist, suggested that contact should be reinstated and shared this view with the father and Children’s Social Care. The father had spoken to the Consultant who reported that the mother was not having any further thoughts of harming her child. The records stated “we rather encourage good contact and relationship with the child unless there is good reason for not doing so”. This would have been understood as an influential opinion by Children’s Social Care and the father, thereby influencing professional and family discussions to re-instate contact.
Later in August, the mother was deemed fit to be discharged, plans were made for her to be formally arrested and interviewed. She was arrested on suspicion of attempted murder and interviewed. She was subjected to bail conditions which were to be reviewed eleven weeks later. The review date was to enable the Constabulary to gather medical notes and Paramedics’ statements.
Constabulary bail conditions are written to protect victims whilst a decision is made regarding the outcome to proceed with criminal proceedings. Once in place they cannot be altered without the authority of the Custody Officer. Bail conditions were clear. The mother was “not to interfere or have any contact with Child AB apart from telephone contact” or “as directed by Social Services”. On reflection, the Constabulary Review advises this condition was too broad, unspecific and effectively allowed Children’s Social Care autonomy regarding contact arrangements. It has made recommendations to change this practice. The caveat as “directed by Social Services “was a significant factor in the Custody Officer being satisfied the risk to the child was being effectively managed.
The child was also reportedly requesting to see the mother.
Consensus agreement between the Constabulary and Children’s Social Care was reached and supervised telephone contact was further discussed in the first care planning approach/strategy meeting in August 2014. During that meeting, it was highlighted Child AB had said to her “you sound better than when you tried to smother me”. The mother was concerned that the father had told the child to say this, indicating communications had already taken place and more robust arrangements for telephone contact were put in place.
Initially, contact between mother and child was positive. Some deterioration, however, did occur. The father observed a change in the child’s relationship with the mother, as the father provided more of the child’s care. The child initially responded positively to the change but then began to “play up slightly” during contact with the mother. The mother then became stricter with the child and the father would then have to intervene, which created challenges.
During her time as an in-patient the mother and father were observed to be supportive and affectionate.
The Psychologist expressed concerns about the father’s reaction, to the attempt on his child’s life, and advised that the father hadn’t yet synthesized the seriousness of the assault. The father was not thought to be focusing upon what had happened with his child at that time and had been noted to be “quite loving and affectionate towards his wife”. The report outlined that this may have represented that the father was not fully accepting of the significance of the events, either in relation to the mother’s actions towards her child or the events that led up to this.
In September 2014, she was discharged to her parents’ home. On discharge, she was supported by Primary Care Mental Health Services and a Care Coordinator was appointed. Oversight of the case was by the Care Programme Approach. The mother’s condition showed no real improvement and there were incidents of self-harm, significant threats and attempts on her own life and disclosed plans to harm her husband which we’ll go into more detail about now.
Attempt 1: Within one week of hospital discharge the mother disclosed further thoughts of serious self-harm and contacted her General Practitioner regarding her deteriorating mental health. Following the first contact session in the sixth week with her child, the mother and her parents informed the Care Coordinator that the mother had in the previous week, attempted to take her own life.
Attempt 2: The mother’s mental health continued to deteriorate, she began to cancel appointments with her Care Coordinator and there was an over-reliance on her parents to assess their daughter’s wellbeing. The mother made a further attempt to end her life at her parents’ home, 7 weeks after discharge from hospital.
Attempt 3: Mental Health Services were notified the mother had been detained by a different cross-boundary Constabulary, under Section 136 of the Mental Health Act, 8 weeks later. She had been located expressing suicidal ideation. Section 136 of the Mental Health Act allows Constabulary officers to detain a person if they are deemed to pose a risk to themselves or others and enables transfer to a place of safety.
Attempt 4: Two weeks later Child AB’s mother was on leave at the marital home and having contact with her child, escorted by the father. She disclosed to the father her plans to seriously harm him and then take her own life, believing her child would be better off being raised by her parents. The father described this point as a realisation of how poorly his wife was and she was returned to the ward. Following this incident all escorted leave with the father was suspended to enable the service the opportunity to assess and manage the risk she posed to her husband. It is surprising and concerning that despite the previous attempt on her child’s life supervised contact continued. The mother continued to have escorted leave from the ward for a further 4 weeks and was then granted periods of unescorted leave. Her leave continued to be excessive, making assessment of her mental health difficult and the risk she posed to her child and others apparently remained un-assessed.
Attempt 5: When on her first period of unescorted leave (four weeks later) the mother bought tablets and on return to the ward took a life-threatening overdose. There was a significant delay in her transfer to the Emergency Department for urgent treatment. This is of significant concern to the maternal grandparents and the mother. The Mental Health Review reports that Child AB’s mother had to be persuaded to have treatment, as she was a voluntary patient. After one week, her physical condition was stabilised and she was transferred back to the mental health ward. She began to openly discuss the challenges in her contact with her child and was more ambivalent about her contact perceiving her child to now be more difficult and challenging.
Escorted leave was re-introduced following this incident and it was stipulated that the leave would need to be facilitated by “people who were fully aware of the history and the risks that she could pose to herself and others”.
Following the attack in 2014, the mother disclosed to numerous professionals that she had felt emotionally abused during her marriage (the Case Review was unable to substantiate these allegations), a perspective also offered by the maternal grandparents. She also felt that contact with her husband was required to gain supervised access to her child. It was observed that contact with her husband at times lifted her mood. The father was made aware of the disclosures and advised that following the first incident, during child contact, he needed to watch all the time and was ready to intervene if he considered his wife was acting inappropriately towards their child. The father felt his wife interpreted this as him being overly controlling. The paternal grandparents were also made aware of the disclosures and expressed surprise having never observed previously anything more than normal marital disagreements.
In November, the bail conditions were extended for approximately sixteen weeks (to the day following the second assault on Child AB), pending submission of the file to the Crown Prosecution Service. Mother and Father formally separate.
In February 2015 (some seven months after the attack), during contact with the child at the maternal grandparent’s home, there was a second serious attempt on the child’s life. The child told the maternal grandfather and mother that she/he was going upstairs to play in the bedroom. The child was then followed by the mother who perpetrated a life-threatening assault on the child. The child screamed and the maternal grandfather entered the room. The mother was returned to Mental Health In-Patient Services by the maternal grandfather, who disclosed the incident to staff. Child AB accompanied the maternal grandfather to the hospital. Mental Health Services reported the incident immediately to the Constabulary and the Emergency Duty Team in Children’s Social Care.
On the day of the incident, Child AB was medically examined at a local Accident and Emergency Department, by an on-call Paediatric Consultant and the injuries documented. The child did not require hospital treatment and was discharged home to care of the father. The Constabulary treated this incident as an attempt on the child’s life. The mother was re-arrested and recharged for attempted murder and all contact with the child was suspended at that point.
In October 2015, criminal proceedings were concluded against the mother and a conviction secured on two counts of child neglect. Two charges of attempted murder were left to lie on the file. The mother pleaded guilty to two counts of child neglect under the Children and Young Persons Act (1933). A Hospital Order, under the Mental Health Act 2007, with restrictions was ordered. No custodial sentence was handed down. In summary, the mother was ordered to remain in hospital until such a time the medical professionals deemed her well enough to be discharged. The restriction element of the sentence is understood to mean that prior to her discharge, an Independent Panel from the Ministry of Justice must review the decision to discharge her.
The Family Court Private Proceedings have been concluded and the father has care of Child AB. There is a Section 8, Child Arrangement Order in place, which directs no contact with the mother. The court encouraged the father to provide written progress updates every 3 months to the child’s mother. After the initial event the child was missing the mother and regularly expressed a desire to see her. The child will now only discuss the experience with the father and Key Family Support Worker.
The father and paternal grandparents described the Constabulary as “very good” with the child in their approach during the memorandum interview, therefore making it a positive experience for Child AB. However, the mother felt the way she was treated by the Constabulary was not nice, as they insisted on putting her in a “suicide suit”, left her in a cell with one blanket overnight and she was cold. Her solicitor advised her to make “no comment” and the Constabulary’s reaction to this was quite negative which also “didn’t feel very nice”.
It was of concern to all family members that the Constabulary did not have oversight of the bail conditions, leaving their interpretation to Children’s Social Care. The family said, this led to confusion in the management of the conditions and child contact arrangements. The father advised that Children’s Social Care’s written agreements were confusing, quickly piled up and changed every day, therefore were not meaningful or understandable. The maternal grandparents did not receive any correspondence or sign any written agreements from Children’s Social Care despite their significant role in managing child contact arrangements. The coordination of contact supervision arrangements was left to the father, which was difficult due to the discrepant interpretations of supervised contact and the increasing pool of supervisors, which on one occasion was the mother’s friend. The mother felt her parents were not supported in understanding what the contact was about. She was concerned contact was organised in line with her child’s expressed wishes rather than what was in the child’s best interests. She wanted to see her child but did not feel strong. Contact was always difficult as there was always someone else there and she didn’t understand why that was required.
The father and maternal grandparents advised that following the second event the Constabulary and Children’s Social Care said the supervision of contact arrangements should always have been 24 hours a day. The family had not been made aware of this and it was not a feasible expectation in dealing with these extreme circumstances. The mother was very ill and there were significant challenges and contradictions in balancing her needs whilst safely supervising child contact arrangements. The paternal grandparents made an offer to Children Social Care to supervise contact but received no further communication.
The maternal grandparents said there was no planning for home leave and their daughter was out of hospital for frequent, long periods irrespective of her presentation. The maternal grandparents were left to make regular decisions whether the mother was well enough for home leave, which was a significant conflict of interest for them. They understood there should have been a handover by the ward staff when they picked the mother up and took her back but in practice this rarely happened. The mother advised that Mental Health Practitioners seemed to want her to go on leave a lot. There were several occasions when she told her parents she was not going to come out as she didn’t want to, but was not listened to by staff. This put a strain on her relationship with her child as she was not able to look after the child as well as she might have done.
The night before the second incident, the mother told her Named Nurse she was feeling suicidal, but that information didn’t seem to have been passed on, so the next day she had to explain it to another Nurse. They thought it would help her to see her child. She didn’t think so and felt pressured to go out. She feels she shouldn’t have been allowed out on the day of the second incident as she had been honest the night before about her feelings.
The mother wants the panel to know that “the person who carried out the assaults doesn’t feel like the person sitting here being interviewed. That person was not rational about actions and was cut off from all emotions.” The mother wants to tell her child “how sorry she is and these things should not have happened once, never mind twice.”
Critical reflection of the information prior to the first event highlighted there were no significant dangers, situational or background hazards that could have led professionals to the prediction that the mother would transform so suddenly from being a loving mother to perpetrating the first assault. Whilst there had been no noticeable improvement in her mental health during the preceding 4 months, she was regularly supported by her General Practitioner, planning to return to work and did not present with serious mental health challenges.
Critical reflection of practice during the time span prior to the second event, highlighted many risk factors that should have alerted professionals to the potential risk that a repeat event was high. All hazards and dangers should have been apparent but partnership working was not always effective, information was not effectively compiled, shared or used to manage the risk. The risks documented within a Psychologist report (September 2014) provided key predictors of factors that may increase the risk of further serious events. This information was buried, not effectively shared with multi-agency partners and “lost” to practice. The mother was not risk assessed in relation to the risks she posed to her child even after she disclosed her intention to harm her husband prior to the second event. The Expert Psychiatric Consultant confirmed the panel’s views that if professionals do not know what risk a mental health patient poses to those around them then it should be assumed that the risk is always high. The second event in 2015, was therefore potentially preventable and given the expert advice provided in hindsight potentially predictable.