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Serious Case Reviews – Baby Peter and beyond

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I have been trying, ever since Baby Peter’s tragic case, to get the Serious Case Review published. A Serious Case Review (SCR) is produced after any such case by the agencies involved in that child’s care. It tells the chronological story of who did what and when. It is an invaluable document – but it is kept secret. An Executive Summary is published – but that really doesn’t tell anything like the whole story.

I have been battling to change this – so that SCR’s can be published. In Baby Peter’s case I have asked the Information Commissioner to publish the SCR for Baby Peter. I don’t believe that the ambition of that over-used phrase ‘lessons must be learned’ can ever be fully realised if the causes and actions are hidden.

The Information Commissioner came back to me to ask for more information as to why I thought it would be in the public interest for the SCR to be published. I sent him my reasons – which I paste below – and now the Information Commissioner is going back to Haringey Council for further information. This was my email to the Commissioner:

Having been Leader of the Opposition on Haringey Council when Victoria Climbie died and now MP in half of Haringey during the Baby P tragedy – I have come to the conclusion that a contributing factor to cases like these (and others) is the secrecy, the closing ranks culture and the lack of transparency.

The Serious Case Review (version 1) which I was allowed to read virtually under lock and key in the Department of Education (where I could not make notes or record any part of the document) was an eye opener to me. The executive summary of the same document which is published did not reflect the key problems, in my view, that were at least part-causal in the eventual tragedy.

The thing that struck me most was the litany of casualness with which people did their jobs (appointments missed, not followed up; files lost, handovers not done, meetings not attended). There was a litany of failures like these at every level, virtually by every person and every agency. I think that most people would expect that once a child is on the protection register and their case being brought to the Safeguarding Board – that there would be a rigour about all aspects connected with them.

This casualness and lack of care is only really demonstrated if you get to read the whole document. It does not come through in the summary and itself is cumulatively causal in my view.

Literally hundreds of professionals across the country emailed me about their knowledge and experience – as did the general public. I believe that the phrase which is dragged out ‘lessons will be learned’ won’t be fully possible if the facts of the case and the failures in the case are kept hidden. As I say, the Executive Summary, does not reveal the extent of the small, but cumulative failures – which I believe many professionals would recognise in their own fields and therefore be able to do something about. Therefore it must be in the public interest to be able to see the whole document.

Simply issuing another 150 Laming-like recommendations every time a tragedy happens simply adds procedures that take professionals away from their work without ever being able to see the why and wherefore of such recommendations – nor to judge or be able to critique the new ways from an informed position. The issues are kept between local authority, the other agencies and the Government – so keeping out those who would, could and should benefit from reading the whole story.

I am not an expert nor a professional – but unless and until we really open out all the issues around cases such as these – there will continue to be an air of defensiveness and self-protection which work against the safety and well-being of children at risk.

Social workers need to work in an atmosphere of support and good management – which can only come from opening up the real events, letting them stand there for all to see – and those in the professions taking those lessons away.

The argument Ed Balls makes to me against publishing the Serious Case Review (s) is that staff would not speak freely if they knew that what they said might be published. My view is that anyone working in any field where there is such an event has a duty to speak and say what happened. They would have to if the case goes to public inquiry or hearing. Names and personal information should be anonymized. It was anyway in the SCR I read and social workers were referred to as social worker 1 or social worker 2. It is also the case that quite a lot of time elapses between the event and the publication as the SCR is written immediately (usually) and the case and the trial and exposure comes much later.

OFSTED did an audit of Serious Case Reviews and found that nearly two thirds, I believe, were inadequate. So – additionally – this would not have come to light without OFSTED’s exposure. If they were published – these inadequate SCRs would have been exposed much earlier. So – whilst the Serious Case Review I am most concerned about is obviously the Haringey one – it is clear there is a wider issue too.

So – I believe it is totally in the public interest for the Serious Case Review to be published. Secrecy, lack of transparency and openess and closing ranks are at the heart of the problem in Haringey.

I hope you find in favour of publication.

Kind regards
Lynne Feathestone

This week's other bits…………

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Liberal Democrat Opposition Day Debates:
The Liberal Democrat opposition day debates were both ones that Labour should have supported. Labour failed to do so on both votes.

The first was on Equitable Life – and I am sure that every MP in the House has had heartbreaking letters from people who have lost their life savings through Equitable Life and are fed up waiting for the always promised, never delivered compensation.

The second motion was asking Parliament to sign up to the 10:10 campaign. Lots of individual MPs (including me) and councils have already signed up to reduce their carbon emissions by 10% by the end of the year 2010. The motion was asking the House itself to sign up, all Government departments and Public Sector Bodies. Given the Labour Government (and the Minister) were so fulsome in their praise for the 10:10 campaign – I am still at a loss as to why they failed to support the motion. They refused to sign us up to the 10:10 campaign. Shame on them. Blimey – even the Tories supported this one.

Women’s Questions
I asked the Minister what the Government was doing about removing the barriers to employing women that had been highlighted in the Equality and Human Rights Commission statement that women’s maternity rights etc were putting employers off. The Minister said she didn’t accept that was the case!

Book on Baby Peter
Met with an author/film maker who is doing the background research on a potential book about Baby Peter. Having received literally thousands of emails during the height of the Baby Peter coverage from people all over the country – including many professionals from relevant fields – who all had such knowledge and contribution, I am very pleased that someone serious is going to do a serious book on this. Whilst Panorama and other documentaries have all tried very hard – it really is not possible to address the complexities of this subject in entertainment format – so am very happy to help.

Meeting with Peter Lewis, Director Children’s Services, Haringey
Following neatly on, had organised a meeting with Peter Lewis to touch base on progress in terms of child protection in Haringey. When I first met Peter after he was appointed following the furore over child protection in Haringey – he told me that it would take him three years to turn Haringey’s Children’s Services around. The first inspection of how he and the department were doing decided things were improving but not fast enough. I hadn’t seen him for about six months – and I thought that some of the measures that Peter has brought in subsequent to that inspection to provide rigour in supervising (human rigour not tick box rigour) sounded like they would be effective. I also thought that his action to address the issue of recruiting social workers to Haringey (much needed – as unfilled posts and many agency workers currently) by bringing in social workers from the States and recruiting from big equivalent cities like New York showed initiative.

On education I brought Peter up to date with the Liberal Democrat campaign for Fair Funding (as our children get £1000 less per head than kids in Hackney or Islington) because we pay inner London staff salaries (high) and only receive outer London per pupil funding (low). Given that Haringey schools showed up recently as having a very high level of deficits in their budgets (one of the worst in the country) not surprisingly given that £1000 differential – the pressure has to be kept up to make the Government give us our fair share.

Meeting with new CEO at Whittington Hospital
First meeting with the new CEO of Whittington, Rob Larkman. This was a basically get to know you type meeting, setting out from my point of view the various key interests I have on behalf of local people. It was also about the funding problems coming down the track at our health services, the impact of the new Community Health Centre at the Hornsey Hospital site and in terms of the Whittington itself – my priority – which is making sure that patients are treated well – not just clinically – but as people.

The aspect which people raise with me about their hospital stays – when there are complaints – is always about how they were treated in human terms by the staff. Obviously – the vast majority of the staff are absolutely fabulous – and there are more people praising the Whittington and their treatment than are critical. But – those who do get badly handled – need their local hospital to take such issues really seriously. I have found that the Whittington has been very responsive in the past to any individual complaints I have taken to them – and now I want the new CEO to take over the last CEO’s promise to me – that patient treatment would be a priority.

I look forward to a good and constructive working relationship.

Sharon Shoesmith's day in court

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So Sharon Shoesmith is having her day in court. That’s her right. But none of the furore in the media, in my view, is responsible for her sacking. The media fire storm was undoubtedly a dreadful thing to go through – but my understanding is that it was her attitude in the press conference Haringey Council held after the trial verdict that brought the media down on her like a ton of bricks. She did that to herself.

The apparent arrogance of saying that Haringey was wonderful, and showing the media charts to point out how brilliant her department was, said everything you need to know about Labour Haringey. In fact, Clare Kober the new Labour Leader, is quoted in the Daily Mail as saying “I have the utmost respect for you (Sharon Shoesmith) as a public servant … I have every confidence that you are the individual to get us where we need to be” demonstrates the sort of poor judgement she and Labour have.

And it is a judgement based on a long history of blag it out, say the moon is the sun, and get out of trouble that way. It is precisely that sort of attitude that leads to the situation where a baby can die even with sixty visits from Social Services because Haringey always rejects criticism, is arrogant and refuses to listen when people try to warn them of problems or trouble. That is the part that worries me the most – because the culture at Haringey is one of cover-up, rank-closing and refusal to accept or deal with problems.

No wonder Haringey supported Sharon Shoesmith at first – regardless of the facts. They had paid a fortune to media trainers to prepare her and others to face the post-trial storm (money they should ask for back). It was all about protecting Haringey’s reputation regardless of the real underlying situation.

That is why Victoria Climbie died and that is why Baby Peter died.

At least this time, unlike with Victoria Climbie, there has been a clear out of those in charge of Children’s Services and I hope that the new Director and new managers will ring the changes and turn the department around – no easy task.

So – back to Sharon and why Ed Balls was 100% right to sack her – regardless of the media and regardless of David Cameron and my contributions at the now famous Prime Minister’s Questions.

After Victoria Climbie died and Lord Laming’s public inquiry made its recommendations – one of the key problems Laming identified was that the leadership was weak and at fault – but took no blame in the consequences. Only Lisa Arthurworry, the social worker at the end of the food chain took the blame. George Meehan (Labour Leader at that time), Gina Adamou (Chair of Social Services at that time) and Mary Richardson (Director of Social Services) all suffered not one bit as a result. The two Labour politicians stayed in post and Mary Richardson subsequently moved to Hackney to be Director there.

The Director of Children’s Services this time with Baby Peter was Sharon Shoesmith. In law, she is accountable and responsible for the litany of failures that went on under her stewardship. She should without doubt have instantly resigned. That – not only would have been the right thing to do – but would also have spared her some of the media fire that followed her dreadful performance at the press conference and beyond.

The investigations that followed Baby Peter’s death all show a litany of casualness and failures by individuals and agencies. The substance of the failures and being the person in the accountable and responsible position in law is why she went.

As Ms Shoesmith refused to do the honourable thing, Ed Balls, therefore, had no choice but to sack her. He understood what had happened – and that if she remained in post despite the law that placed her in the accountable position and despite the terrible things that had occurred under her supervision – then Victoria, Peter, all Lord Laming’s work and the safety of children at risk in future would all be for nought.

Baby Peter, the Equality and Human Rights Commission … and West Ham

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As I blogged earlier this week, I was interviewed by Yoosk – answering a series of questions posted by visitors to their website. Here’s a selection of the answers I gave:

On the death of Baby Peter

(Also on YouTube here.)

On the Equality and Human Rights Commission

(Also on YouTube here.)

On similarities between the Liberal Democrats and West Ham

(Also on YouTube here.)

Child protection: my conference speech

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Here’s my speech in the child protection debate at the Lib Dem conference in Bournemouth:

I was leader of the opposition on Haringey Council when Victoria Climbie died.

We were promised that lessons would be learned. That it would never happen again.

But lessons were not learned.

And it did happen again – with the tragic death of Baby Peter.

And it happened because the rotten culture of Haringey didn’t change, the secrecy didn’t change, the unwillingness to listen to outsiders didn’t change, the instinct to close ranks and turn backs on warnings of problems didn’t change and key senior people didn’t change.

After Victoria Climbie’s death, the only person who had to carry the can for all the failings right up and down the management chain was Lisa Artherworry – the most junior social worker at the end of the food chain. She took all the blame – and it’s the memory of that buck-shifting and failure to change that drove me and my colleagues to campaign so hard to say that this time, after the death of Baby Peter, there had to be a real clearout of those who had failed – however senior.

But my deep-seated fear is that it was only the outpouring of public grief and anger , the focus of national media coverage and – yes, to his credit – the intervention of Ed Balls – that forced change – and so when that attention moves on, will the old ways return once more to Haringey?

That is why we need to attract the brightest and the best social workers and managers to Haringey and give them the support and the resources they need to do the job.

We need to get rid of the tick box culture that takes away all personal responsibility. We need to enable professionals to use their brains and their instincts and their critical faculties. We need a performance regime that doesn’t give gold stars based on rubbish inspections which, the moment things go wrong, turn out to have failed to spot a myriad of problems. We need whistleblowers to be listened to and followed up on.

And, above all, we need to ensure that all those running similar services in future know the full lessons of what went wrong and why and how – so that they can do their level best to ensure such mistakes do not happen again.

But there are still too many unanswered questions.

Why did all four senior consultant paediatricians in the children’s health team resign, go off sick or go on special leave? That’s why there was a locum –the locum who unbelievably didn’t recognise Baby Peter’s broken back and broken ribs. Has whatever caused that health team to descend into such chaos really been sorted?

And what about the inspection regime that gave three stars when only weeks later Haringey Children’s Services was damned to hell by that same inspection authority – Ofsted? What value in the next inspection – whichever council it may be – saying all is good?

What about, what about, what about?

Too many questions to fit into this one speech are still unanswered – and that is why we still need a public inquiry and we need to publish the Serious Case Review.

We cannot stop innocent children being born into families where – instead of love and comfort – they get cruelty and misery – but we can and must do better than we have.

That must be our commitment. That must be our mission.

Support the motion.

Haringey hid the truth!

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I don’t know where Andrew Gilligan got the information from about the fact that Haringey had placed a child to be fostered with the family where Abdulla Achmed Ali was living – but he must have phenomenal sources. Not a peep, not a dicky-bird had been said by the Council about this latest incident.

At this point whilst we are asking the questions that need to be asked of Haringey – we don’t know how badly or otherwise Haringey has performed in its duties to safeguard children it places in foster care – but unfortunately with Haringey’s track record we can only think the worst. And as there still has been no public inquiry into Child Protection in Haringey – we all suspect that there is much more of this under the radar as this revelation today has demonstrated.

However, what we do know now, is that Haringey Council has known about this for three years and not brought it forward as something that needs to be examined. Again we see Haringey cloak the whole incident in secrecy. Hide it away and hope that no one will find out. It is secrecy that has bread the breathtaking failures in child protection and elsewhere.

Robert Gorrie, Liberal Democrat leader on Haringey Council said of this latest shocking story:

‘Haringey Council vowed during the Baby Peter tragedy that they would end the silence and cover up in Children’s Services yet this shows a Council still committed to a culture of secrecy.

‘How many more cases of Council failures do we not yet know about? Who knew about this fiasco and was keeping it a secret and how many more cases of Haringey Labour failure do we not yet know about?’

Haringey to get new Chief Executive!

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Got a surprise this morning – Ita O’Donovan – Chief Executive of Haringey is retiring. Good! That means that another person who presided over the Baby Peter tragedy and aftermath is going.

I always thought it was strange that the Chief Executive’s voice was hardly heard at all during the Baby Peter case. Sharon Shoesmith – for all her faults – was out there taking the full force of public, media and everyone’s disapproval.

Anyway – moving onward and upward is the most important thing for Haringey Council. So – hopefully not only will we get a top notch new Chief Executive – we will also have a new administration next May when we have local elections – a Liberal Democrat one!

Naming those convicted over Baby Peter's death

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Came back from holiday to breaking news of those convicted following the death of Baby Peter being named and shamed in a media tsunami which has only just (mostly) abated.

Had been on Monday to Bangla TV to do a long (one and a half hours) interview on various issues that affect the Bangladeshi community – chief amongst them – stop and search; ID cards; work issues (my anonymous job application proposal); terrorism and so on. Very nice to be given time to actually expand discussion properly around a topic rather than the usual nano second soundbite.

Around four o’clock calls start coming in from newspapers that the names and faces of the three people convicted of ‘allowing Baby Peter to die’ will be released at midnight. Immediate phone call from Newsnight who think that the Mail and others will go earlier – can I be there for 10.30pm to go as lead story if reporting injunction removed earlier? In the event – we go at 11pm.

The next day the media tsunami that has accompanied every twist and turn and new event of this tragic case sweeps me into around twenty interviews across the spectrum of media outlets. It was not only important that the names were published – that is the law for those who are convicted and is the guarantee to the people of this country that justice has been done and been seen to be done. However, it was also inevitable – as the names have been out on the internet for months now.

So – what do I think? I am late in blogging this as the story was yesterday’s news – the future is about whether change will really be delivered and will the closing ranks, secretive culture in Haringey ever end?

And yes – of course there will be problems arising from the notoriety of these criminals which may make their lives hell when they emerge from their sentences because people hate them and may demonstrate that hate with violence.

My own view is that the length of the sentences they serve is quite critical. If they were to only serve a minimum then the people would be rightly angry – but I doubt that this will be the case as the judge when sentencing was extremely robust in his criticisms and put a question mark over whether two of them would ever come out by delivering ‘indeterminate’ sentences.
In a civilised country with a civilised justice system – their time in prison is the punishment and they would be entitled to protection if their lives were still in danger.

For me, however, the real issue is still around how much safer will children at risk be in the future – particularly in Haringey? I am not going to repeat the litany of all the questions that remain unanswered and the agencies who have not yet born the punishments and scrutiny they deserve. I have intoned the need for a public inquiry and the publication of the two Serious Case Reviews often enough.

This isn’t nearly over!

Two years since the Baby Peter tragedy

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A spate of phone calls and texts from the media remind me that it is two years since Baby Peter was ‘allowed to die’. The anniversaries will come and go. The investigations, inspections and reports come and go. But what will really change?

The fear that haunts me is that the words are easy – ‘lessons must be learnt’ – but we heard that beating of the chest and wringing of hands post Victoria Climbie – but nothing much actually changed at Haringey Council. New processes were brought in post Lord Laming’s inquiry – but the culture of Haringey didn’t change one iota. It remained arrogant, unwilling to let in the light scrutiny – or even to be questioned. That defensiveness, secrecy and closing of ranks allowed a second tragedy of immense proportion to take place despite the promises that lessons would be learned.

What I think is that unless and until processes take place in a culture that is open, welcoming of questioning and where people do their own job to the highest standard possible (not relying on tick boxes but on conscience, good training and supervision) it could all happen again. I fear that some of the investigations and recommendations, followed by numerous action plans and inspections feel like lots is being done – but real change can only come from leadership at every level.

Sadly, secrecy prevails. The Government refuses to hold a public inquiry. The Government refuses to publish the (now two) Serious Case Reviews.

We still need that inquiry. Whilst Haringey, quite rightly, was held firmly in the spotlight of blame as the lead agency, the other agencies have had relatively scant focus. They have contributed their reports to the investigations – but the pressure is not so focused.

In terms of health – the managers at Great Ormond Street who refused to take the concerns of four paediatric consultants seriously (the four who signed a letter to the management flagging up the dangers for children because management were not listening) are still in place.

Ofsted, who inspected Haringey at the time of Baby Peter and gave them a three star rating which plummeted to one star post Baby Peter scandal, have got away virtually scot free.

The police, whose poor handovers and missing files led to the Crown Prosecution Service saying that had this been done properly they might have been able to bring an early conviction, are out of the limelight. And so on and so on.

Ed Balls says he doesn’t want to publish the Serious Case Review – even though this would allow professionals right across the country in all the agencies to witness the litany of failures, both personal and systemic – and so learn for their own services and their own work.

The shock of that document (which I am still forbidden to speak about – and I only saw the first one not the second one re-commissioned by Balls) is the casualness with which people did their jobs. To most people, if a child is on an at risk register – we would expect more rigour and absolute professionalism around such care. What we see is lots small failures: files lost, people not attending important meetings, missed appointments unchecked and unquestioned, inadequate or no handovers, etc etc etc.

How can lessons be learned when the details of what went wrong and how and why are kept secret?

So – I plough on trying to get things out in the open and done publicly. That is the first step only in my view. In Haringey, at least, the people have changed. The accountable people have actually lost their jobs – which at least sends the message that there is a point to the position – that there is responsibility and consequences. But as I say – in the end the two things I believe would offer better protection are a change in culture and the reinstatement of personal responsibility within any function – above and beyond putting a tick in a box.

Meanwhile, in other business…

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I am remiss in blogging the things I am doing outside of the Equality Bill – but I am still doing the usual level of meetings, events and so on. I met with the Gurkhas at Parliament to support the campaign for equal pension rights. I met with a local woman who is starting a campaign to get a counsellor (talking therapy kind – not Haringey Council) into every primary school. I think this is a very good idea – and in principle am supporting her campaign. I met with a Japanese reporter who wanted my assessment of the key issues around the Baby Peter case as they have a similar case in Japan – where they don’t have children’s social services. I did a lecture on ‘ A Different Future’ to a progressive group – expounding my theories that we mustn’t return to the same old same old greed and avarice – both in banking and in politics. I did an interview with the programme ‘How to Look Good Naked’ and no – it didn’t involve me in taking my clothes off – and no I am not going to reveal here what it was about! All will be revealed in the autumn when the program goes out! I did an interview with the Westminster Hour (pre-recorded) on the Parliamentary procedures around Bill Committee – don’t get me started – just so wrong.

I visited a local hostel run by St Mungo’s – famous for its work with rough sleepers and the homeless. This hostel works with those coming out of prison – and is doing really great work with some of the most difficult and challenging persistent offenders. They are having quite a lot of success in reducing re-offending – which in my view is the way to go. Currently re-offending rates are astronomical – but often because those in prison have mental health or substance issues and come out with no skills, sometimes illiterate and no home or job. The work that St Mungo’s do is to give people the ability to take their place back in society by helping them with all those things.

I went to Abyssinia Court – a local sheltered housing scheme – where a local volunteer had organised a fantastic afternoon. Yolanthe had persuaded local therapists and nutritionists to come into the home to talk about important, really important things for the not so young – like nutrition, exercise, yoga, homeopathy and many other alternative therapies. There were talks explaining the different things in the main room – and then you could go to any of the advisers or therapists for a taster. What a fabulous thing to do for our older citizens. And then there’s been the the Hornsey Carnival and Bazm-e-shero adab at Wood Green library!