CASE management reviews are carried out when a child dies or is seriously injured and abuse or neglect is known or suspected to be a factor. Kathryn Torney, who writes for The Detail, puts forward the case for executive summaries of the reports to be published in full and made available to the public in Northern Ireland. The article below is her contribution to a recent debate in Belfast hosted by the Northern Ireland Association of Social Workers and the British Association for the Study and Prevention of Child Abuse and Neglect.
I wrote my first article on Northern Ireland’s case management reviews (CMRs) in May 2009. Using Freedom of Information legislation, I asked for the executive summaries of all CMRs carried out in Northern Ireland since 2003 when the Department of Health revised its policies on child protection.
The reports are not currently available for members of the public to read – even though they examine important life and death issues and put forward important recommendations after children have been seriously injured or even killed.
I eventually received 13 completed summary reports ranging in length from 10 to 40 pages. One case was withheld pending an inquest and a further nine – at that point – were still being worked on. The executive summaries contained pseudonyms and references to specific locations were removed.
I was shocked at the content of the reports. The papers contained heartbreaking and tragic stories centred on young babies, children and teenagers. They included a baby seriously injured by his father who had already been convicted of the manslaughter of another of his children; a child in foster care being forced to scavenge for food in bins and a 14-year-old girl raped by her foster father. He killed himself when she spoke out about what had been happening to her.
All of the reports made multiple recommendations about how the case could have been handled better. Many of these recommendations overlapped.
Most of the children’s stories had never been publicised before. Others – like the death of seven members of the McElhill family in Omagh and the deaths of mother and daughter Madeleine and Lauren O’Neill – were more familiar. Who could forget the horror of hearing how convicted sex offender Arthur McElhill killed himself, his partner Lorraine McGovern and their five children in a house fire in 2007.
I read carefully through each report – realising at the time that I was doing so with the benefit of hindsight. Like reading a well known fairy tale or watching a pantomime, I knew something bad was going to happen as I started reading each child’s story but sadly was powerless to intervene or help.
I wrote up extracts from each report and we were ready to publish. However, what we weren’t prepared for was the onslaught of attempted court injunctions from families which began to flood into the Belfast Telegraph newsroom where I worked at the time the night before publication. I think we had seven legal challenges in total but it may have been more.
An excellent legal mind at the Telegraph took control and we were able to publish all but one of the cases. For that single case, we agreed to hold the report back as we were told there was a serious risk the sibling of a teenager who committed suicide was at risk of heading in the same direction. It was thought that our coverage may put him over the edge. In another case, we decided not to run a photograph of one of the children in a case which had already been in the public domain.
We handled our deliberations responsibly and carefully – balancing the concerns of families with the desire to publish stories which had strong public interest. We did everything we could not to silence the stories of children seriously injured or killed by adults and, in some cases, let down by others who opted to keep silent about their problems when they were alive.
At this time, our Children’s Commissioner Patricia Lewsley said that she did not receive copies of the reports. It says a lot that they weren’t even sent to our official children’s watchdog. Ms Lewsley said she wanted an urgent meeting with the Health Minister and also called for the recommendations from each review to be implemented immediately.
Many months later, a family member of a young girl who had died telephoned me. They said they were glad that we had published the report on her death. They also told me that they had been contacted by telephone and told that the report was due to appear in the Belfast Telegraph. They were told that they should try to get it stopped. How many of these calls were made, who were the callers and who were they really trying to protect?
Wind forward to February 2010 and I lodged another Freedom of Information request asking for copies of the executive summaries of any new reports completed since my last request. Only one case – the death of a 16-year-old autistic boy by hanging – was sent to me. The report said that Social Services mismanaged an investigation into claims the teenager was being abused by his mother. The report made 22 recommendations. At that point, another 12 case management reviews were ongoing.
Later in 2010, I asked again. This time four more reports were released to me and I wrote about them in the Belfast Telegraph in October 2010. The reports looked at two teenage suicides and the deaths of two babies. Issues raised in the recommendations were starting to sound very familiar. They included staff shortages, social workers failing to act upon referrals, policies not being adhered to and a lack of inter-agency working.
These four reports possibly should have been released to me earlier but were previously not considered for release. The Health and Social Care Board apologised in its response and said the omission of the reports was not intentional.
At this point – October 2010 – 16 CMRs still had to be completed or were subject to ongoing legal issues or other agency work.
Some of the reports I have covered in the last two years are clear and easy to follow but many are not. Some have been so seriously redacted that they are confusing. Ages, dates and places had been taken out of some. One of the reports I covered last October examined the death of a teenager by hanging. The girl had a twin but at times it was very unclear which twin the report was referring to. Both girls were troubled after the death of their father from cancer and the death of their mother after three years in a coma following a failed attempt to hang herself.
In November last year I asked the Department of Health if it could reassure the public that each of the recommendations in the reports is dealt with and followed through. I received a one word answer – “yes”. I would be amazed if this is the case. How many recommendations have been completely dealt with and if they are all being addressed, why do so many recur time and time again?
The executive summaries of all case management reviews should be accessible to the public in Northern Ireland. There is full publication of reports into child deaths in England so it’s hard to understand why it should be dramatically different here.
The reason for the reports is for lessons to be learned. There is no point in reviewing a case and then shoving the findings into a drawer. The reality is that children have died and others have been seriously injured. We all have a responsibility to try and ensure that any mistakes made in these children’s care are not repeated. We owe it to the children not to bury the bad news – even if it causes some people to squirm uncomfortably. Some of these children weren’t listened to when they were alive – it is right to hush up their stories now?
However, it’s important to stress that these reports are not intended to be a witch hunt. It’s not about finger pointing, naming and shaming or hanging any individual out to dry. The reports released to the public should not contain names – of the victims or the professionals associated with their case. Very often the failures I have read about are system failures, rather than the failure of one individual.
However, where blame is attributed to someone, a different forum should deal with the fallout from this – for example the General Medical Council.
Health and educational professionals need to check for any common themes or patterns coming from the full reports. Is there a specific problem in one geographical area? Is anyone’s name cropping up on a regular basis?
The public needs to know that children are more at risk from people they know than from the stereotypical creepy man wearing a trench coat and standing on a street corner. The children in the vast majority of the CMR reports have been hurt by family members or foster carers or siblings. Members of the public need to look out for the children living next door. The child we read about next really could be someone they know.
The case of Baby Peter Connelly in England has brought the issue of child abuse strongly into the public domain. But worrying about the impact on, for example individual social workers, of publishing the reports takes the focus away from where it should be – on the children.
I cannot deny that the reports I have seen make very newsworthy news articles. Many of the stories are shocking, horrifying and, dare I say it, fascinating to read. However, the vast majority of journalists are sensitive and keen to inform the public. Many are also parents whose greatest nightmare is contained within the pages of CMRs.
To imply that all journalists keen to cover these reports are headline seeking, insensitive and ruthless would be as unfair as claiming that every social worker fails to spot the signs of abuse and does a bad job at protecting children. Both statements are simply not true.
Working together and sensitively with journalists would enable these cases to be brought out into the public domain with care. Briefings should be given on the issues raised in each case. The facts should be clear and the recommendations succinct and achievable. We should be told what steps have been taken or will be taken in response to these.
I have not seen any of the full CMR reports but have found the executive summaries often very detailed. I do not currently see the need for the full reports to be made available to the public. This would allow extremely sensitive information – for example confidential evidence given by family members or friends about a case – to remain confidential. The executive summary should contain the main facts and the recommendations.
One former journalist colleague once said to me that my coverage of CMR reports could put readers off their breakfast. I said that I hoped that it would.
Pretending that these incidents didn’t happen would be the worst possible outcome. The cases are shocking, often horrific and definitely very, very sad – but for the children at the centre of each case this was their life. We need to learn from what happened to them and try our very best to make sure it doesn’t happen again.
Seeing recommendations repeated in reports time and time again in cases years apart is all the evidence needed to show that how the reports are handled now simply isn’t working.