What does it look like if you take home education out of the equation in the Dylan Seabridge case?
Dylan Seabridge died in Pembrokeshire age 8 in December 2011. After Dylan’s death, the parents were investigated for neglect.
The family lived in Pembrokeshire, but Dylan’s mother was employed as a teacher in neighbouring Ceredigion while Dylan was being home educated. During an employment tribunal, professionals in Ceredigion became aware that Dylan’s mother was suffering severe mental ill-health and a referral was made to Pembrokeshire. It would seem that information was not shared properly. The officers who went out to the family house only thought they were making contact with a new home educating family, and had not been informed of any safeguarding concerns, hence when the parents would not speak to them, officers saw no reason to take things further themselves and did not make a safeguarding referral.
Pembrokeshire at the time was being blasted for failure to safeguard children in its area; this was widely publicised, the Welsh Government put in an Ministerial Board to oversee improvements, and the Chair of the Local Safeguarding Children Board who was also Head of Child Care Commissioning, resigned. Problems continued .
In November 2014 a decision was taken not to prosecute the parents for neglect when the Crown Prosecution Service dropped charges.
At an inquest in January 2015 the cause of death was found to be scurvy.
While neglect investigations were ongoing, Pembrokeshire undertook a Serious Case Review which was apparently completed in draft form by 2013 but could not be published until criminal investigations had been completed.
In fact this Serious Case Review [SCR] was never published. It was apparently decided that there would be a new-style Child Practice Review instead, which would be about “learning lessons” rather than blame.
The Child Practice Review into the death of Dylan Seabridge was not published until July 2016.
WELSH ASSEMBLY DEBATE INDEPENDENT REVIEW, JANUARY 26TH 2016
Mark Dyson has now retired, giving up his career after 20 years in public service, he says that the fight for a full and robust investigation had a profound impact on him.
[Mark Dyson:]You feel that even the thread of reason is broken, or there’s something so profoundly wrong that you cannot put it right. It exhausts you. It goes on and on and on. You are just trying to find somebody who can listen fairly to what you are saying. Not necessarily agree with you, just listen fairly to what you are saying. And all that I’m saying is, a child is dead, where are we in terms of learning the lessons? Who is asking questions? The answer seems to be, nobody is. [LINK]
Members of the children’s workforce in Pembrokeshire may have been constrained by local protocols suggesting that parental consent was required for investigation.
“CP Section 47 Enquiries Thresholds Protocol Approved by Powys, Carms, Pembs, Ceredigion LSCBs and Dyfed Powys Police. Review date December 31st 2011. Author Dyfed Powys Safeguarding Children Forum” says
The consent of a parent/person with parental responsibility should be sought before undertaking the initial assessment and any continuing intervention unless professional judgement suggests that this would place a child at risk of further harm. The manager in social services with responsibility for child protection should only consider dispensing with the consent of the parent/person with parental responsibility if the matter is child protection.
The BBC (who have seen the 2013 draft Serious Case Review and interviewed a former Council solitor who appears to have detailed knowledge of the tribunal) stated that during an employment tribunal by Ceredigion council professionals became aware that Dylan’s mother Julie Seabridge was suffering severe mental ill-health
Working Together safeguarding guidance Wales says
2.130 All those providing mental health services must be alert to the
possibility that their clients, whether adults or children, may be a risk to
children. If they have any such suspicions they should make a referral
to social services and follow child protection procedures.
Working Together also says
The process of initial assessment should involve: seeing and speaking to the child (according to age and understanding) and family members as appropriate. The child should be seen as part of the initial assessment within a timescale that is appropriate to the nature of concerns expressed at the time of the referral, (which may include seeing the child without his or her caregivers present). Following an initial assessment, where there is reasonable cause to suspect a child is suffering, or likely to suffer, significant harm, the local authority is required by section 47 of the Children Act 1989 to make enquiries, to enable it to decide whether it should take any action to safeguard and promote the welfare of the child.
In 2013 Serious Case Reviews in Wales were replaced by Child Practice Reviews.
In April 2014 the 22 individual Local Safeguarding Children Boards in Wales were replaced by 6 Regional Boards. The Board covering Pembrokeshire and Ceredigion is the Mid and West Wales Board.
By January 2015 the Mid and West Wales Board had not completed any Child Practice Reviews and had only notified the Welsh Government of the intention to complete only 2 Reviews or Multi-Agency Forums, fewer than any other areas.
A Government review of Child Practice Reviews in 2015 found that they take an average of 12 months which is seen as too long. They were felt to be problematic where the case was complex or subject to parallel criminal proceedings. There was apparently a general view that if a child was not known to services then a CPR is unlikely to be completed.
Below is the transcript of a feature by journalist India Pollock:
Dylan Seabridge was eight years old when he died of scurvy in 2011 and yet his inquest heard he saw no doctors, dentists or teachers from when he was just 13 months old until his death.
Now a BBC Wales investigation has found that concerns were raised to the authorities more than a year before he died. And now more than four years on, nothing has been published about whether more could have been done to prevent it. India Pollock has this special report.
Dylan Seabridge was invisible to local councils according to a serious case review leaked to BBC Wales. The report’s author knew so little about him that it was impossible to draw a picture she said. The inquest heard that he did not see a doctor or dentist from the age of 13 months until he died of scurvy at the age of eight.
Scurvy is caused by a lack of vitamin C. The inquest took place in January last year heard it was an easily preventable, treatable disease. Some of the clinical features described by the ambulance crew were very typical of scurvy, swelling in the lower limbs, a rash on the legs, and discolouration and bruising, all characteristic features of scurvy. His parents however do not believe that he died of scurvy, or that he was invisible to the outside world. They were charged with neglect but the charges were dropped in 2014.
Dylan lived here in Pembrokeshire, but his mother worked as a teacher in neighbouring Ceredigion. It was during an employment tribunal by the council that professionals became aware she was suffering severe mental ill-health, they contacted home [?] services who told them that Dylan was home educated. He died a few [?] years later in 2011.
The safeguarding children board looked at the involvement of any agencies and should have completed the report quickly so that any lessons can be learnt and shared. The draft review we have seen has never been published. Four years after the death nothing else has been published.
Mark Dyson is a former solicitor for the Council [Ceredigion?] and was one of those who contacted social services. He also told senior officials that he was anxious about the investigation they were carrying out. He also says the delay in publication is worrying.
[Mark Dyson:] The whole purpose of serious case reviews is to learn lessons. They need to be approached with a sense of urgency. If lessons are not learned with a sense of urgency, these things will have again. It has been wholly inadequate. There just does not seem to have been any fully coordinated response, no sense of urgency, no focus on the child and the fact that the child is dead.
The council [Ceredigion?] denies those claims and says they are [were?] not responsible for safeguarding Dylan, who lived in Pembrokeshire.
They [?] had to wait until the criminal investigation was completed, and then the inquest which took place in January last year. They [?] also said the process was very complex because of a change in government guidance and the structure of the safeguarding board. They [?] say a new review will be published soon.
Dylan was home educated, as are around 1500 children in Wales, though we don’t have exact numbers because there is no legal obligation to register the fact you teach a child at home. The Childrens Commissioner for Wales says that needs to change.
[Sally Holland, Children’s Commissioner:] This is rare but probably not the only child under the radar in Britain. So we should be learning what we can, very clearly, from this case, and, of course, as quickly as possible.
The Welsh Government did not want to be interviewed but we asked them a number of questions. They said they would not comment on an individual case but that non-statutory guidance on home education would be published soon.
Mark Dyson has now retired, giving up his career after 20 years in public service, he says that the fight for a full and robust investigation had a profound impact on him.
[Mark Dyson:]You feel that even the thread of reason is broken, or there’s something so profoundly wrong that you cannot put it right. It exhausts you. It goes on and on and on. You are just trying to find somebody who can listen fairly to what you are saying. Not necessarily agree with you, just listen fairly to what you are saying. And all that I’m saying is, a child is dead, where are we in terms of learning the lessons? Who is asking questions? The answer seems to be, nobody is.
Four years on we still don’t know what has happened.
That is right.
They had to wait for the criminal charges to end, charges of neglect were dropped against the parents in 2014. The inquest was just about a year ago.
The other things that had been in play are changes to safeguarding board in Wales and a change in guidance from the Welsh Government around this kind of investigation.
However, as you can imagine, there is still criticism of how long this is taken. A new review should be out soon. And that this has prompted calls for a register of home educated children.
That is right, the Children’s Commissioner wants a register of when children are being registered [taught?] at home. It is not just about home education but building relationships with doctors, dentists, other relationships.
I spoke to an education consultant who said the moment you try to police this barriers will go up and it will be harder to [work cooperatively] cooperate with families who want to home educate their children. She also said the cases made it inevitable [there would be] talk about this register again but at the end of the day, hard cases should not make bad laws. transcript
Do we know that the former employers said the mother was suffering *severe* mental ill-health? Wondering as the reports I’ve found just say that the former head called SS saying that mother was home educating and mentally ill. That could be anything from mild depression to psychosis. It’s *possible * that, if the concerns weren’t specific, or were mild and largely related to home – ed, that SS may have acted correctly. Eg if they said “Home education in itself is not a concern unless you have substantial concerns – this is a matter for the Education department”. I am not attempting to draw conclusions, but if SS are to have a duty to investigate everyone who has, say, a disgruntled former colleague call about them, yet has not actually seen anything worrying about the child, that is different from what I believe the requirements are at present.
” severe mental ill-health was a quote from the transcript of the India Pollock feature http://subsaga.com/bbc/weather/bbc-wales-today/2016/01/21.html But again, take home education out of the equation, the relevance is that the former employee was a parent.
Yes, I had the same question concerning report of mental illness, and it needs to be answered in order to appraise what happened next regarding concerns met by health and social services. What indications were specified as mental illness?
I’d also like to hear what the cause of death was as established by coroner before I hear about what this all means for the future.
The coroner concluded that the cause of death was scurvy, and it was this report which triggered all the media reports in the last week – http://www.bbc.co.uk/news/uk-wales-31039895 . The parents commissioned a report disputing this: “Representing Mr. and Mrs. Seabridge, who were not present at the inquest, solicitor Katy Hanson told the hearing that the couple did not accept the findings that their son had died of scurvy.
She read out a report from Belgian Professor Joris Delanghe, which said that the diagnosis had been focused on scurvy, but he believed that this interpretation was “questionable” and Dylan’s conditions may have been caused by a number of other conditions.” [http://www.tenby-today.co.uk/article.cfm?id=196&headline=Boy,%208,%20died%20of%20scurvy,%20coroner%20concludes§ionIs=news&searchyear=2015]
Professor Delanghe has published academic papers discussing vitamin C deficiency from non-dietary causes, eg http://www.clinchem.org/content/53/8/1397.full notes that there is a lot of genetic variance in vitamin C absorption.
I’m not sure how relevant this is though; I can imagine that Dylan’s parents may feel that he ate a good diet, and that they took good care of him in this respect – but if he was not absorbing the vitamin C, he would still have had symptoms of vitamin C deficiency. So the question is not “did these parents not feed their child properly?” but “were signs of ill-health missed at a stage when something could have been done about them?” And from a home education point of view, would the earlier signs of vitamin C deficiency have been significant enough that a teacher would have noticed, and acted upon, them?
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If we think it was scurvy then we think it could have been fixed? But maybe non-scurvy could have been fixed also? Is that what you’re saying?
Yes, vitamin C deficiency through malabsorption is still scurvy, it’s just the cause is genetic rather than a poor diet. But even if you have trouble absorbing it, that can still be treated – scurvy through malabsorption would have the same symptoms as scurvy caused by diet, as I understand it, and could be treated. For instance, you might have targeted dietary support or supplements – if you absorb vitamin C poorly, you might have a diet with especially high vitamin C taken in easily absorbed form. We all absorb nutrients to a greater or lesser degree than the average, hence some people becoming anaemic on the same diet which is adequate for others.
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Added link to Welsh Assembly debate on independent review of the case http://www.assembly.wales/en/bus-home/pages/rop.aspx?meetingid=3532&c=Record+of+Proceedings
Signs of scurvy may indeed be caused by its malabsorption, as opposed to poor diet. Malabsorption is not necessarily genetic either. Variance in uptake is always a factor, bur ‘Malassimiliation’ as I understand it in the gut is likely to be due to any of numerous underlying conditions.
Here we have a problem of not knowing enough about the timing in emergence of particular signs, as being obvious to the carer/parent, whoever. I don’t even think I’ve heard wether the poor son died at home or in hospital after parent referral.
Certainly a teacher wouldn’t spot them earlier than a parent.
It is most likely the child would be off home feeling tired or achey before more telling symptoms emerged symptoms.
We know little of that detail, and neither does it seem so the press; People in all walks talk of learning lessons, but sometimes appear to jump to conclusions. The parents were cleared of neglect. We don’t know those details either, which must be important.
“Four years on we still don’t know what has happened….
They had to wait for the criminal charges to end, charges of neglect were dropped against the parents in 2014. The inquest was just about a year ago.”
It would be good to liaise with parents, offer support in that way, and gain full knowledge before any speculation.
The press can be told simply: certain insinuations having been made are premature, and therefore a misadventure and, asked to respectfully retract these immediately on behalf of the parents, and even all parents in general including Home educators.
Fiona, have you seen the little post on the NSPCC website? That, coupled with the comments from a Welsh NSPCC bod re Dylan S., suggest that they have not shifted their opinions one little bit. Your meeting with them (no minutes yet?) might have been a holding exercise, knowing that this story was going to be in the media, and they could add to the anti-home ed publicity.
PS I am not that cynical about everyone, but for the NSPCC I’ll make an exception.
Anthea I am so sorry, but for some reason your comment went into spam and I have only just found it to let it through. Thank you so much for drawing the change to my attention! I hadn’t spotted it and will blog about it now. I have to say that I think the latest change is BETTER
I will expand now in a fullscale blog post but … the short version is that I do agree that a major issue is lack of clarity amongst professionals.
I regret having to agree not to talk about the meeting until the NSPCC had provided its own notes, because it could have been predicted that they’d take a while to produce, and meanwhile, speculation fills the vacuum.
I have no way of knowing whether the NSPCC in London was aware that this case was about to hit the media.
Obviously I am constrained as to what I can say about the NSPCC meeting at this stage but…for what its worth I don’t think the meeting was intended a holding exercise in the sense of lulling us into a false sense of security, if I’m interpreting you correctly.
I think the NSPCC reps at the meeting genuinely wanted to open up a conversation.
At the same time I would be stunned if the NSPCC has had a Damascene conversion as a result of the conversation and suddenly has switched 180 degrees and no longer believes that registration and monitoring is a Good Thing (although they MAY no longer think it is The Answer, which would be tremendous progress, in my opinion)
I must add: Given an underlying condition that gives the signs of scurvy, a hospital may well administer Vitimin C “too late” without investigating underlying conditions. I doubt in an acute condition that hey would do so. In fact I doubt they ever do so, but rarely and with parental input and long history.
Furthermore, administration of high dose vitamin C in such circumstances might consequently cause further damaging complications, for instance due to oxalase poisoning.
“Dylan Seabridge was eight years old when he died of scurvy in 2011 and yet his inquest heard he saw no doctors, dentists or teachers from when he was just 13 months old until his death.
Now a BBC Wales investigation has found that concerns were raised to the authorities more than a year before he died. ”
What concerns of whom were these, and raise to what authorities – It implies that child health concerns were raised by the order in which this statement appears. Is it not in fact repetition of concern for mental health of the mother? Pretty irrelevant, from what little we are told, which is little. A former teacher, once capable and employable, indulges in home education and has conflict with a head teacher. No report of errant or worrying behaviour. A teacher possibly worn out at school herself, anxious and depressed inside its halls.
From the above, we may deduce that the onset of vitamin C deficiency was rather later on than infant, and not simply genetic or long term malnutrition. Not, as insinuated, that he was dying for 7 years merely because he wasn’t presented to a doctor in that time. THe signs present at the time of calling an ambulance ( I presume Dylan – bless his soul, and his parents who called an ambulance – was alive at the time) were the acute signs , those more definite signs following signs of tiredness and possibly generalised aches … not easy for a child of eight to describe. Not something that a parent takes a child to a GP for to be told, what exactly? That he’s suffering form Vitamin C deficiency? Most unlikely.
So, how long after their emergence was the ambulance called – certainly not seven years, probably more like a matter of a few days at most. Or was it weeks? I doubt that.
Why the ambulance, then? Well, I have taken my son to the GP when I would gave done better to have called the ambulance: some symptoms emerge quickly over a weekend, and are an obvious cause for emergency call for expertise in hospital settings.
Could the hospital have saved him even at that time – maybe not, because of an underlying condition rather than malnutrition or, even in that case may be so, but only by rare specialists armed with a very clear history taken from parents; that is most unlikely.
Oops forgot the link —
In January 2015 the coroner identified the cause of death as scurvy. I’m sorry I didn’t make that clear. I have added a hyperlink to the media report of the inquest.
I think I see what you are saying about mental illness. For example I suffered from depression and had several nervous breakdowns myself (albeit before I became a parent) and am still periodically afflicted by severe anxiety, and the idea that someone could have pointed the finger and questioned my capacity to care for my son (I put in the past tense as he is now 22) is quite troubling, as is the notion that someone could make a malicious referral because eg they disagreed with home education.
But the law does say that various bodies must make arrangements for ensuring that their functions are discharged having regard to the need to safeguard and promote the welfare of children http://www.legislation.gov.uk/ukpga/2004/31/section/28 and the statutory guidance for Wales I quoted in the post above – which differs between Wales and England – specifically says:
6.23 Mental illness in a parent or carer does not necessarily have an
adverse impact on a child, but it is essential always to assess its
implications for any children involved in the family. […]
6.24 The adverse effects on children of parental mental illness are less likely
when parental problems are mild, last only a short time, are not
associated with family disharmony, and do not result in the family
breaking up. Children may also be protected when the other parent or
a family member can help respond to the child’s needs. Children most
at risk of significant harm are those who feature within parental
delusions, and children who become targets for parental aggression or
rejection, or who are neglected as a result of parental mental illness.”
Can I be clear, I’m NOT saying there is information in the public domain to suggest that immediate action should have been taken under section 47 of the Children Act 1989 (immediate risk of significant harm), I am saying it seems to ME that a referral about parental mental health would come within scope of INVESTIGATION by children’s social care as outlined in the statutory guidance (ie assess its implications), and that this is what appears not to have happened.
Instead, the council sent someone from education to talk about education, when the education law does not require the parent to do that.
In short, I am saying that the information in the public domain (I have not seen the draft serious case review myself) suggests that things were left undone which should have been done, although that is not the same as saying that a child’s death could have been “predicted” or that a child could have been “saved.”
It seems that social services did receive at least one referral. The Welsh Guidance says:
Referrals to social services may lead to:
The need for immediate action to be taken (see below).
The decision that an initial assessment/the provision of services is
The referral being more appropriately signposted to another agency
No further action being necessary.
8.52 Where a local authority children’s social services decides to take no
further action at this stage, feedback should be provided to the referrer,
who should be told of this decision and the reasons for making it. In the
case of public referrals, this should be done in a manner consistent
with respecting the confidentiality of the child.
I agree that more information is needed about how children’s services reached the decision there were no grounds for commencing the more formal approach of a section 47 investigation. On the surface the referral may not have raised concerns about emotional abuse or neglect – and social workers are at the centre of many conflicting views about how best to intervene when a mother has a serious mental illness. It was the fact that Dylan was home educated that might have raised concerns about his apparent social isolation – but of course we don’t know the facts about this.
This case confirms my impression that some children suffering from parenting that might be harmful to the child’s well-being are failing through the net because social workers fail to use their legal powers appropriately. I think that the reason for this is that emotional harm/neglect is difficult to define – and it’s not very sexy!
It looks like we won’t see the 2013 draft serious case review; one paper I saw was saying that there would be a “concise” Child Practice Review released soon. From the facts reported, there doesn’t seem to have been any assessment of the impact of (alleged) mental health concerns, which the guidance to me suggests should have happened. That’s why I keep saying can we look at it without home education being part of the equation. It is also relevant I think that for whatever reason, the parents were ultimately not prosecuted for “neglect” and there can be other reasons for a particular child having a very restricted diet (making the assumption that the inquest verdict of scurvy was correct and that it was due to an actual LACK of Vit C rather than eg inability to absorb Vit C) Deciding whether “parenting” is “harmful” when it is below the threshold for actual “harm” can be intensely subjective, and difficulties could be compounded by the fact that the person making the assessment might be wary of being rebuffed by the parents, and how “harmful” could that potentially be. Much easier when caregivers present as obviously “evil” or at least ill-intentioned
related blog over here http://gritsday.blogspot.co.uk/2016/01/the-problems-with-registering-and.html
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Dylan died in hospital.
http://www.bbc.co.uk/news/uk-wales-31039895 “Dylan Mungo Seabridge, from Dolau, Eglwyswrw, died from the disease shortly after being taken to hospital on 6 December 2011.
The inquest in Milford Haven heard how he had been rushed to hospital after his father called 999 because Dylan had collapsed. The inquest was told when ambulance crews arrived Dylan was unconscious and was not breathing and had bruising to his ankle and knee along with swollen legs. He went into cardiac arrest at hospital but doctors were unable to save him.” http://www.walesonline.co.uk/news/wales-news/dylan-mungo-seabridge-inquest-eight-year-old-8539284 “At 8.21pm on December 6, 2010 [SHOULD BE 2011, TYPO IN PAPER], ambulance control took a call from Mr Glynn Seabridge stating that his eight-year-old son had just collapsed and had been poorly for the last couple of days. He went on to say his son had stopped breathing and was completely out of it. Paramedics attended the property seven minutes later found Dylan lying on the lounge floor, not breathing and unconscious. His father was kneeling next to him. Paramedic Richard Tucker noticed mottled bruising to Dylan’s leg.
“The paramedics commenced CPR, was continued in the ambulance and throughout the journey to Withybush Hospital in Haverfordwest,” added Mr Davies. “Neither parents travelled with Dylan, Mrs Seabridge was unable to go with him due to ill-health and Mr Seabridge made his way to the hospital in his own car.” By the time Dylan arrived at hospital he was in cardiac arrest. “Attempts were made to resuscitate him, but were unsuccessful,” added Mr Davies.Police officers and paramedics said they had noticed bruising to Dylan’s left ankle and heel area, bruising to his left inner and rear knee, swelling on his legs and a rash or red spots on skin on his lower legs. “Dylan was noted to have marks on his body, which together with comments made by his parents, suggested he had perhaps contracted meningitis,” added Mr Davies. A post-mortem revealed a number of abnormal findings including anaemia, soft tissue haemorrhage to the lower legs, lower limb odemia and dental abnormalities including loose teeth. Pathologist Dr Deryk Simon James concluded that the cause of death was down to a long standing vitamin C deficiency, commonly referred to as scurvy, and not meningitis. Dr David Tuthill, an expert paediatrician, said there was no evidence to suggest that Dylan could not eat a normal diet. “Leg pains appear to have happened on at least two or more occasions,” added Mr Davies. “He received unknown amounts of analgesia. At no time was medical assistance sought for these problems. This death was from scurvy, an easily preventable disease.”
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