taking home education out of the equation in Dylan Seabridge case

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. 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ongoing, Pembrokeshire undertook a Serious Case Review which was apparently completed in draft form by 2013 but could not be published until criminal investigations had been completed.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