Dylan Seabridge Child Practice Review July 2016

The Concise Child Practice Review  into Dylan Seabridge’s death was published on July 8th 2016. (These replaced Serious Case Reviews in Wales a few years ago)  The Review makes it clear that the family was not “hidden” but that information was not evaluated  appropriately and was not shared with the relevant professionals. The Review also finds that procedures were followed.

Quotes  from the Review appear below  underlined in italics.

“in following the correct procedures there was nothing any individual agency or practitioner could have done differently to avoid this outcome”  because “vulnerable adults were not routinely seen in relation to their role as parents.”

Dylan Seabridge died in Pembrokeshire age 8 in December  2011. At an inquest in January 2015 the cause of death was found to be scurvy. The Seabridge family  had lived in Pembrokeshire since 2001.  

Earlier reports indicated that Mrs Seabridge worked as an IT teacher in a school in neighbouring Ceredigion until 2006 when she tripped at work and was injured. In 2009 Ceredigion Council dismissed Mrs Seabridge on ill health grounds and the Seabridges took the case to an employment tribunal.

In early 2016 the BBC  stated that during this tribunal  professionals (in Ceredigion) became aware Mrs Seabridge was suffering severe mental ill-health. According to this  transcript  Mark Dyson was working as a solicitor for Ceredigion Council and was one of those who contacted social services.

 

“There were potential opportunities to see the child as a result of a protracted employment and litigation issue that involved the child’s mother in which the father was heavily involved.”

“A practitioner in LA2 [Ceredigion] raised their concern about the deteriorating mental health and vulnerability of the child’s mother and the behaviour of the father in dealing with the professionals involved.”

The Review establishes that social services in Ceredigion [LA2asked itself just one question, namely whether Dylan Seabridge’s mother was  “a vulnerable adult” as a result of her deteriorating mental health ie whether Mrs Seabridge herself was at risk.

“In May 2010, adult protection concerns were raised with Local Authority 2’s (LA2) [Ceredigion] social services directorate by an employee of LA2 [Ceredigion] as a result of an employment dispute involving the child’s mother, who was employed within LA2 [Ceredigion].”

“LA2’s [Ceredigion] social services directorate took the view that the criteria for triggering the Protection of Vulnerable Adults (POVA) procedures were not met”

Local authority employees (unspecified) from Pembrokeshire AND Ceredigion did have “a case discussion” of some description (on the telephone?) but nobody can remember much about it and it  led nowhere.

This followed a case discussion between practitioners from both Local Authorities, from which it cannot be recalled whether the personal details of the family were shared. As a result of this telephone conversation, no referral to Adult Services in LA1 [Pembrokeshire] was made.

“There is a lack of clarity in the review submissions surrounding whether there was a referral from LA2 [Ceredigion] to LA1 [Pembrokeshire] in relation to the child’s mother as a potentially vulnerable adult. There is no record of such a referral being received.

The Review doesn’t seem to consider it relevant that the only people who would have direct contact with the family in Pembrokeshire were not made aware of significant concerns about the mother’s mental health.

Social Services LA1 [Pembrokeshire] received telephone call from an employee of LA2 [Ceredigion] regarding the family. No child protection concerns and no police information to suggest concerns. Therefore, no further action. Education  LA1 [Pembrokeshire] to contact family to ascertain education status as not known to LA1[Pembrokeshire]

The LA1 [Pembrokeshire] Education directorate were first made aware of the family in June 2010, after a Head teacher at a school in LA2 [Ceredigion, possibly the mother’s former employer] contacted the Education directorate in LA1 [Pembrokeshire], with a notification of a family with two children being educated at home.

“There is much known about the parents from agencies records (mainly health) and almost nothing about both children.”

“the practitioners involved with the family were very much focused on the health needs of the parents”

“The national and local practice based on the policies and procedures at the time did not advocate strongly enough the need for practitioners to work collectively across adult and children’s services. Vulnerable adults were not routinely seen in relation to their role as parents. “

At that time the national and local policy and guidance did not prompt practitioners to take this holistic family assessment approach.”

“had all practitioners shared their combined experience and knowledge of the family in a multi-agency approach, allowing all of the members of the family’s needs to be considered, it is possible the level of concern may have been raised and further enquiries initiated into the welfare of the children.” 

 

The Reviewer asserts that if parents refuse to cooperate, then “without evidence of significant harm none of the agencies had the right of entry to check on the children. “

Following from this belief, the Reviewer seems to be claiming that if ALL home educating parents had to allow people into their home as a matter of course, then if there WERE problems, over time, “evidence of significant harm” could be amassed and this could be passed to other agencies who could then “check on the children”.

This is a bizarre conclusion, which COMPLETELY IGNORES the failings of the two councils involved, where two social services departments had ALREADY been given information which should have prompted social workers to take a closer look.

Dylan Seabridge also had an older brother but there was no offer of support as a Young Carer.

“As the eldest child was eight years older it is possible he may have had caring duties for his younger brother and potentially his mother, when father was preoccupied or poorly himself…

The Review does note that multi-agency work should now be improving across Wales as a result of new legislation ie professionals WOULD now consider the IMPACT on children of parents’ mental health beyond immediate “safeguarding” risks whereas the Review seems to suggest this wasn’t the case 6 years ago.

Current guidance as a result of the newly implemented Social Services and Well-being (Wales) Act [implemented 2016] addresses this and advocates for a much more integrated partnership approach.”

As an aside, local authority officers and managers who were interviewed for the Review don’t seem to have mentioned the crisis in Pembrokeshire social services  during the period examined by this Review, which was so bad that the Welsh Government put in an Ministerial Board to oversee improvements (with a “final warning”  still needed in 2012.)

An inquiry into Pembrokeshire found  that “the absence of effective governance in relation to safeguarding and protecting children reflects the specific failures within the culture of the authority as a whole. The shortcomings with the authority’s arrangements to safeguard and protect children are longstanding and systemic. This is indicative of the deep-seated nature of these problems and failings within the authority.” 

Members of the Welsh Assembly had hoped that the Review would not be a whitewash (see 14.21 Urgent Question: Safeguarding Children in Pembrokeshire, 26/01/2016) with one AM saying “what has emerged since the inquest a year ago into Dylan’s death is that several opportunities were in fact missed by professionals who, perhaps, should have been more alert to the situation that he was in”  and another saying “it is time that authorities recognise that the first duty that they have is to protect the child, not to hide behind artificial county boundaries.” 

Media reports have focused on the home education angle.

This is the Press Release about the Review which was sent in advance to journalists but under strict embargo until 12 noon on July 8th. The first media reports didn’t have a link to the actual Review and all were hyperfocused on the home education angle with the Press and Public Relations Manager for Pembrokeshire Council promising “an opportunity for one-to-one interviews with the independent author of the Child Practice Review, Gladys Rhodes White, from 12 noon on Friday, 8th July, at County Hall, Haverfordwest.” 

The Press Release mentioned home education in the very first sentence and also referenced home education in the Review’s recommending a national register of home educated children “and that they are seen and spoken to and their wishes recorded on an annual basis.” 

What has received much LESS attention is the recommendation that professionals should look beyond the adults’ needs.

“The Review also calls for CYSUR [Welsh word for reassurance, also an acronym for Children and Youth Safeguarding and Unifying the Region, Mid and West Wales Safeguarding Children Board] to write to the National Independent Safeguarding Board to ensure there is widespread training for all practitioners working with children, adults and families on the implications of the new guidance for the Social Services and Well-being (Wales) Act 2014 to ensure that assessments on individuals also consider the wider family context, including the impact on parenting and the needs of carers.”

The author of the Review, Gladys Rhodes White, takes everything from the councils at face value, doesn’t probe “policy”, doesn’t see the context of failing children’s services, and concludes that the only way to put things right is for all home educated children to be interviewed every year.

It won’t come as a surprise that I take issue with this line. It seems clear to me that concerns were raised by at least two people in Ceredigion, initially with social services in Ceredigion and subsequently with Pembrokeshire social services, but when Ceredigion social services played it down as “not child protection”  Pembrokeshire social services – widely accepted as failing during that time – took no further interest. Home education registration would have made no difference.

Postscript 

http://www.assembly.wales/en/bus-home/pages/rop.aspx?meetingid=3616&assembly=5&c=Record%20of%20Proceedings#420620 Ministerial Statement July 12th 2016:

“the home-education element is just one part of this particular case…In terms of home schooling, I’ve already met with the Minister responsible for that decision, and we are, again, looking at the whole principle of well-being, about how that will look, and I’ll continue those discussions. I had a team meeting today, across the departments, to start looking about what we are going to do about this particular case, and what the lessons learnt will be, and how we will interpret them, in terms of legislation or otherwise, if we need to do that…, my personal view is that I don’t think a register will fix this problem. It may be part of a solution, but it’s not the only fix here and that’s what we’ve got to understand better to make sure that Dylan’s scenario doesn’t happen to any child again”  Carl Sargeant, Cabinet Secretary for Communities and Children

(my emphasis)

 

 

 

 

 

 

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11 thoughts on “Dylan Seabridge Child Practice Review July 2016

  1. Angela Horn

    As the family were known to be home educating, they were already registered, so a register would not have affected this. I think the push here is for meeting the children. The argument would be, I think, that social services only had one opportunity (or few opportunities) to get this right, because the children weren’t coming into contact with health or education staff. “Registration” is a trigger word for home educators, but I think it may be a distraction in this case as the real change being called for is monitoring of child welfare.

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  2. ANON

    Sadly what happens is everyone passes responsibility on to another person. Children welfare as the previous reply highlights is the key. This review deflects from the failings of the professionals and the system. It would not have mattered if he was in school or not. The other high profile cases demonstrate that children who go to school, showing obvious signs of malnutrition/neglect etc. yet no one raises the alarm.
    A register would not have meant anything. There is no guarantee that just because a name is on such a register than anyone follows it up.
    The failings come when individuals fail to follow the procedures already in place to protect vulnerable people including children.

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  3. ANON

    The Reviewer asserts that if parents refuse to cooperate, then “without evidence of significant harm none of the agencies had the right of entry to check on the children. “

    THIS POINT IS CRITICAL… This would apply whether a child is in school or not.
    How is a yearly check going to ‘amass’ evidence. Who is meant to do this type of check anyway?
    The lack of involvement with health or other similar professionals should of triggered further assessment.
    The system and people involved in it failed this little boy and that is a tragedy. Those same people failed his parents as well by failing to ensure the mother received the correct help for her mental health issues. Mental health issues deserve the same treatment as physical health issues.

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    1. Fiona Nicholson Post author

      I had to read that bit several times in the Review. It seems to hyperfocus on “right of entry” and this would something like be the police eg being called out if the parent had been spotted on high ledge. It’s a melodramatic situation which is very confusing to get mixed up with a social worker being empowered to investigate concerns.

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      1. ANON

        The key is the “evidence of significant harm”. It would correct following of procedures under section 47(child protection) enquiries.
        The over attention to “home education” in this case is deflecting away from the fact that people had concerns about the mother’s mental health yet did not do anything. That is very sad.

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  4. Fiona Nicholson Post author

    Sorry I thought I had accidentally liked this so I clicked on like to toggle it off, and then it came on. I’m not touching it again. But obviously I didn’t “like” my own comment on purpose!

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  5. ANON

    Exactly but if they had of helped the mother then perhaps the family would have received the correct help and support. People are understandably scared of social workers. They are not seen in a positive light. Maybe the father was overwhelmed and scared. It just didn’t know what to do for the best.
    It is a tragic case which flags up so many issues including the stigma surrounding mental illness, the assumption that it is someone else’s job, and the failure to follow polices and procedures is what time and time again is what goes wrong in these cases.
    Home education becomes the scapegoat……..
    Maybe they had been let down by those in the system in the past so were understandably reluctant to engage with health etc…

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