More training is needed for staff involved in the care of children, the author of the serious case review says following Ayeeshia-Jayne Smith’s murder, as it is highlighted greater confidence is needed to deal with difficult situations.
Chris Cook, independent chairman of the Derbyshire Safeguarding Children’s Board, led the serious case review and published the findings which laid out nine recommendations for the agencies who came into contact with Ayeeshia-Jayne, known as AJ to her family.
A wide variety of services took part. Derbyshire County Council was described as a key service by Mr Cook. The health community and the police service also took part in the review and helped build a detailed picture of what happened in the case of the 21-month-old who was murdered by her mother, and what can be done to ensure it does not happen again.
Ayeeshia-Jayne was killed by her mother, Kathryn Smith, at their home in Britannia Drive, Stretton, after they moved there from their home in Alexandra Road, Swadlincote.
Smith stamped on her daughter, causing a tear to her heart and cardiac arrest. It was just one of several instances when Ayeeshia-Jayne had been injured; from the cut lip said to be caused by her falling in the bath, to the more serious febrile convulsion.
The report stated that Smith seemed to be the primary focus of the agencies and more could have been done to note Ayeeshia Jayne’s father’s concerns about Smith.
Mr Cook said: “It is important with fathers and male partners that communication is important; that we mustn’t keep them in the dark. We need to engage with fathers.
"In this case the focus of the attention was too much on the domestic abuse vulnerability to the mother and not on AJ.
"When focus of attention is on mother then Ayeeshia-Jayne wasn’t being supported properly by the agencies and that is very important. That does impact on children.”
He hopes the report will lead to social workers and medical staff having more confidence when dealing with these difficult situations.
He said: "Training is really important for frontline practitioners. We need to give them the confidence to deal with difficult and complex situations and the key agencies have implemented training programmes.
"There is a need for a more authoritative approach by social workers when dealing with difficult families."
The report says there were missed signs of "disguised compliance" which allowed Smith to manipulate social workers and health professionals into believing everything was fine at home.
Mr Cook said: “The trial judge in this case described the mother as devious and manipulative and I think at times the social worker was actually persuaded by her.
"There is actually a need to stand back from that and be more authoritative using an evidence base and actually controlling a situation better than it was controlled.
"Disguised compliance is manipulation; people perceive the parent is doing what they expect them to do, but actually disguising that.
"So on the surface everything looks like it is working well but underneath it isn’t and that’s why you need a more authoritative approach to delve deeper into those situations."
As a result, changes have been implemented, giving practitioners the confidence to deal with difficult and challenging families.
He said: "There are those families around, and it is important that staff are able to deal with them and it isn't easy.
"It is finding a balance so relationships between social services and parents don’t break down because that is even worse for the child."
Featuring heavily in the trial was the relationship between Smith and her social workers and community health visitors who would often find that surprise visits, and even pre-arranged visits, would never materialise as Smith wouldn't answer her phone or would reply to a text at 1pm saying she had been asleep.
Mr Cook called these occasions ‘triggers’, saying: “The lack of engagement that should be seen as a trigger and more professional curiosity is needed in those cases to understand why is the mother not engaging with us?
"Why is she not going to her GP? Why are they not attending hospital appointments? All those issues.
"Dealing with safeguarding children is like building a jigsaw and building all those key pieces in place. When some of those pieces are missing that is when children are harmed so it is important to have a full picture of what is going on.
"Some pieces were missing from the case at different times."
Mr Cook explained that although Ayeeshia-Jayne made good progess under the Child Protection Plan and went into foster care, "it was in the latter stages that things began to escalate".
Ayeeshia-Jayne was also under a supervision order, which Mr Cook recommends should walk hand in hand with a child protection plan to make it a more robust concept.
Mr Cook also said more professional curiosity was needed by medical staff at Burton’s Queen’s Hospital following the diagnosis of an apparent febrile convulsion; this is often widely assumed to be the first time Smith attacked her daughter.
He said: "All the pieces of the jigsaw need to be in place and people need to look at the whole picture. If they are looking at things in isolation then they are not actually going to make the right professional decision.
"There were some minor injuries but they weren't looked at in isolation and I think they should have been looked at in the rounder picture and someone having an overall picture of what was going on."
Asked why the febrile convulsion was not looked into, Mr Cook said: "I think medical staff had a diagnosis. It may have been an assumption at times but it is a difficult call.
"They have to make a professional judgement but what we need to do is give them the confidence to deal with these matters, to look at the wider picture and be curious."
One of the final findings stressed how important suitable housing was in the cases of children such as Ayeeshia-Jayne.
He said: "Housing is important to families and their stability. So housing issues should always be considered. If people are being moved from one premises to another or even becoming homeless then things can escalate and problems can seriously occur."
Mr Cook revealed that Ayeeshia-Jayne’s family had seen the report, saying: "They are still traumatised and that is understandable. They understand that it is not about apportioning blame, it is about improving practice and that is the role of the serious case review.
"They have all been affected by the outcome of this case, a tragic case. Clearly the family are very traumatised but so are staff that dealt with the family.
"The most important thing about this report is to have that wider picture and not just focus on what did happen on the domestic abuse and vulnerability of the mother, but to have the wider picture of the family."