"Between October 2009 and March 2010 there were 7 separate incidents… whereby the local authority should have responded to incidents regarding the children by making enquiries to enable them to decide whether to take action to safeguard or promote the child's welfare. The failure to take such action and to hold strategy meetings between the Police, Children's Social Care and other key agencies was a significant feature in this case."
12 year old Tia Rigg was murdered by her uncle in 2010, right in the middle of the fall-out from the scandal surrounding the failure of Salford Children's Services.
Jill Baker, Head of Salford Children's Services had recently been sacked; OFSTED criticisms of Salford Council's failure to protect vulnerable children were piling up – and the reassuring words of Salford Council Leader John Merry were still ringing around the corridors of the council chamber… "We've made considerable improvements and addressed particular issues and concerns"…
And then a 12 year old girl was murdered who was known to Salford Council as vulnerable - and was within the very category that should have seen these "considerable improvements" made. The Salford Safeguarding Children Board serious case review, released today, makes some severe criticisms of Salford Council and related agencies…
The Review states that "Although there was a significant amount of historical information* known about Adult A (Tia's mum), "that information was never adequately analysed and used appropriately to help gain an accurate understanding of the level of risk to the children". Neither was that information always shared between agencies… "This effectively meant that there was only a partial understanding by many agencies about the full extent of problems within the family".
The Review adds that "There was substantial evidence that the child protection plans that were in place in 2008-2009 were ineffective and never fully implemented. Consideration should have been made at this time to safeguarding the children through legal proceedings."
It gives the examples of "incidents relating to the children being left at home alone, increased levels of violence in the community, out of control drug use and increased examples of disturbed behaviour at school by Child H (Tia)" .
The most damning paragraph in the Review states that "Between October 2009 and March 2010 there were 7 separate incidents when Section 47 Enquiries under the Children Act 1989 should have been undertaken whereby the local authority should have responded to incidents regarding the children by making enquiries to enable them to decide whether to take action to safeguard or promote the child's welfare. The failure to take such action and to hold strategy meetings between the Police, Children's Social Care and other key agencies was a significant feature in this case."
It adds that "The combination of drugs misuse, domestic violence and parental mental health alongside historical factors should have led to a much higher level of concern than was seen in this case."
While the Review concludes that "the death of Child H was not predictable or preventable" it adds that "the ongoing harm to Child H because of the poor quality of care offered by her mother was both predictable and preventable, if Child H (and her siblings) had been removed from their mother's care in 2008-2009 through legal proceedings".
In other words, there was a complete failure of Salford Children's Services in safeguarding Tia Rigg. And this after all the reassurances coming from Salford Council in the wake of the Demi Leigh Mahon case and constant OFSTED criticism of Salford's safeguarding being `inadequate' (see here).
Jill Baker, Head of Children's Services, was sacked before this tragedy happened (see here). The accountable elected Lead Member for Children's Services , John Warmisham, has subsequently been `moved' to Adult Services, and a few months after this case came to light, Michael Kemp, head of Salford's Child Protection Service resigned (see here)
Yet, throughout all the safeguarding disasters at Salford Council one person with direct responsibility is still in post – Chief Executive Barbara Spicer.
Back in 2006, Salford Council drew up a list of exact roles and responsibilities for Safeguarding Children, and included the role of the Chief Executive…
"Make sure statutory inter-agency arrangements are in place…and ensure there is an open culture between local agencies and good direct communications between senior managers so that they accept and address concerns brought to their attention" (click here for further information)
The Serious Case Board makes 105 recommendations for improvements across children's services, ranging from Salford Children's Social Care to Greater Manchester Police, to Salford Education to Great Places Housing Group. Many of the main recommendations cover the specific failures associated with Salford City Council Chief Executive's exact roles and responsibilities.
We asked Salford Council if Barbara Spicer will be resigning. It has been met with no response.
The Salford Star last called for Barbara Spicer's resignation in December 2009 after Jill Baker was sacked (see here) in the aftermath of the Demi Leigh case. How many more cases of inadequacy will it take before this highly paid official (see here) takes some responsibility?
Gill Rigg, Chair of Salford's Safeguarding Board said: "This report does highlight a number of missed opportunities to help this child and it is important all of the agencies involved learn from this so they can better protect children living in Salford.
"In Salford we have already implemented a multi agency action plan that is being monitored by the Safeguarding Board to ensure these changes happen. A lot has already been achieved but we are continuing to work to ensure all children living in the city are fully protected from harm."
John Merry, Leader of Salford City Council added: ""This is a tragic case and our thoughts remain with this child's family. No-one could have predicted what happened to her when she visited her uncle that day, but we know more could have been done during her childhood to support her in coping with her unstable home life.
"However, even if this child has been removed from her home, she would not have been prevented from having contact with her family as there was no indication she was at risk from her uncle and therefore no reason to stop her having access to him and other members of the extended family. Removing her from her home would therefore not have prevented her death.
"The serious case review has made a number of recommendations on what we need to do to improve safeguarding in Salford. We have already taken these recommendations very seriously and the feedback we have had from Ofsted is that we have a good grasp of what improvements needed to be made and we are making good progress with implementing them. This was further supported by a recent unannounced inspection from Ofsted which showed a marked improvement in this area.
"But I know we still have work to do and we are committed to continuing to improve the service we provide to protect children and young people living in Salford."
See the Executive Report of the Salford Safeguarding Children Board into this case: click here
* Historical information…
• Tia was placed on the Child Protection Register in a different local authority before she was even born, and was later, firstly categorised as "likely to suffer neglect", and then "likely to suffer physical abuse" due to her parental background.
• Tia was deregistered before she moved to Salford but a first visit by a Salford health visitor in 2000 revealed that her home had "no cooking facilities" and "no heating".
• In mid 2008, Tia's mother tried to commit suicide three times in front of her children. Tia and her three siblings were put on the Child Protection Register and Tia was looked after by her aunt for a few months but was returned to her mother after a "conflict". This was supposed to be "an emergency measure" but "an absence of appropriate planning meant that this move became permanent".
• In May 2009 a Child Protection Review Conference made the decision to discontinue protection for the children… "This was a flawed decision and based on inaccurate information given to the Review Conference about the progress that Adult A (Tia's mum) was making".
• Throughout 2009 the Review states that there were … "Incidents of violence between family members, Continued problems with Adult A's illicit drug use, Incidents of the children being left `home alone', Child H (Tia) being given too much responsibility for looking after the younger children, Accommodation problems and Adult A's lack of cooperation with agencies"