DANIELLE REID Independent Review Into the Circumstances Surrounding Her Death i Author of Report Dr. Jean Herbison M.B.Ch.B MRCP FRCPCH DCCH Consultant Paediatrician Lead Clinician for Child Protection Greater Glasgow NHS Board ii “When I woke they did not care, Nobody, nobody replied” “When my silent terror cried, Nobody, nobody replied”. Louise MacNeice (1907-63) iii TABLE OF CONTENTS PAGE Part I INTRODUCTION Introduction 1 Methodology 3 Remit 6 Acknowledgements 8 Part II CHRONOLOGY Highland Child Protection Committee Chronology 9 Some Initial Comments on Chronology 16 Part III SUMMARIES OF KEY WITNESS STATEMENTS A. The Family’s Story Family Member 1 22 Family Member 2 24 Family Members 3 & 5 26 Family Member 4 29 B. Anonymised Witnesses To Police Inquiry From The Crown Area 31 C. Social Work Social Worker 1 33 Social Worker 2 35 Social Worker 3 37 Social Worker 6 39 Social Worker 9 42 Social Worker 10 43 Social Worker 7 50 Social Worker 8 52 D. Police Synopsis of Information recorded by Police on “Impact” System 55 Police Officer 1 57 Police Officer 2 59 Police Officer 3 63 Police Officer 6 66 Police Officer 7 67 iv Police Officer 11 70 Police Officer 12 73 Police Officer 14 78 Police Officer 4 79 Police Officer 5 83 Police Intelligence Information 85 E. Education Nursery Staff Member 1 86 Nursery Staff Member 2 88 School Staff Member 1 89 School Staff Member 4 91 Education Staff Member 5 92 F. Health The Child’s Journey Through Health Services 94 Further Detail in Relation to the Child’s Genetic Condition and Past Medical History 97 Health Professional 1 98 Health Professional 2 99 Health Professional 4 101 Health Professional 10 103 Health Professional 11 108 Health Professional 8 110 Health Professional 3 112 Health Professional 7 114 Health Professional 5 116 G. Reporter to the Children’s Panel 118 Part IV CONCLUSIONS IN RELATION TO REMIT 1st Point 119 2nd Point 121 3rd Point 123 4th Point 124 Part V ANALYSIS AND RECOMMENDATIONS Inter-Agency 131 Social Work 142 Police 150 Education 158 v Health 166 Children’s Hearing System 175 Similarities Between Independent Inquiry Findings In Recent Years 179 Author’s Final Comments 183 Summary of Recommendations 184 Part VI APPENDICES AND BIBLIOGRAPHY 193 vi PART I INTRODUCTION Danielle Reid aged 5 years was murdered in early November 2002. The level of violence involved and the way in which her body was disposed of shocked those who knew and loved her and anyone who heard the details throughout the media coverage. There was a call for a Public Inquiry into the circumstances. Internal management reviews were conducted by the Council, the Health Service and Police. After further debate, Highland Child Protection Committee commissioned this Independent Review into all the circumstances surrounding her death. In Scotland Child Protection systems are still responding to recommendations of Child Death Reviews over the past 4-5 years. Firstly, there was the death of Kennedy McFarlane in Dumfries & Galloway in May 2000. Secondly, the death of Carla Nicole Bone took place on 13th May 2002 in Aberdeenshire. More recently the death, by shaking, of baby Caleb Ness occurred on 18th October 2003 in Edinburgh. In England, Lord Laming has published his report into the death of Victoria Climbié, who died on 25th February 2000. His recommendations were the most detailed in relation to system change and professional practice throughout the United Kingdom. The reader of this report in relation to Danielle Reid will be struck by similarities in all these reports. The findings reveal serious gaps in service provision to the vulnerable and at risk child. There has been an identification of lack of robust systems in place early enough to protect Scotland’s children. Each professional/agency appears to have a subjective view of the threshold for appropriate intervention and support to children. Unfortunately, senior managers often await detailed Scottish Executive Guidance on issues rather than moving speedily to implement robust systems which would provide more protection to children in their local settings. Professionals, Agencies, Neighbours, Communities all appear to grapple with the same difficult issues. Some examples are:- 1. Is it my role to tell someone else about my concern(s) for this child? ……… surely someone else will do it? 2. This is not my business to intervene in family life – or is it? 3. If I do report something …..surely I’ll only punish an already vulnerable parent? 4. If I tell, my neighbour/boss/manager will think I’ve gone too far and will not support me? 5. I don’t understand the law – e.g. the Data Protection Act …. so I better not give the information to anyone 1 There is little doubt that the violent death of this 5 year old girl was not directly preventable by any of the individuals concerned. Nevertheless, during my investigations it has become clear that there are major single agency and inter–agency system failures, which could lead to continuing high-risk situations for children in the future. These system failures need to be addressed urgently and regularly audited in future. It has also become clear during my review that a child matching the description of Danielle, living in the Crown area of Inverness was in the full view of some community members. The little girl was seen to enter establishments in her nightie late in the evening and, on occasion, was returned back by another adult to her mother’s door. There must be more meaningful systems (Ref. It’s Everyone’s Job to Make Sure I’m Alright, Scottish Executive, 2002) in place to facilitate alerting of agencies to such a level of vulnerability. The Scottish National Audit and Review stated that it is everyone’s responsibility to ensure the protection of children. This means every professional within every agency, mainly working with adults or children and families, but also every human being living in their own local community. I do not believe the risk to children can possibly diminish without a change in our thinking about vulnerable children. This must be led by the Scottish Executive and debated in the Scottish Parliament. It requires in my view, intensive and difficult questions to be asked of us all and potential change in legislation. Do we in Scotland wish openness and transparency about the needs of our children and a culture of alertness to every child’s needs and vulnerabilities, rather than inappropriate misplaced defensiveness about “intrusion” into family life? Are we really wanting professionals to intervene at the earliest stages of vulnerability, when indeed they must? Are professionals, in future, going to be able to share information early, freely and appropriately both within and between agencies in the best interests of children? If we all do not share in the early detection and support of Scotland’s vulnerable children, then the consequences of their subsequent neglect and abuse will re-visit us for many generations to come. 2 METHODOLOGY “Part 8” Reviews as described in Working Together to Safeguard Children (DoH 99) are embedded in legislation in England and Wales. There is currently no such legislation or nationally standardised process for these reviews in Scotland. This review is therefore based primarily on the Part 8 Review Structure. Aspects of methodology are detailed below:- Purpose of Reviews The purpose of case reviews carried out under Department of Health guidance (known widely as “Part 8” reviews) is to: Establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children; Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result; And as a consequence, to improve inter-agency working and better safeguard children Individual Management Reviews The Department of Health guidance requires each individual agency to carry out a management review, as a first step. Once it is known that a case is being considered for review, each agency should secure records relating to the case to guard against loss or interference. The aim of management reviews should be to look openly and critically at individual and organisational practice to see whether the case indicates that changes could and should be made, and if so, to identify how those changes will be brought about. Management review reports should be accepted by the senior officer in the agency who has commissioned the report and who will be responsible for ensuring that recommendations are acted upon. The agencies in this case all carried out reviews shortly after Danielle’s death. Individual Agency Report The guidance proposes the following outline format should guide the preparation of management reviews, to help ensure that the relevant questions are addressed, and to provide information to Child Protection Committees in a consistent format to help with the subsequent preparation of an overview report. The questions posed do not comprise a comprehensive checklist relevant to all situations. It is recognised that each case may give rise to specific questions or issues which need to be explored, and each review should consider carefully the circumstances of individual cases and how best to structure a review in the light of those particular circumstances. Agencies are however expected to deal with the following questions: 3 "What was our involvement with this child and family?" Construct a comprehensive chronology of involvement by the agency and/or professional(s) in contact with the child and family over the period of time set out in the review’s terms of reference. Briefly summarise decisions reached, the services offered and/or provided to the child(ren) and family, and other action taken.