March 1981 – May 1990 Q aged 0 to 9
Throughout the 1980's there is a catalogue of injury and incidents experienced by Q and her siblings, that appears not to have been brought together, investigated or acted upon coherently. In retrospect, all of this information presented a situation demanding intervention, notwithstanding the attitude and avoidance of engagement by the parents.
Period 3 May 1990 – December 1991 Q aged 9 to 10
Q refused to go home after school in May 1990 when she was 9 years old.
For a child to take such a step and to maintain it for several months takes an enormous effort and reflects the great anxiety and fear she felt for herself and her younger sister,
D4.
While in care away from the family home Q spoke to professionals, acted with disturbed behaviour in the foster homes and broadly maintained her account of abuse and threats, the substance of which accorded with the known history of events in the household.
During Q's period in the care of the local authority new children's legislation, namely the Children Act 1989, was introduced into practice from October 1991.
In the weeks before she went home for a trial period in September 1990 there was considerable disagreement and discussion in the agencies about the best course of action for Q.
The Guardian Ad Litem, possibly in line with his reading of the new legislation, took the view that Q should return home, recommending to the Court that the Care Order be revoked.
The Court's decision was to revoke the Care Order.
This was probably the most damaging decision taken during her history of engagement with statutory authorities.
In Q's view, and probably that of her sisters, it is likely that this failure to listen to and safeguard them determined their view of their parents' power and invulnerability, and, especially for Q, of the inadequacy of the authority figures to listen to what she was saying and to act in her best interests.
Period 4 December 1991 to July 1994 Q aged 10 to 13
On 3 June 1992 the Supervision Order lapsed and in July 1992, the case conference noted that the social worker found it hard to arrange times to meet with the family and when she visited, after the supervision order had ended, she was refused access to Q.
The decision of the meeting was to remove Q's name from the Child Protection Register.
It should be noted that even before the Supervision Order had expired in June 1992, the parents had ceased their co-operation with social services.
The decision in July 1992 to remove Q from the Child Protection Register was surprising, given her attendance at the Accident and Emergency department the previous week and the extreme difficulty faced in working with this family.
Throughout these years there are reports for both children that show a continuing pattern of abuse within the household that the authorities were unable to penetrate and from which they were therefore unable to protect these girls.
Period 5 July 1994 to January 1995 Q aged 13
This period marks the beginning of Q's demanding behaviour and management activities that continued in various forms over the next few years.
Statutory procedures were followed and appropriate assessments sought, placements with foster carers assessed, and preparation made to cope with Q's behaviour, which was all thought to be in Q's best interests. However, in November 1994 it could be argued that a residential therapeutic setting should have been more actively pursued in line with the assessments of need and the clear breakdown in the foster placements.
Period 6 January 1995 to March 1996 Q aged 14
Q was now offending on a regular basis. She had become dangerous and violent. She could be very threatening and could seriously frighten staff, which increased the anxiety in, and risk for, those responsible for her care. This was compounded by the serious risk of self-harm that Q posed.
The emphasis remained on finding stabilising and tolerant therapeutic accommodation that would enable her to develop self-esteem in a safe setting. However by this time it was too late as she was too old for most therapeutic settings to accommodate her.
Period 7 March 1996 to March 1997 Q aged 15
During this year Q's behaviour became more demanding and there was a feeling that the agencies had run out of options. There does not appear to have been a coherent, continuing, shared interagency care plan, but rather a series of reactions to crises or to legal requirements, such as Q leaving secure accommodation.
There was considerable assessment activity with insufficient indication of effective follow-through, even granted the serious difficulties presented in this case.
The placement of Q at home after she went home for Christmas in December 1996 appears to have been a pragmatic move as no other care could be provided for her, reflecting the paucity of suitable settings nationally.
This view is reinforced by her subsequent placement in supported lodging and then bed & breakfast accommodation before her 16th birthday.
Period 8 March 1997 to March 1998 Q aged 16
!! ...During this year Q was in a succession of supported accommodation and B&B settings.
She worked occasionally as a chambermaid.
She engaged in drug and solvent use, had overdosed and her offending behaviour was increasing.
This level of unsupported accommodation for a girl known to be self-harming and potentially dangerous to others was ill-advised, even given the immense placement and management difficulties presented to the social and health care agencies.
She was not mentally ill, and therefore could not be "treated" by mental health services. She was the wrong age for some of the communities, and she undermined some of the placements that were available to her in spectacular ways.
Period 9 March 1998 to March 1999 Q aged 17
In June, Q stabbed an adult male, S, in the arm.
She appeared before magistrates and was then remanded to Holloway Prison, charged with Grievous Bodily Harm, (GBH) and possession of an offensive weapon.
This year was marked by Q's increasingly dangerous behaviour, both to herself and to others.
She underwent further assessments in connection with the offence of GBH and remanded to prison, with a potential care path identified through a possible placement at the Cassell Hospital, a NHS mental health hospital.
However the Cassell was not prepared to accept her immediately, following their assessment. There was no clear alternative care plan for her.
The Pre-Sentence Report had linked the offence to alcohol and substance misuse, referring only to "turbulent family relationships" and not to the substantial abuse the Inquiry panel consider she had experienced in her family.
Within two months of the order being made, Q attacked her sister and threatened to poison her mother.
Social Services referred her to an adult psychiatrist, who began to work with her and, on learning of Q's thoughts about causing harm to children, considered that she needed forensic psychiatric intervention.
East Sussex, along with other areas, did not have in place a Dangerous Persons Panel or similar interagency forum in 1998 to which Q could have been referred, and which would have enabled an agreed risk assessment to have been prepared.
Such interagency forums are now in place, (since 2001), which would now automatically consider cases such as Q's. The absence of such a forum, or its equivalent, made tracking Q's activities harder
Period 10 March 1999 to March 2000 Q aged 18
At the beginning of May Q assaulted a woman neighbour and was subsequently charged with Actual Bodily Harm.
She was remanded in custody in mid-May for breaching bail conditions and in early June she was sentenced to 9 months imprisonment at Bullwood Hall, a Young Offenders Institution.
Q was released from prison under Licence at the beginning of October and although a National Children's Home worker became aware during October that Q was again seeing S, this was not passed on to the probation officer or social services.
This year saw a repeat of Q's previous behaviour pattern.
However the differences are that the risk posed was escalating as her propensity to violence increased and, notwithstanding the number of professionals and agencies involved, the level of monitoring and contact decreased.
To some degree she was 'lost' to the local services while in Bullwood Hall, especially as she was expected to go to London on her release.
It is as if, at each phase the agencies knew the background but there was no significant progress in how they would work with Q, the strategies they would use, the objectives of their engagement with her or the main resources they would seek to obtain to contain her behaviour.
The difficulties that she and her family presented were not underestimated and there is no doubt that this was a very challenging case, and also that professionals involved with her showed commendable tenacity and tolerance in their work.
However at each phase it felt as if the professionals were chasing the game which was played at Q's pace.
Similarly, her transition out of care to adulthood and the transfer of responsibility from Social Services to the Probation Service was not managed well. Notwithstanding the efforts of the individual workers, this process lacked coherence and strategic intent.
Comment
|