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Monday, 22 March 2010

Apologies over the loss of three young lives

Written by This Is South Wales
POLICE and council officials have apologised for the failures in the care of three children who died aged 16. The details of the circumstances leading to the deaths of Carly Townsend, from Llanelli, Kyle Bates, from Hafod, and a Swansea school pupil Chloe Nicole Davies were revealed yesterday.

All three were just 16 when they died.

The deaths of Carly and Kyle were both drug- related, while Chloe committed suicide.

Because all three children were known to the authorities and had been in contact with care agencies, their deaths triggered a serious case review.

While the full reports have not been made public, yesterday afternoon the Swansea Safeguarding Children Board released the executive summaries — triggering apologies from Swansea Council and the police.

The summaries highlight failures to deal with the needs of the three children. They found that agencies involved had failed to properly communicate with one other.

Steve Walker, Swansea Council's Head of Child and Family Services, said: "The deaths of these three teenagers in 2007 and 2008 were a tragedy, and we would like to express our sincere condolences to their families at this difficult time.

"We deeply regret that at the time social services were involved with these young people, there were shortcomings in our child protection procedures.

"We believe that these shortcomings led to errors of judgement in the management of these cases, and we apologise unreservedly for this.

"We fully accept the recommendations in the serious case reviews, and I would like to reassure people that over the past two years we have taken a range of actions to help minimise the risk of this happening in the future.

"There is now better information-sharing with partners, so that all of the agencies have a more complete picture of the relevant issues before deciding collectively how best to protect a vulnerable child.

"We have more robust child protection procedures in place, more social workers, and better supervision and training, including how we engage better with those families who are reluctant to accept our support.

Chief Superintendent Mark Mathias said: "The deaths of these three young people touched the lives of many people, and our thoughts today are with the families and friends who lost loved ones in such tragic circumstances.

"South Wales Police fully accepts the recommendations made in the serious case reviews, but I would like to reassure the public that many of them have already been addressed through enhanced training for officers and new referral processes which are more robust and subject to more scrutiny than ever before.

"Drug misuse features in two of these tragic deaths, and Swansea is leading the way in Wales in establishing innovative measures to tackle this issue, which affects communities across the country."

THE CASES:

CARLY TOWNSEND died while living with drug-abusing members of her family in Llanelli on May 3, 2007.

Her death came just 10 days after her release from Neath's Hillside Secure Unit — and just hours after being visited by a social worker.

The 16-year-old's mother and half sister — Andrea Townsend, aged 46, and Gemma Evans, aged 25 — were convicted of her manslaughter through gross negligence and jailed for a total of six years.

But Swansea Council had been responsible for Carly's care for the previous decade, since a court had made her the subject of a care order while she was living in the city, and the report catalogues a list of failings from a host of agencies and bodies.

In particular it highlights failures in communications which meant vital information was not known by people who needed to know it.

The probation service had considerable involvement with Carly's mother and sister, both of whom were long-term criminals and drug users, but the report says there was a lack of "effective engagement" between probation and other agencies, and Carly's probation officer was unaware that she was to be released from secure care and returned to her mother.

The report also says the exchange of information between the youth offending team and Swansea social services was "insufficient". and that as a consequence the team's judgements were made without knowing all the facts. Information held by criminal justice agencies about Carly's family and their friends was not available to social services.

Meanwhile the file in her secondary school contained no information from her junior school, and nothing about her status as looked-after child, and insufficient communication between school and social services, meant the school was "unaware of many of the problems as they developed."

The report found that though there were good links between South Wales Police and Dyfed-Powys Police and Swansea social services, there were circumstances in which procedures had not been followed. and there were failures to make appropriate child protection referrals.

The report also highlights occasions when referrals between health services and social services were not made.

The report says that the actions of social services were mostly driven by events or by what the teen wanted, and were "not based on careful assessments". It says Carly had learned to influence decisions "by threats or use of reassuring words."

CHLOE NICOLE DAVIES was just 16 when she committed suicide in April 2008.

At the time she was living in a Swansea care home. An inquest into her death heard that she had never got over the death of her father when she was nine.

A serious case review concerning her death found that agencies that were in contact with Chloe were making assessments, "but not always sharing them appropriately with partner agencies."

The review states that Chloe "and her family had been known to and received services from a number of agencies both statutory and voluntary throughout her life.

"There were a number of areas of concern ... including ongoing neglect, self harm, substance misuse, problems at school and unresolved emotional issues."

Chloe had a history of self harming and had started cutting herself at age 12 and by that time had also been brought home drunk by police.

The report states that "she continued to abuse alcohol to the extent of needing several admissions to A&E and referrals to her General Practitioner, but there was a lack of engagement with services offered."

The report also states that "a theme running throughout the case was the failure of agencies to adequately take account of the child's voice, or to give sufficient weight to her communication of her feelings through anger or self-harming behaviour.

"She frequently articulated her unhappiness but insufficient account was taken of this in planning. However, she frequently rejected the help she was offered."

A number of themes were identified during the serious case review.

The report states: "Many indicators for neglect which were persistent throughout agencies involvement were not adequately and actively addressed.

"There were occasions of missed opportunity due to the failure of a timely response to concerns where the threshold for making a referral to social services was met, but not made.

"Agencies were making assessments within their own agencies but not always sharing them appropriately with partner agencies. This meant that other assessing agencies did not have full information on which to base their assessments."

KYLE BATES

THE tragic case of Kyle Bates contains serious failings to tackle the problems he faced for almost his whole life.

Shortly after he was born he was given to a neighbour to raise.

After moving to Swansea aged 11, he never attended school and was not registered with a doctor.

He was repeatedly arrested and had been referred to Social Services. On a number of occasions he told police that he had been self harming.

However, public agencies were not involved with Kyle in the period before he died aged 16, from complications after taking drugs.

A number of referrals made to socials services were not acted on correctly.

The report, which refers to Kyle as Child D, issued yesterday states: "The Review found during this period the social work staff and their immediate managers failed to apply the appropriate procedures or standards of professional practice in carrying out their duties and responsibilities towards Child D.

"Referrals were not properly considered and acted upon. Judgements were not properly reached and assessments of risk were inadequate or not carried out at all. No enquiries were carried out into the possible underlying causes of the child's presentation.

"Child D's case was closed on several occasions without enquires being carried out. The serious impact of chronic failure to receive education was not recognised."

Speaking after the serious case review was released yesterday, Swansea Council's head of child and family services, Steve Walker said: "Between 2002 and 2005, I think there were a number of concerns expressed to social services that were not always acted upon appropriately."

While the exact number of times Kyle was referred to social services is not included in the executive summary made public yesterday, Swansea Council's director of Social Services, Chris Maggs, said the number "doesn't stop the fact that appropriate action wasn't taken about those referrals."

He added that improvements had been made in the way social services deal with these issues.

He said: "The process now wouldn't be the same today as it was during 2002 to 2005."

Kyle lived in Newport until October 2002 when the family moved to Swansea. However he was not registered to attend any school, nor was he registered with any GP.

Despite involvement of the Swansea Education Welfare Service, including arranging home tuition, referral to a specialist unit, and prosecution of his carer, he never again attended school.

From early in 2003 he began to be involved in criminal activities, and received a Police Reprimand which was notified to the Youth Offending Team.

During 2004 and 2005 he was repeatedly found out in the early hours of the morning by police, was arrested for theft and, breach of police bail and was involved in violent acts, confrontation and obscene language.

In total he was arrested 24 times for incidents including assault, criminal damage and theft.

He was taken to hospital by ambulance after taking cannabis, amphetamines, ecstasy and excess alcohol, found by police unkempt, dirty and smelly, and with no money.

David Spicer, the independent author of the reviews, acknowledged that Kyle had refused to accept the help offered to him by the authorities.

He said Kyle "was determined to avoid any involvement with public agencies and much of what happened in his life remains unknown."