Predictable and preventable: Gove rejects report on Edlington child attacks and orders new inquiry

The Department for Education this morning published a “redacted” version of its full serious case review into the brutal and “preventable” attack on an 11-year-old and a nine-year-old by two brothers, aged 10 and 11, in Edlington, near Doncaster, in 2009.

The executive summary of the report was published by Doncaster Council in January 2010 and prompted a political row over whether to publish the full version.

The coalition Government made a commitment in June 2010 to publish serious case reviews (SCR) in full. Since then, reports into the deaths of Baby P and Khyra Ishaq have been made public.

Mr Gove said: “The redacted serious case review overview report published today does not meet my expectations.

“It is an example of how the current model of SCRs is failing.

“It documents everything that happened but with insufficient analysis of why and what could have been done differently.

“In the future, we want SCRs to focus on why professionals acted the way they did, and what was getting in the way of them taking the right action at the right time.”

The sadistic torture of the Edlington boys shocked the nation in the spring of 2009. The two brothers, who admitted the attack, were known to social services, the police and the education service. At the time of the attack, one was subject to a supervision order after he was convicted of battery and the other was on bail charged with actual bodily harm and burglary.

And in the days before the main attack, the brothers attacked two other youngsters in Edlington. Both boys were being looked after by the local authority and had been placed with foster carers.

In the attack, the brothers lured their victims to a secluded spot and subjected them to 90 minutes of violence and sexual humiliation.

The victims, who are uncle and nephew, were strangled, hit with bricks, made to eat nettles, stripped and forced to sexually abuse each other.

The older boy was seriously injured when a piece of ceramic sink was dropped on his head.

In court, the younger brother told how they stuffed socks into their victims’ mouths “to stop their screaming”.

Later, he said, they could not find any more missiles to throw at the stricken children, “so we kept stamping on ‘em and kicking ‘em”.

The older victim told his battered and bloodied friend, “You go and I’ll just die here,” as he lay horrifically injured at the bottom of a muddy ravine.

The attackers were jailed in 2010 for a minimum of five years and will only be released at the end of their sentence if the Parole Board believes they are no longer a danger to the public.

The brothers had grown up in an extremely violent home in Doncaster, where they watched ultra-violent movies and pornography and were exposed to drink and drugs.

The case provoked widespread criticism of agencies involved with the brothers’ family in Doncaster.

The previously published version of the serious case review found that the attack could have been prevented.

Doncaster Council said today that following an independent investigation, it is taking disciplinary action against five members of staff and has referred one former employee to the General Social Care Council, the social care regulator.

The council said in a statement that 279 members of staff were involved with the brothers’ family over a 15-year period.

In today’s report, the victims are referred to as V1 and V2, while the convicted brothers are called J1 and J2 to protect their identities. Large sections of the report are blacked out.

In one section the report states: “The panel are very mindful that examining events and decision making through hindsight can fundamentally distort how obvious the right or wrong judgments and action looked to practitioners at the time.

“Nonetheless, the following chapters provide compelling evidence about the extent to which XXXXXXXXXXXXXXXX children suffered neglect and that different decisions could and should have been taken at several points during the extensive involvement of agencies with this family from 1995 up to April 2009 and that better outcomes could and should have been achieved for the J children.”

“It was...entirely predictable that the boys would continue to assault and cause injuries to other children (and adults).

“This is a pattern of escalating behaviour established over many months. For this reason, more assertive and effective action should have been taken and as late as a week before the assault on V1 and V2 and there were opportunities to do this. As such, the assault on V1 and V2 was a preventable incident.”

One section covered the role of agencies in assessing the parenting skills of the parents of the convicted brothers.

The report stated: “There was no assessment of either parent’s capacity to meet the needs of a XXXXXXXXXXXXXXXXXXXXXXXXXXXX at any time during the 14 years of agency involvement.

The report concluded that “professionals were generally ineffectual in planning and executing more effective intervention”.

The report also highlighted “missed opportunities”. It identified “more than 30 opportunities that could, with different and clearer judgment and action have reduced the harm suffered by XXXXXXXXXX and their harm to others,” the authors concluded.

It continued: “This is a case where the agency with the lead responsibility for safeguarding children inadequately fulfilled its statutory functions and responsibilities over several years. However, it would be wrong to conclude that it is only children’s social care services that face significant challenges for improvement.

“This case illustrates what can happen when those who have lead responsibility for safeguarding children are unable to fulfil that important and statutory role.”

“This is a case that shows up very serious shortcomings in the corporate functioning of children’s services, a lack of effective leadership, and ineffectual oversight by the local safeguarding board and a statutory children’s service failing to comply with legal duties and national standards.

“There is a persistent inability to intervene effectively with the family over many years. Knowledge about the violence in the family is known from the outset.”

One section of the report criticised the council for not being assertive enough once the brothers had been put into foster care.

It said: “The decision to look after J1 and J2 in XXXXX 2009 should have been an opportunity to develop a clear plan with purpose.

“The arrangements proved to be chaotic. The decision to place the boys close to FJ (their father) is unexplained. The plan is weak and the placement inadequately supported and supervised. MJ (their mother) describes the arrangement as one of shared care.

“In deciding to use section 20 of the Children Act the arrangement was a voluntary agreement where all parental responsibility remained vested in MJ. This was a case that required the local authority to be much more assertive and exercising far more influence and control.”

At the beginning of the recommendations section, it said: “This review identifies serious inadequacy in the organisational arrangements and the quality of decision making.

“If other reviews had not already identified action plans, and if the intervention team was not in place, the panel would have made many more recommendations as a result of this review.”

The review recommended a number of changes to the way services were managed in Doncaster.

These included:

• Better monitoring and implementation of recommendations from previous serious case reviews;

• Social workers taking into account the link between adult domestic violence and children’s behaviour;

• Vastly improving organisation, procedures and frameworks within child protection services;

• Improvements in training for those dealing with vulnerable children.

The review said the level of violence shown by the brothers was so great that no-one could predict it.

“The level of violence displayed by J1 and J2 in April 2009 is rare. None of the professionals including child psychiatry services and an independent expert predicted or anticipated such a violent assault.”

Commenting on today’s publication, Roger Thompson, chair of Doncaster council’s Safeguarding Children Board, said: “On behalf of the Board, I would like to reiterate our apology and our thoughts continue to remain with the victims and their families.

“The publication provides a real reflection of just how weak individual services and multi-agency working was at the time of this incident, and we made a commitment then to make sure lessons were learned and ensure as best as we can that something like this never happens again.”

In response to Mr Gove’s letter, Mr Thompson said: “The serious case review was prepared under the Government guidance at the time, and all aspects were judged to be good by Ofsted.

“Comments made by the Secretary of State today are about the reporting of serious case reviews nationally, not just Doncaster.”

Seven children known to Doncaster Council have died in the borough since 2004, prompting serious case reports, Ofsted inspections and a Government investigation.

Doncaster council’s director of children’s services, Chris Pratt, said a recent Ofsted report found major improvements in child protection services.

He said the council had set up a new referral and assessment service, with the council, police and health services all working “under one roof”.

Mary Shepherd, NHS Doncaster’s associate director of quality and safety, said health and social care workers were now working together under the same management structure and training for front-line staff had been improved.