Child D Serious Case Review And Domestic Homicide

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Child D Serious Case Review And Domestic Homicide

Transcript Of Child D Serious Case Review And Domestic Homicide

Report into the death of Child D aged 17
Died February 2016

Independent Reviewers:

Sian Griffiths & Deborah Jeremiah November 2017




1.1 The circumstances leading to the review.

1.2 Purpose of the Review and methodology.


The Circumstances of Child D’s death


Chronology of key events

3.1 Summary of what is known about the family history and circumstances.

3.2 The significant events and involvement of agencies for the main period under review (April 2013-February 2016)


Contribution of Child D’s family and friends


Analysis and appraisal of Agencies’ Practice

5.1 What this case tells us about the multi-agency response to domestic abuse which is not intimate partner abuse.

5.2 What this case tells us about the system’s response to families where there are multiple needs and potential risks, which individually are not assessed as meeting threshold criteria.

5.3 What does this case tell us about the effectiveness of safeguarding in relation to older children.

5.4 Concluding remarks.



Appendix A


Page 1 Page 1 Page 2 Page 4 Page 5 Page 5
Page 7
Page 13 Page 15 Page 15
Page 24
Page 33
Page 34 Page 35 Page 37 Page 48


1.1 The circumstances that led to undertaking this Joint Review


This Review was commissioned jointly by the Bristol Safeguarding Children Board and the Safer Bristol Partnership, following the death of a 17 year old boy, Child D, in February 2016. Child D died after being stabbed by his halfbrother, who subsequently pleaded guilty to Child D’s murder and was sentenced to life imprisonment in October 2016.


The Bristol Safeguarding Children Board’s Serious Case Review Sub Group
concluded that the case met the criteria for a Serious Case Review (SCR), as outlined in Working Together to Safeguard Children 20151, in that Child D was
a child at the time of his death and there was information that:

a) abuse or neglect of a child is known or suspected; and

b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.


The Safer Bristol Partnership also identified that the circumstances of Child D’s death met the criteria for undertaking a Domestic Homicide Review (DHR) under Section 9(3) of the Domestic Violence, Crime and Victims Act 2004. A DHR is:

a review of the circumstances in which the death of a person aged 16 or over has, or appears to have resulted from violence, abuse, or neglect by:

(a) by a person to whom he was related and who was a member of the same household.
(b) A member of the same household as himself,
With a view to identifying the lessons to be learnt from the death2

1.1.4 The Review takes as its starting point the government definition of domestic abuse as follows:

Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members, regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse:

• Psychological • Physical • Sexual • Financial • Emotional

1 Working Together: HM Govt March 2015 2 Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews: (December 2016:5)

Home Office


Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.

Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim


A decision was made by the Chairs of the Bristol Safeguarding Board and the Safer Bristol Partnership to convene one Review combining the requirements of both a Domestic Homicide Review and a Serious Case Review. Advice was sought from the Home Office as to the methodology that would be used given the joint nature of this report and the approach to be adopted was subsequently agreed by the Home Office by e-mail on 5th December 2016.

1.2 Purpose of the Review and Methodology

1.2.1. The key purpose in undertaking this joint SCR and DHR is to ensure that learning can be identified following the death of this individual child3. Most importantly the purpose is to ensure the Review achieves the fullest understanding possible both of what happened but also why, in order to identify improvements and contribute to the prevention of future similar


The methodology and format required of Serious Case Reviews and Domestic Homicide Reviews are different in some ways. This combined Review has been structured so as to balance the requirements of both. In particular the methodology was underpinned by a systems approach and unusually for a DHR did not include the use of Individual Management Reviews for each agency. The methodology and processes adopted are described in more detail in Appendix A of this report.

1.2.3. This Review examines the responses of all the relevant agencies that had contact with Child D and his family and considers whether there were gaps in services or wider learning about domestic abuse and the safeguarding of children. The main timeframe for the Review was identified as beginning with the first recorded incident which indicated the possibility of conflict or domestic abuse within the family and ending at the point of Child D’s death, that is:

April 2013 – February 2016

1.2.4. This timeframe was identified as it was agreed it represented the period that would provide the greatest learning. Nevertheless, where there was significant relevant information prior to this point, which could improve our understanding of the family’s experience, particularly in relation to any history of violence within the home, this was requested and has been included in the report.

3 The word ‘child‘ is used in this Review to refer to Child D in order to clearly identify his legal status and the resulting duties of agencies to protect him. It is recognised that as a 16 year old, this is not how Child D may have described himself and should not be taken as a wider comment on his maturity.


1.2.5. The full Terms of Reference are to be found in Appendix A. In particular these include three specific areas for focus within the Review
A: What does this case tell us about the multi-agency response to domestic abuse in families in situations when this is not intimate partner abuse?
 Are agencies equipped to recognise potential adolescent to sibling or parent abuse and is the professional response effective?
 How well do agencies recognise whole family working and the risks and needs of different family members, where there is domestic abuse taking place?
 How effective is the interface between the frameworks for children’s safeguarding and domestic abuse services?
B: What does this case tell us about the effectiveness of safeguarding in relation to older children?
 For safeguarding children does the age of the child impact on the response of agencies?
 How do professionals balance the older child’s need for autonomy with the duty to safeguard a child?
C: What does this case tell us about the system’s response to families where there are multiple needs and potential risks, which individually are not assessed as meeting threshold criteria?
 How can professionals’ best gain an accurate understanding of a family who may be demonstrating multiple risk factors, e.g. early sexual activity of a child; drug and alcohol abuse, criminal activity. What role does community intelligence properly play in gaining this understanding?
 How effective is the single and multi-agency early intervention for families with multiple risks?
 Are the risks associated with young people using or carrying knives fully understood by all agencies?
 How do agencies understand the significance of non-resident fathers in the lives of young people and what is the impact for young people.
 How can professionals work with families who do not engage?
1.2.6. In line with the expectations both of the SCR and the DHR, full consideration was given to the involvement and potential contribution of key family members and friends, including Brother D, within this review. With the exception of Child D’s father, none of those contacted wished to be involved in this Review. The steps taken to seek their involvement are outlined in more detail in Appendix A.
1.2.7. Both of Child D’s parents were asked their views as to choosing a pseudonym for Child D and other family members. Child D’s mother initially said that she would wish to choose a name, but ultimately decided that she did not want to

use alternative names but preferred the style that has been adopted in this report. The Review considered it proper to follow the Mother’s wishes in this regard.

Subject of Review
Half Brother of Subject 4
Half Brother of Subject
Half Sister of Subject
Half Sister of Child D Mother of above Father of Child D Father of Brother D

Anonymisation Child D Brother D Brother D2 Older Sister Younger Sister

Age at February 2016
17 years old
19 years old
Adult (not in living household)
Adult (not in living household) 4years old

Race (as identified in
service records)
Dual Heritage: Black Caribbean
and White Dual Heritage: Black Caribbean
and White Information not
Information not available
White British

Mother Father of Child D Father of Brother D

Adult Adult Adult

White British Black Caribbean Black Caribbean

2.1. 17 year old Child D lived in Bristol with his mother, his 19 year old brother, Brother D, and his 4 year old Younger Sister. The family lived in settled accommodation and were established in their community. Prior to his death Child D had made plans with his local college to re-enrol in September to undertake a course he had previously been unable to complete. His girlfriend was expecting their child.
2.2. One night in February 2016 both Child D and Brother D had been out at clubs and bars in the city with their friends and had also spent time with Brother D’s father. They had both consumed significant amounts of alcohol as well as illegal drugs. The two brothers returned separately to their home early in the morning, Child D accompanied by one of his friends. Child D arrived home first and became involved in a verbal argument with his mother who was angry that he had driven home in her car.
2.3. Shortly afterwards Brother D returned and a fight started upstairs between the two brothers. The fight continued onto the stairs during which time Brother D
4 Child D, Younger Sister and Brother D were half siblings, but will be referred to as brother and sister during the report reflecting their family situation as it was lived.

stabbed Child D a number of times. Brother D then left the house. The Mother immediately called 999 and both police and ambulance attended. The police and subsequently paramedics undertook CPR at the scene, and Child D was then taken by ambulance to hospital. However shortly after arriving at hospital he was declared dead. The Post Mortem identified that several of the stab wounds were comparatively superficial but one wound to his chest was more serious and was the cause of Child D’s death.
2.4. Brother D subsequently handed himself in to the police and was charged with murder. He pleaded guilty at Crown Court and was sentenced to Life Imprisonment with a minimum tariff of 11 years and 3 months.
2.5. Information was provided to the Review by a number of different professionals with knowledge of the family’s local community that there was an ‘outpouring of grief’ following Child D’s death. The local Youth Club was opened specifically following his death and there was a collection for the family. A ‘big parade’ took place in his memory and his funeral was attended by a very large number of friends and family.


Full chronologies were provided by all the agencies5 known to be involved with the family. The resulting combined chronology was considered in detail within the Review and the relevant information is summarised here.

The information available to this Review is almost totally reliant on the records of the various agencies who were involved at different times with the family. Inevitably this means that the picture provided will be an incomplete one and cannot effectively describe Child D’s experience from his perspective.

3.1 Summary of what is known about the family history and circumstances.


Child D had lived all his life in Bristol, the family having moved to their current address some years earlier. Child D’s father lived separately from the family and had occasional contact with his son. The wider family included 2 older siblings (Brother D2 and Older Sister) who had previously left home, Brother D’s father, who it is understood had limited routine contact with Child D, and also Brother D’s wider paternal family. The level of involvement of the older siblings with the family is not known. It is understood that the Mother had been the main or sole carer for her children, with some contact but no regular involvement from the fathers of her children. Her brother was a regular visitor to the home and appeared to have a good relationship with Child D. There is very little information as to whether the Mother had employment outside of the home but it is known that she was reliant on benefits for much, if not all, of the time.

3.1.2. The Mother is recorded as being White British. Child D and his brother are both recorded as Black Caribbean and White. There is no information that

5 The agencies concerned are listed in Appendix A


identifies faith as a significant feature in the family. There is also no information to suggest that any of the family members had any disabilities. Whilst there is evidence to suggest that the family were settled in their locality, in the absence of their own perspective the Review has little information about how either the mother or the boys experienced their world, family and community. One of the few insights is that the Mother was described by some as quite protective about the two boys and told staff at the college that she thought Brother D in particular was picked on, some of which she believed was due to racism.


Child D’s Mother had herself been in the care system as a child and later had a history of involvement with drugs and possibly drug dealing, and was therefore known to the police. Following Child D’s death it was discovered that cannabis had been grown in the house which, irrespective of who initiated this, could not have been without the knowledge of the Mother. The level and seriousness of the Mother’s personal drug use is not properly understood, but it did not appear to have had a debilitating effect on her daily life.


Both Child D and Brother D had problematic school attendance, with Child D having a number of changes of school and for a period of a few months being described as home educated. In 2011 Brother D was excluded from school and received support from the Local Authority for his learning at home. They also both had some involvement with the criminal justice system as young teenagers. Throughout their childhoods there was a repeating pattern of not responding to appointments or letters with health services and on one occasion the Mother discharged 20 month old Child D against medical advice after he had been admitted for possible meningitis. In 2000 the family were noted by the GP surgery as a ‘family of concern’, which is an internal note that is kept on the GP System. The GP believes that this was triggered by the concern about health appointments being missed.


There is some information to suggest that the relationship between Child D and Brother D was not always easy. The Review has had a consistently positive picture of Child D from those professionals and other individuals who had contact with him. He has been described as ‘a lovely, pleasant lad, very polite’ ‘easy going and not one to get into fights’. There were more expressed concerns about Brother D, particularly in relation to his use of violence. One of the professionals described him as a bright boy, who was very stern, unwilling to open up and who could be ‘quite intimidating’. The Mother is recorded as being friendly and pleasant, she had previous experience of social work, and came across as considered and helpful when she spoke to professionals. The Mother also had a history of depression and previous experience of domestic abuse. Information from the GP was that she used cannabis to help her sleep and when she was low in mood and there is some suggestion that she also used other prescription drugs.

3.1.6. Very little is known about the Younger Sister. Younger Sister was a premature baby, as a result of which she was under the neonatal team to monitor her development. Health professionals recorded concerns from the outset about her not being brought in promptly for checks ups and immunisations, as well as health visitors being unable to see her. The


housing provider had not been told when Younger Sister became a member of the household and they remained unaware of this until after Child D’s death.
3.1.7. The significant key events known to agencies prior to the main timescale identified for this Review are as follows:

DATE June 2001 June 2002 July 2003
March 2004
June 2006 October 2010
June 2011
March 2011
October 2011 Feb 2012
April 2012
April 2012
August 2012 January 2013

BRIEF SUMMARY OF EVENT 2 year old Child D attends A&E with fractures to fingers. 3 year old Child D attends A&E with injury to lower body. Referral to Children’s Social Care (CSC) by Mother, allegation that an 11 year old had assaulted 5 year old Child D. Initial Assessment. Case closed September 2003. 5 year old Child D attends A&E with burn to arm from inhaler caused by brother. 9 year old Child D seen by GP with ‘superficial’ injury to face. 12 year old Child D seen by GP with minor head injury having been punched in the face – not known by whom. Referred by school nurse. 12 year old Child D seen by GP with mother who asked for him to be given an STI test. Information sought but not given re partner. Test negative. Referral made to CSC. Advice given by CSC, no further action Brother D receives 6 month Referral Order for Burglary of a dwelling Child D charged with Affray. Sentenced in November 2012 to 12 month Youth Rehabilitation Order Brother D receives Youth Rehabilitation Order for robbery/criminal damage Child D receives a Referral order for Handling Stolen Goods. Completed August 2012 Education Welfare planning to take action re non-school attendance Child D receives Conditional Discharge for Possession Class B Drugs Brother D’s Youth Rehabilitation Order revoked, replaced with Attendance Centre Order.

3.2 The significant events and involvement of agencies for the main period under review (April 2013-February 2016)


In April 2013 Child D was living at home and attending school. Information about Brother D at this time is limited, although there a record to say that he did have periods of time being educated at home following the exclusion in 2011 and also received individual support from the Local Authority with his learning.

3.2.2. The first significant event was an argument between the two brothers and their Mother in early April 2013 which led to the Mother calling the police.


Police Officers attended the house, but did not identify any offences and subsequently sent a Domestic Incident notification to Children’s Social Care (CSC). The Police safeguarding unit also made a referral to the Victims Advocate Unit as had been requested by the Mother. However, there was no record that the Victims Unit did in fact call the Mother or that this was followed up either by the Mother or by any professional concerned. It was noted in the CSC Records that this was a domestic incident and there was recognition that the perpetrator, Brother D was a child. CSC concluded that no further action was required as the incident did not meet the threshold for involvement. The Mother was considered to have acted appropriately and had received advice about seeking support from the police.


The Police received an anonymous call on a second occasion in the early hours of the morning in April 2013 reporting that there was fighting and shouting at the house. Police attended and both Brother D and their older brother (Brother D2) were present, as was the Mother, but it is not recorded which other family members were in the house. There had been an argument but none of those present were willing to speak about what had happened. The Police gave words of advice and this was recorded as AntiSocial Behaviour.


The following month an abandoned 999 call was made to the Police who went to the address provided and found that a 15 year old boy, who was drunk, was in charge of his own 9 year old brother as well as 2 year old Younger Sister. Nearly an hour later the boy’s parents and Child D’s Mother returned to the house, which was the home of the boy’s parents. A referral was made by the Police to CSC as a result. Child D’s mother acknowledged that she should not have left Younger Sister with the 15 year old, but stated that they had only left because of an emergency in relation to other family members and the boy had not been drunk when the adults went out. The Mother told CSC that there had been social work involvement with her two older children, but there was no information about this on the computerised records. CSC concluded that given the Mother had acknowledged their concerns and as there had been no referrals for the family since the records were computerised there was no need for further action.


Child D had been subject to a Youth Rehabilitation Order since November 2012 as a result of an offence of affray. In August 2013 his Mother spoke to his YOT worker about Child D having recently disclosed another occasion when he had been subject to an assault as a young child which was causing him flashbacks. She was concerned about this and wanted to access some support for Child D. The YOT worker made a referral to CSC and a Strategy Discussion involving Children’s Services and the Police took place. The conclusion was that no further action would be taken as Child D did not want the issue pursued. Child D also spoke to his GP about the assault and told the GP about the Police involvement. Although Child D was distressed, no referral for counselling or other support was made by the GP. It was suggested that he return to see the GP again in a few weeks, but did not do so and there was no follow up by the surgery. Neither is there evidence of any contact between CSC and the GP. Child D told his YOT worker that he did not want any support.