Serious Case Review: Safeguarding a child with disabilities

In September 2009, Charlotte Avenall, an eight-year-old girl with severe learning difficulties, was found dead in her bedroom in Mansfield. She had accidentally hanged herself.

Her room was in squalid condition, with faeces smeared over the walls. She was locked in for 12 hours each night and forced to use a chest of drawers as a toilet.

In April this year, her mother and step-father were both jailed for 12 months for wilful neglect.

A serious case review undertaken by the Nottinghamshire Safeguarding Children Board established that a number of agencies had been involved with Charlotte and her parents since her birth. But despite the intention to provide a good service, there were lessons to be learnt in the way different agencies co-ordinated their approach and identified safeguarding issues.

According to board chair Chris Few, one significant issue was that the main focus of the professionals involved was in providing support for Charlotte's parents in caring for a disabled child.

"Charlotte as an individual was often lost sight of behind her disability and her safeguarding needs overlooked," he concludes.

It is an issue that crops up again and again in serious case reviews.

"One of the difficulties here can be that over a period of time we become less concerned about continuing neglect and general standards of care because we become accustomed to it within a family," says Ken Jones, professor of social work at Kingston University and St George's, University of London.

"We become, to some extent, desensitised to it. There is a danger then that we fail to see what is really in front of us."

It is an issue for every agency working with children, says Few. "We all need to ensure we are maintaining the focus on the child at the centre of the intervention and that, wherever possible, they are communicated with and their views are taken into account."

While agencies need to share information, each should have followed up on its own concerns, the report said. It also called for national guidance on alternatives to door-locking as a way of dealing with difficult behaviour.

An Ofsted report into Nottinghamshire County Council's safeguarding services in May warned of a "significant shortage" of frontline social workers, which meant children were not effectively safeguarded.

The county council has responded by spending £7m in strengthening safeguarding services. Ten new social workers started work in April, alongside four new senior social workers.

A new head of service for disabled children will be appointed. The council is also creating a safeguarding improvement programme board, under an independent chair.

Recruitment has been a problem in the wake of the Baby Peter case, admits Few. "There is still a capacity issue, but it is being addressed," he says.

"At the moment there are a number of agency social workers employed in a specific team to clear cases that have been around for a while and need urgent attention."

KEY LESSONS

• Disability and child protection issues should be distinguished
• Each agency should be following up concerns and not assume other professionals will deal with it
• Place children's experiences, wishes and feelings at the heart of assessments
• The NSPCC offers a two-day Safeguarding Disabled Children training course cypnow.co.uk/doc
• The Labour government issued safeguarding disabled children guidance in its 2008 Staying Safe: Action Plan cypnow.co.uk/doc