Flawed social work let John die

That is the tragic and damning finding of an inquiry report prepared for the Brighton and Hove and West Sussex Area Child Protection Committees.

Its author, Alyson Leslie, described John as a typical, lovely, little boy who fell victim to poor investigations, flawed social work and unsuitable adoptive parents.

Had the McWilliams been investigated properly, they would never have been allowed to adopt and John would be looking forward to a healthy and bright future.

John was born on May 19, 1995, and taken into care in February 1998. Ms Leslie said he was considered by his class teacher as an able, responsive child who would have been very clever.

She said: "People who knew John in his early life, including his former foster carers, describe him as a lovely, typical little boy."

From her research, Ms Leslie found no evidence to support the McWilliams' claim that John was a self-harmer or that he was damaged, unsociable or an intensely anxious child. "Indeed, a substantial body of evidence to the contrary exists."

The McWilliams were assessed over eight months but the decision to approve them was based almost entirely on self-reported information and on input from two referees whom the couple had chosen.

She said there were significant gaps in facts provided by the couple and details of personal and employment histories were not checked.

"Most importantly, Mr McWilliam's past experience as a parent was not investigated. Had this been done, I believe the assessment process would have been immediately terminated."

She said the professional preparation for John's placement with the McWilliams was "seriously deficient", the transition period was too short and, when problems surfaced, the pace should have been slowed.

One social worker recorded seeing bruising on John on nine of the 11 visits he made to the McWilliams's home.

An independent GP who reviewed the injuries and accounts of John vomiting suggested there were at least seven occasions when medical attention should have been sought for the boy. Neither the McWilliams nor professionals once arranged for the boy to see a doctor.

The McWilliams' claim that John self harmed after a visit by his former foster parents, Pauline and Rod Mears, was a "complete red herring" but it was accepted by professionals.

"The confidence with which this explanation was propagated, untested, were indicative of sub-standard social work and health visiting practice."

John had no behavioural problems at school. "His class teacher speaks very highly and fondly of him and saw his behaviour as appropriate to his age. In her view, he was a delightful, excitable, fun-loving little boy."

Friends and professionals accepted the McWilliams' explanation of self harming and did not question or comment further.

"People were actively discouraged by the McWilliams from talking to John about his injuries, lest it provoked more 'self harming'.

"Apart from biting his lip (a typical nervous reaction of a child under stress), which increased from November onwards, and problems with eating, I am aware of no evidence, beyond the claims of the McWilliams, that John self harmed or mutilated himself."

Ms Leslie said the level and quality of social services' input and the monitoring of John's welfare were inadequate and the failure of professionals to seek medical help for John was "unacceptable".

Inadequate assessments, sympathy for the McWilliams's desire for a family and poor professional liaison led staff to convey to managers and the adoption panel that John's placement was going well.

The McWilliams, by this time, were in the process of adopting John and another child and, on the basis of this "inadequate, untested and incomplete information", social workers recommended a third child be placed with the couple.

The adoption panel saw John as a difficult child on the basis of information supplied by the McWilliams and social workers.

Ms Leslie said: "They praised the McWilliams for their care and agreed practical support in the form of an adoption allowance of £300 a week."

Almost all the professional input was geared to helping the McWilliams cope with pressures created by John and the hurt Simon McWilliam experienced as a child.

Ms Leslie said: "John was portrayed in this period as an ungrateful and disturbed little boy who was rejecting the care and nurture of two people who simply wanted children of their own to love. This view dishonours the memory of John."

Seventy-two hours before he died, John was seen three times by three separate professionals. His face was bruised and the injuries should have warranted further investigation.

"However, John was failed by poor professional judgement and poor professional practice.

"It was a tragic conclusion to a case which illustrates the dangers of promoting trust at the expense of vigilance.

"While a major reduction in fieldwork posts and weaknesses in first-line management systems in Brighton and Hove social services contributed to the pressures under which social workers were working, the critical failures in this case were not in resourcing or systems but in the performance of basic social work tasks.

"The mishandling of this case arose from sub-standard practice and the poor exercise of professional judgement.

"Social workers exist because there are aspects of our society the rest of us do not want to deal with. They are our eyes and our judgement when it comes to our society's vulnerable children.

"They are there to ensure such children have access to safe, nurturing, fulfilling environments where they can achieve their full potential.

"To do their job effectively, social workers must, on our behalf, ask awkward questions and always be thinking the unthinkable.

"And if, in the course of so doing, some people feel intruded upon and scrutinised, it is an acceptable price to pay for safeguarding the welfare of children who are ultimately in all our care."

Ms Leslie criticised the "flawed" assessment of the McWilliams as suitable adoptive parents.

"Currently in the UK, more documentary evidence is required when an individual is seeking a mortgage than when they are adopting a child."

Little verification was carried out on what the McWilliams told them. Simon McWilliam's two previous wives, for instance, were never contacted.

Ms Leslie reached them within an hour and both had grave concerns about him adopting a child, describing him as violent and cruel.

Ms Leslie said the adoption process would have stopped had investigators spoken to the women.

A woman social worker assigned to investigate the couple, she said, "actually knew very little about Mr and Mrs McWilliams, other than what they themselves had volunteered" and the adoption panel never challenged the findings. It failed to distinguish opinion from fact.

The social worker, she said, "worked to the standards she knew; the standards were lax and ill-informed.

"In any society, there exist people whose intentions towards children are malicious and others unsuited by temperament or circumstances.

"No test is too rigorous and no questioning too intrusive, where the credibility, honesty and reliability of individuals who wish to become adopters are concerned."

Alarm bells over the McWilliams' suitability rang even before John moved in with the couple.

The boy's foster parents, Pauline and Rod Mears, praised for taking "excellent" care of John, were deeply worried.

Mr Mears disliked the McWilliams and felt "there was something about the man that did not ring true."

McWilliam was abusive to the Mears at meetings during the nine-day transition period before John moved homes.

Ms Leslie said little was done to prepare the McWilliams. "Nature gives people about 40 weeks to prepare for the massive changes parenthood brings. Adopters do not have nature's preparation."

Social workers, she said, lost sight of John's needs in the "morass of issues raised by the McWilliams" and the adoption should have been put on hold.

It was not and the McWilliams collected John on June 24. Just over a month later, on August 6, came the first reports from a social worker of bruises and John "self-harming".

Ms Leslie said no doctor was contacted and John's social worker failed to investigate thoroughly. Over the ensuing weeks, social workers reported seeing more injuries but again no action was taken.

The excuse from the McWilliams that John was hurting himself because he had been upset by a visit from the Mears was accepted.

In fact, John told the Mears he wanted to go home with them and did not want them to leave but the social worker accepted the McWilliams' request to stop contact between the Mears and John.

Ms Leslie found the idea of allowing the McWilliams to adopt a third child incredible. "By any reckoning, to put a child into a situation so poorly understood, so inadequately monitored and so fraught with uncertainties was a disaster waiting to happen.

"Sadly, none of the professionals was aware at that stage of the extent of their own ignorance or of how it was compromising their judgements and actions and ultimately the children's safety."

Social workers continually saw bruising but reported to superiors that the adoption was going well and a review panel even praised the McWilliams. "Well done to Michelle and Simon for their excellent efforts and tenacity!" it said.

Ms Leslie said the social worker allowed the McWilliams to present a glowing picture while being fully aware of John's unsettled behaviour and the couple's anger and frustration.

He concentrated on the McWilliams when John should have been the focus of attention.

"It would appear at this point that he had completely lost the plot."

Ms Leslie said injuries on John seen on December 20, four days before his death, shocked social workers.

"Had they sought medical attention and an investigation then, injuries which subsequently led to his death would have been prevented."

John's social worker had child protection concerns but did not follow them through.

Ms Leslie did not mince her words. "We have to live with the reality that some members of our society do harm children and that there are no easy ways of identifying who they might be.

"Whether we like the idea or not, we need the services of skilled, thoughtful and decisive social work practitioners prepared to work long hours, in the face of constant public criticism, whose successes are never broadcast.

"We need them to keep thinking the unthinkable things the rest of us never want to contemplate in order to keep safe the children who are ultimately in all our care."

She said the majority of professionals in John's case had turned their primary concern, that "the welfare of the child is paramount" into a "meaningless mantra".