“Could have been prevented”…….(Inquiries into child protection) by @costofcameron

Time and time again the words (or very similar) “abuse, could have been prevented” are coming out of the ‘Serious Case Reviews’ of various child protection bodies and departments.

Look at these and see the pattern I’ve highlighted in what they are saying, but BEAR IN MIND, the oldest story I’ve listed here is Victoria Climbie, who was murdered in 2000! AND WE ARE STILL SAYING……… “Lessons must be learnt???…….

22743AE700000578-3406342-image-m-17_1453202400115January 2016 – Poppy Worthington

Both Cumbria County Council and Cumbria Police say “Lessons will be learnt” over the investigation into the death of 13 month old Poppy.


December 2014 – Levi-Blu Cassin – ‘a serious case review is being carried out’  

A “selfish and manipulative” couple who both denied delivering the fatal blow that killed their toddler son have each been jailed for nine years.

Levi-Blu suffered “catastrophic” internal injuries at his West Midlands home in February 2013.


August 2014 – “Lessons learnt” – AGAIN!


“LESSONS have been learned from the systematic neglect suffered by children at the hands of their Gloucestershire parents, according to the authorities involved.

Despite awareness of the family for some 16 years and at least seven bodies having involvement with the family, the youngsters’ plight continued for years”



dean harris murderer of amina agboola

Nov 2013 – Amina Agboola aged 2 – Kicked in the stomach, liver split in two murdered by mother’s boyfriend Callum Wilson (above) He will serve 17 yrs. When he kicked her, it was so hard, she landed 6ft away.

Will an inquiry into this by the local authority come out with “Lessons must be learnt”?


The Independent – 1st April 2014 -partial

An 11-month-old boy who was beaten to death by his mother could have been saved if health and social workers had raised the alarm about his earlier injuries, a serious case review has concluded.

Ms Wilson, 25, received a life sentence for his murder at the Old Bailey in January. She killed her son in March 2011 after months of abuse, yet GPs, health workers and those in children’s services did not pick up the signs.

A serious case review was launched following his death, and today found that professionals working in three different settings – a GP practice, a children’s centre and a child health clinic – all failed to report Callum’s suspicious injuries to social care services.

Had they done so, in keeping with their training, it would “very likely have led to the detection of serious injuries and would probably have prevented his death”, the review said.

Emma Wilson, from Windsor, was convicted of the murder at the Old Bailey and jailed for life in January this year.


Victoria Climbie BBC News 6th Jan 2003 – partial

Lessons must be learned from the case of murdered child abuse victim Victoria Climbie, Health Secretary Alan Milburn has said.

The report by Lord Laming, chairman of the public inquiry into her death, is expected to identify a catalogue of failures by child protection services and call for a shake-up.

Chances missed

“Protecting children, particularly the most vulnerable, is a central priority for health and social services whether provided by government or non-government agencies.”

The report could be published within weeks.

Victoria Climbie died in February 2000 after being tortured and abused by her aunt Marie-Therese Kouao and her boyfriend Carl Manning at a flat in Tottenham, north London.

She had 128 injuries on her body, had been starved and forced to sleep in a rubbish bag in the bath.

Kouao and Manning were sentenced to life imprisonment for her murder.

Marie Therese Kouao
Kouao made Victoria sleep in a bath

The inquiry looked at why at least 12 chances to save Victoria’s life were missed by local authorities, by doctors and the police.

Ealing social services failed to intervene after being told by a relative that Victoria was being abused.

After moving to Manning’s flat in Tottenham, Haringey, Victoria was once more in hospital but social services failed to speak to her on home visits.

Haringey social services was criticised for having a “chaotic” team and for delays in producing documents for the inquiry.

Daniel Pelka – BBC News 17September 2013 – partial

Chances were missed to help a child who was murdered by his mother and her partner after suffering “terrifying and dreadful” abuse, a report has found.

A serious case review found Daniel Pelka, four, was “invisible” at times and “no professional tried sufficiently hard enough” to talk to him.

He was starved and beaten for months before he died in March 2012, at his Coventry home.

The review said “critical lessons” must be “translated into action“.

Magdelena Luczak, 27, and Mariusz Krezolek, 34, were told they must serve at least 30 years in jail, after being found guilty of murder at Birmingham Crown Court in July 2013.

The review’s key findings include:

  • Police were called to 26 separate incidents at the family home, many involving domestic violence and alcohol abuse
  • Excuses made by Daniel’s “controlling” mother were accepted by agencies
  • Professionals needed to “think the unthinkable” and act upon what they saw, rather than accept “parental versions”
  • Daniel’s “voice was not heard” because English was not his first language and he lacked confidence
  • No record of “any conversation” held with Daniel about his home life, his experiences outside school, or of his relationships with his siblings, mother and her partners
  • None of the agencies involved could have predicted Daniel’s death
  • There were “committed attempts” by his school and health workers to address his “health and behavioural issues” in the months before his death
  • But “too many opportunities were missed for more urgent and purposeful interventions”
  • Two of those chances were when Daniel was taken to an accident and emergency department with injuries

Daniel Pelka

Daniel Pelka

The review said the hospital “rightly raised immediate concerns about the [fractured arm]” and a meeting was held to decide if it was caused by a fall from a settee, as Daniel’s mother claimed, or was the result of abuse.

The meeting decided Luczak’s explanation was “plausible”.

But the review said the reasons for other bruises found on Daniel at the time, which his mother claimed came from bicycle accidents, were not “fully explored”.

Keanu Williams – BBC News 3rd October 2013 – partial

There were “a number of significant missed opportunities” to save a two-year-old boy from being beaten to death by his mother, a report has found.

Rebecca Shuttleworth is serving a life sentence for murdering Keanu Williams.

The toddler was found with 37 injuries including a fractured skull and torn abdomen, in Ward End, Birmingham.

A serious case review said social care workers, the police and health professionals had “collectively failed to prevent Keanu’s death”.

Shuttleworth, 25, was spoken to in prison by members of the serious case review team, telling them she was “surprised” social workers allowed her to keep custody of Keanu.

The report states: “She expressed some surprise that Keanu had not been removed from her care when born.

The report found different agencies had “become confused” as their strategy discussions had focused on the medical and forensic aspect of his injuries, the report said.

It concluded that although Keanu’s death on 9 January 2011 could not have been predicted, the agencies involved could have seen that he was “likely to suffer significant harm“.

The toddler should have been subject to a child protection plan “on at least two occasions” to address issues of neglect and physical harm, the report said.

Hamzah Kahn – The Guardian 13th November 2013 – partial

A serious case review (SCR) into the starvation of four-year-old Hamzah Khan has concluded that while his death was “not predictable”, Bradford social services missed signs that, had they been put together, could have warned that Hamzah and his seven siblings were at risk.

Last month, Hamzah’s mother, Amanda Hutton, 44, was found guilty of his manslaughter and of neglecting six of her eight children. When Hamzah’s partially mummified body was found in September 2011, almost two years after his death in December 2009, aged four, he was wearing a Babygro meant for a child aged six to nine months.

Neither he nor any of his siblings was on social services’ “at risk” register. Two months before his death he and his family had been struck off their GP’s list for persistent non-attendance.

Hamzah was “unknown and invisible to services throughout his short life”, receiving no inoculations or help from early years, education or health services almost from birth, the SCR authors write. Like Victoria Climbié, the eight-year-old girl tortured and murdered by her great-aunt in London in 2000, he had not been registered with a GP. As in the Climbié case, and that of Baby P, 17-month-old Peter Connelly, who died in 2007 after being abused by his mother and her partner, there were insufficient challenges to Hamzah’s mother when she refused help.

Hutton’s deliberate decision to withdraw him from all of the usual and universal services was a significant factor in both his death and why she was able to hide it for so long, the report says.

While not blaming any one agency for failing Hamzah, the authors make 50 recommendations for “learning”, which have been accepted by the Bradford safeguarding children board.

The independent experts examining Hamzah’s case also found that in late 2006, when Hamzah was one-and-a-half, one of his older siblings went to the police complaining that both Hutton and her partner, Aftab Khan – father to all eight children – had assaulted him.

Police used their powers of protection to try to arrange safe accommodation with Bradford children’s social care (CSC). But they were unable to find a placement and the boy returned home.

The boy made another complaint of physical and emotional abuse in May 2007 although at the time it was interpreted by social workers as being “teenage angst” rather than something more serious. He spent two nights in emergency accommodation before being returned back to the family home by the end of the month.



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