The family of a popular but troubled 17-year-old boy from Brighton have blamed social workers for his death, according to a review.
Their views are at odds with the professionals who were responsible for his care and those who contributed to a serious case review published yesterday (Monday 26 September).
Kyle Birchall died after hanging himself having fled Brighton, fearing that someone he knew wanted to kill him.
He had confronted a friend who he suspected of breaking into the family home where he grew up – and blamed him on Facebook.
The serious case review said: “Kyle’s subsequent assault on this boy led swiftly to an exchange of social media threats which apparently terrified Kyle and prompted his desire to leave Brighton immediately … He was genuinely in fear for his life.”
In hindsight officials have expressed doubts about the seriousness of the threat but in the days before his death they moved fast and failed to follow rules.Kyle, who went to Dorothy Stringer School, was raised by Lisa Birchall and Grant Jackson, his aunt and uncle who acted as foster parents.
Mrs Birchall was his dead mother’s sister – she took her own life when Kyle was eight, as her own mother and uncle had previously.
The review said: “Kyle was a child with a complex and sad history of repeated separation and loss.”
He met his father, Rick Markham, for the first time just days before he died. Kyle had been due to spend the day working with him when he was found hanging at his father’s friend’s house.
He was staying there, after leaving Brighton in fear of his life, in part because Mr Markham’s new family were unaware of Kyle’s existence.
Kyle had not been well prepared for the first meeting, according to the serious case review. It said: “Mr Markham and Mrs Birchall expressed a very strong sense of anger at the actions of agencies, Children’s Social Work Services in particular.
“They believed that Kyle would not have died had he not been allowed to go to the local authority area of Mr Markham.
“They felt that there had been ‘a total lack of preparation, a failure to follow protocols and, more generally, a lack of resources offered to Kyle’.”
In contrast, the review said: “There were no findings, nor any data captured in the review process, that suggested that any agency’s actions (by commission or omission) could have predicted or prevented Kyle’s death. The coroner’s judgment supported this conclusion.”
The coroner recorded an open verdict at Kyle’s inquest, saying: “There is insufficient evidence to conclude that this was either an accident or suicide.”
The serious case review refers to Kyle as Child E and gives anonymised letters to Kyle’s family members and the professionals involved in his care, as is common in such cases.
In this report, E and the other depersonalising letters have been replaced with people’s real names.
The review – commissioned by the Brighton and Hove Local Safeguarding Children Board – is intended as a way of sharing lessons among those responsible for caring for children and young people.
Excerpts from the 60-page report, including the findings, are reprinted below along with comments from some of those with relevant responsibilities and/or an interest in learning lessons from the review.
What the family said (according to the review)
“Both Lisa Birchall and Rick Markham dispute the account outlined (in the review).
“Mr Markham believes he was pressurised into providing a solution to an immediate crisis. He only agreed because he was convinced of the reality of the risk to Kyle and because of his desire to help his son in these circumstances.
“He was reluctant on the grounds of meeting his child for the first time in this way and also because his other children did not know of Kyle’s existence.
“Mrs Birchall states that she never agreed to Kyle’s move and in fact says that by the end of the afternoon he had calmed down and agreed to remain at home with her and Mr Jackson.
“This was not communicated to Children’s Social Work Services. She feels the decision was taken out of her hands by the practice manager negotiating the plan directly with Mr Markham.
“Both Mrs Birchall and Mr Markham believe that Children’s Social Work Services exaggerated the risk to Kyle and were determined to move him away.
“They find it hard to understand how the decision in the morning (that he should not be moved to Mr Markham) was changed in the afternoon.
“Brighton and Hove Children’s Services remained in phone contact with Mr Markham and Kyle on (Friday) 28 November.
“His social worker, in her own time, kept in touch with him by telephone over the weekend. However, there was no contact with Mr Markham’s friend/neighbour with whom Kyle was staying and no checks were carried out regarding him.
“The minimum of a police check was agreed but not carried out due to a misunderstanding about who would do this.
“Having made the arrangement, there should have been immediate follow up to risk-assess, including a home visit to both Mr Markham and his friend/neighbour before the weekend (possibly by local children’s services).
“A foster placement in/near the area that Mr Markham lived had been identified for discussion on the Monday.
“Kyle died as a result of self-strangulation (by hanging) on the following day.”
What his old head teacher said
In the days after Kyle died his head teacher at Dorothy Stringer, Richard Bradford, paid tribute to the bright student who had been working at McDonald’s but who had realistic hopes of becoming an engineer in the Royal Air Force.
Mr Bradford said: “Kyle was a big-hearted, generous and kind young man. He spent a lot of time helping other people.
“He was very popular at school with students and teachers and had a large friendship group.
“Everyone is devastated at the news and are thinking of his family and loved ones.”
What the review said about Kyle
“One of the most notable features of this case was Kyle’s presentation at school (and later college), as a ‘model pupil’ and a hard-working ‘cheeky cheerful chappie’, which was in stark contrast to the angry and potentially self-destructive behaviour acted out elsewhere.
“Kyle liked school and did reasonably well in his studies. He was charming, polite and willing – thus popular with school staff as well as pupils.
“Elsewhere, however, his behaviour, especially as he reached adolescence, became increasingly challenging at home and risk-taking elsewhere.
“He began to come to the notice of the police, sometimes in association with other young people, and there were concerns that he was experimenting with alcohol and drugs (cannabis and possibly cocaine).
“During Kyle’s first year of college, his anti-social behaviour outside the home, and anger and sometimes violence within it, increased.”
What the review said about Children’s Services
Kyle had been “looked after” by the council since he was three years old. For much of his life, his foster placement with his aunt and uncle was supervised by the same social worker.
But Brighton and Hove Children’s Services faced staffing challenges. The review said: “These related to problems of staff retention and recruitment of managers, of weak management and non-reflective supervision and of large teams which meant that children and families as service users experienced too many transitions/changes of workers.
“It is fair to say that most of these featured, in one way or another, in Kyle’s case.
“Mrs Birchall was well supported by her (supervising social worker) who had known the whole family for several years.
“(The supervising social worker) understood Kyle’s past and his current difficulties and was in many ways the lynch pin for communicating about these to the new social workers who followed on from March 2013.
“During the period under review there were four changes of social worker and, in the last 22 months of his life, the records indicate that no social worker saw Kyle more than five times.
“Inevitably this led to difficulties for each social worker in being able to establish a relationship with him, with Kyle becoming increasingly elusive.
“Mr Markham described Kyle, when they were together, as bitterly complaining about his changes in social workers: ‘Why am I going to confide in someone I have only known for five minutes?’
“Kyle also spoke to Mr Markham about the earlier loss of (the second supervising social worker).
“We know that children in care can feel particularly let down and alienated when they experience repeated changes of social worker and the loss of a familiar relationship seems to have affected Kyle, his family and co-workers in the Friends and Families Team.
“Some workers were involved for a very brief time (one never meeting Kyle) and held varying degrees of understanding about Kyle’s personal and family history.
“The disadvantages of using a succession of agency workers for a child in care are well understood by Children’s Social Work Services.
“Unfortunately for Kyle, the 16+ Team, at the time when he transferred into its care, was struggling with an absent manager and a far higher than usual number of agency staff (this was in contrast to the rest of the service).
“He thus experienced four social workers in a period of 18 months and this lack of continuity inevitably affected the ability of both sides to work effectively together.”
The review’s conclusion
“The review team have given much thought to the events immediately preceding Kyle’s death and have scrutinised the decision-making by all parties.
“After a tragedy such as this, it is natural to seek explanations and sometimes to want to blame an individual or an organisation. This is not the position of this review.
“It is the case that practice could and should have been better at different times and in ways that the findings consider in broader terms.
“It is also the case that there were examples of good individual practice in what we have seen.
“It is our view that there is no justification for making a causal link between practice, even poor practice, and Kyle’s death.”
The wider relevance of the review
The review said: “The turbulence of adolescence brings greater challenges for carers and young persons alike.
“These patterns are ones which affect the work of agencies (especially Children’s Social Work Services) far beyond this local authority.
“We found a number of additional local challenges in the inconsistent use of case history, record-keeping and, in one team, a period of over-reliance on agency staff.
“There were recognised problems in the number of electronic record systems (three separate ones, at the time, now reduced to two).
“There were also some familiar ‘attitudinal’ patterns in relation to male carers and connecting with young people who do not easily share their underlying distress or vulnerabilities.”
What the Local Safeguarding Children Board said
“The Brighton and Hove Local Safeguarding Children Board (LSCB) has published a serious case review into the death in 2014 of Child ‘E’, a young person from the city.
“The full report can be read at: http://brightonandhovelscb.org.uk/child-e.
“The young person is not named in order to protect the privacy of the young person’s wider family and acquaintances, as is normal practice for LSCBs.
“The aim of the review is to establish whether there are lessons that need to be learned by the agencies involved to help prevent this type of tragedy being repeated.”
The independent chair of the Brighton and Hove LSCB, Graham Bartlett, said: “This is an extremely sad case and I would like to express my deepest condolences to this young person’s family.
“We very much value the input they have given to this serious case review and would like to thank them for their participation.
“The purpose of the review is to establish whether there are lessons that need to be learned in order to help prevent these types of tragedy being repeated and to improve child protection and safeguarding in Brighton and Hove.
“The Local Safeguarding Children Board has accepted each of the review’s findings.
“The coroner’s inquest into the tragic incident that caused this young person’s death found that it was neither predictable nor preventable. The review has found no evidence to contradict this view.
“However, as this serious case review has indicated we think it’s clear that there are a number of things that need to be done differently in future.
“Kyle was in the council’s care but was being looked after by other family members. While we recognise that this was in his best interests, we found that this had led to a blurring of boundaries with regard to decision-making.
“This is a very complex area and there is a lack of guidance both nationally and locally on balancing these responsibilities.
“We are therefore calling on the council to develop clearer guidance for its staff and for their ‘family and friends’ carers.
“There are recurring themes in the review around poor record-keeping by the agencies involved, the sharing of information among the professionals involved and communication between the agencies.
“We think it is clear that agencies working with children and families should have done more to take into account the views of the non-primary carer and should have done more to try to maintain good levels of communication with the primary carer.
“We are calling on our partners to reassess their policies and guidance in this area.
“We also think it is clear that Sussex Police could have kept better records of their contacts with Kyle and should have worked more closely with the council’s children’s services to address the concerns these contacts raised.
“We have therefore called on the police to review the way they operate in this key area.
“The review also highlights a need to create different and more ‘young-people friendly’ mental health and emotional wellbeing services in this area.
“We acknowledge that much has been done to rectify the issues highlighted in the review and the LSCB will be evaluating the impact of these changes and those that follow from our proposals to enhance the safeguarding of children and young people in the city.”
What Brighton and Hove City Council said
Brighton and Hove City Council’s executive director for families, children and learning, Pinaki Ghoshal, said: “We would above all like to extend our condolences to the carers and family of the young person ‘E’ who was the subject of this review, and also to members of our children’s services team who worked with the young person and have been profoundly affected by this case.
“We accept the findings of this review and all of its recommendations.
“We note that there were no findings that suggested that any agency’s actions could have predicted or prevented Kyle’s death and that the review found no justification for making a causal link between the work of our children’s services team and Kyle’s death.
“However, we accept that some of our practice wasn’t as good as it should have been and we apologise for this.
“Since this tragic incident in late 2014 we have reviewed and improved the way we run some of our children’s services, particularly with regard to record keeping and data management, care planning and communication with carers.
“In particular we have restructured our social workers into small teams where information about the young people they work with is held by a whole team rather than by individuals.
“In this sense we have anticipated and already implemented most of the recommendations put forward in this review. We are committed to making all the other changes called for by the report as soon as possible.
“We have also recruited a number of permanent staff and are radically reducing the number of agency staff we use in our children’s services teams.
“Social work is an incredibly complex area, with difficult judgments often having to be made instantly under extreme pressure.
“Our role as a corporate parent can sometimes conflict with the wishes of our ‘family and friends’ carers as well as with the often conflicting wishes of the young people they are looking after for us.
“We accept that more needs to be done to develop our guidance and policies in this area and we are addressing this.”
What Sussex Police said
Sussex Police said: “Only one of the eight findings in the serious case review is directed to Sussex Police.
“In relation to that finding, we have recognised that on occasions there can be a lack of clarity for officers as to when a ‘SCARF’ (Single Combined Assessment Report Form) should be completed and we are therefore reviewing the procedures in consultation with multi-agency colleagues.
“Following that, an audit will be completed and reported to the Local Safeguarding Children Board and any necessary changes will be made.
“However, we also note that the coroner’s inquest into the tragic incident that caused this young person’s death found that it was neither predictable nor preventable and that the review published on Monday 26 September has found no evidence to contradict this view.”
What the social workers’ union said
A convenor from the Unison union, Sue Beatty, said: “It has long been Brighton and Hove Unison’s view that social workers are hugely overworked and very underpaid.
“The current starting salary for newly qualified social workers in this area of work is £25,694 and this has caused huge problems in terms of recruitment and retention to certain teams.
“Quite simply there are not enough staff to cover the huge and ever growing caseloads that social workers are dealing with.
“Added to this, agency staff are expensive and using them for months, even years, adds to the problem as the money could and should be better used to retain existing and future permanent employees giving greater consistency of care.
“It is not a secret that the council will often not recruit to a permanent post when a vacancy occurs in the hope of saving money through on-costs such as pension, national insurance, sick pay, etc.
“This is certainly not in any child’s interests to have several social workers allocated over a short period of time.
“Our members in children’s services are as concerned about this extremely sad situation as anyone else. The council really needs more social workers and more investment into those services.
“It is extremely fortunate that the council has extremely dedicated and committed staff who work very hard in, often, very difficult circumstances.”
The review findings
1. There is an inherent tension regarding the respective roles of the local authority as corporate parent and ‘family and friends’ carers who are seen as ‘parents’ or ‘family’. This can result in unhelpfully blurred boundaries and a difficulty in asserting the local authority’s statutory responsibility for a child or young person when this is required.
2. In Children’s Social Work Services it is difficult to access the various sources of a looked-after child’s past records, leading to an associated response of not prioritising this essential preparation. The result in many cases is that the corporate parent does not easily know the life story of its children.
3. The tools for transmitting background information about a child or young person (transfer summaries and chronologies) are not produced to a consistent standard, meaning that a new social worker may not have the background and qualitative information which would support a holistic understanding of the child or young person and family and their needs and risks.
4. Is there a risk for professionals, in following care planning, placement and case review regulations, to give too much responsibility to young people over their ‘pathway plan reviews’, with the result that difficult subjects are not raised if the young person objects?
5. Nationally, there is no routine framework for multi-agency professionals to meet outside of ‘pathway plan reviews’, leaving the responsibility with an individual practitioner to convene such a forum. The result is that planning and decision-making for a child often proceed without the benefit of a joined-up discussion of others’ perspectives and concerns about a child.
6. There is a pattern of focusing only on the primary (usually female) carer for a child in care, and not giving sufficient attention to the role of the non-primary carer (usually male). This can result in professionals’ lack of awareness of both positives and negatives that the other carer may bring to his/her role.
7. In Brighton and Hove Children’s Social Work Services there is inconsistent recording. Without a complete and accurate record, it is difficult for practitioners and their managers to analyse the facts and context of a child’s situation and to make appropriate decisions and plans.
8. Sussex Police do not always act in accordance with their own guidelines by informing Children’s Social Work Services about their observations of, contact or interventions with young people. This means that opportunities for joint thinking, decision-making and interventions may be lost.
What about specialist help from CAMHS?
Kyle was referred to the Child and Adolescent Mental Health Services (CAMHS) which have been criticised locally and nationally.
The review said: “He was referred to CAMHS because of persistent distress and low mood.
“Kyle himself, while he was in respite foster care (October 2014), approached his GP asking for anti-depressant medication for anxiety and depression.
“At other times, Kyle was adept at covering these feelings and was seen by many as a cheerful cheeky lad who got on with adults and children alike.
“Kyle declined to use the CAMH service to which he was referred in autumn 2012. He went for one appointment and decided it wasn’t for him.
“The case was closed by CAMHS shortly after his decision.
“Kyle’s reluctance to engage with CAMHS echoes the findings in two recent learning reviews in Brighton and Hove, both in relation to the deaths of vulnerable adolescents.
“These have highlighted what is a local and national issue: the need to create different ‘young-people friendly’ ways of improving access to CAMHS for adolescents.
“In the second of these reviews … Finding 4 asserted that: ‘There is inadequate choice in mental health service provision to meet the preferences of many young people, leaving them with the option of attending, or not, the available medically focused option.’
“The associated action point for Brighton and Hove LSCB was that it needed … ‘to be assured that mental health and emotional wellbeing services for adolescents are receptive, responsive and attractive to the needs of young people’.
“The idea of ‘assertive outreach’ is not accepted as critical, in order to create services which ‘reach out to where children and young people are within the community, not just receiving support in clinical areas’.
“In this spirit, Brighton and Hove CCG have reviewed their CAMH Services in the past 12 months and have developed a Local Transformation Plan for Children and Young People’s Mental Health Services as part of a five-year strategy of change and development across the whole system.
“There is increasing recognition that the work to support children and young people may sometimes of necessity be carried out via CAMHS’ input to their parents/carers, to enable them to understand and help their child/young person with their emotional distress.
“And parents/carers may themselves benefit in a number of ways from such support, to help them cope better with the demands on them of helping their child.”
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