An abused Brighton teenager was struggling with a planned move to new foster carers and his fears that he might become an abuser himself before his body was found on a railway track on New Year’s Day last year, a new report says.
Steffan Bonnot, 17, had been moved 31 times since being placed under Brighton and Hove City Council’s care.
A serious case review published today recommends that the council should ensure all relevant material is passed over to new carers and that looked-after children are made aware that this is happening.
It also says that a “polarised debate” between the council and the residential unit where he had been living for five years when he died about where he should go next had “unhelpfully confused” Steffan, who the report referred to as A.
The council wanted to move Steffan from the unit to foster carers but staff at the unit were concerned that he was not ready for such a move.
The report adds that neither Steffan’s family, who he was still in touch with, nor professionals knew that he was at risk of self-harm.
Steffan’s mother disputes this and said that there were concerns that he might take his life. An inquest into the his death is currently adjourned until next month, awaiting further evidence.
The independent chairman of the Brighton and Hove Local Safeguarding Children Board, Graham Bartlett, said: “The death of (Steffan) was an absolute tragedy. Those the report author talked with spoke of (Steffan’s) charm, good looks, sporting prowess and dry sense of humour.
“We know that (Steffan) had been in the council’s care since 2004, under a care order, and that he had very complex needs having been subjected to significant levels of physical and emotional abuse and neglect in the context of chronic domestic violence in his early childhood.
“(Steffan) had experienced a number of unsuccessful attempts to be placed in foster families. Such placements were not able to manage his troubled and troublesome behaviours so, at the age of 12, (Steffan) lived in a residential therapeutic unit in a neighbouring county and remained there until his death. He benefited from good continuity of support from his social work resource officer and independent reviewing officer.
“However, this report highlights a number of differing perspectives between Brighton and Hove City Council, as the responsible commissioners, and the residential therapeutic unit, as providers, and the polarised positions that existed between the two and the absence of negotiated consensus in a number of areas impacting (Steffan).”
The report was commissioned by Brighton and Hove Local Safeguarding Children Board and written by Fergus Smith, an experienced independent author. Frontline professionals who supported Steffan participated in the review. His mother and maternal grandmother also contributed to the review along with a female carer with whom (together with her husband) it had been hoped that Steffan would live.
Mr Smith’s report concludes: “Among those who knew (Steffan) well and cared greatly about him, neither professionals or family had discerned that he was thinking about self-harm.
“Subject to the coroner’s judgment, it appears that behind a ‘brave face’, anxiety about leaving the security of his home of five years to face the emotional pressure of normal family life, expectations of age-appropriate education and, above all, an immediate panic about what sort of a person he might become, overwhelmed him.”
The report author recommends
- Brighton and Hove social services should assure itself that, with respect to its looked-after children, all relevant available information is being passed over (when possible ahead of placement), in accordance with Care Planning Regulations 2010, to those individuals who are be entrusted with the care of a child
- That the individual being placed is provided with an age-appropriate appreciation of information being passed over
- All care and placement plans (the priority being high-risk cases) include a clear contingency position (a plan B as per para. 2.45 Volume 2 Care Planning, Placement and Case Review Regulations Guidance 2015)
- In the context of “Who Pays” commissioning guidance, Sussex Partnership NHS Foundation Trust should continue to progress discussions with the relevant three authorities (West Sussex, East Sussex and Brighton and Hove) to facilitate access for “looked-after children” to specialist mental health services for those placed “out of area” and still remaining within Sussex
- Management at the therapeutic unit should review organisational capacity (knowledge and assertiveness) to challenge any care plan about which the unit has insufficient confidence
Mr Bartlett said: “As well asking for assurance from organisations in Brighton and Hove about the changes they have made since the death of (Steffan), the role of the Local Safeguarding Children Board is to address multi-agency working, the relationship and co-operation between services that should keep children safe and to tackle areas where joint working could improve.”
He added: “The Brighton and Hove LSCB accept the serious case review report in its entirety and our case review subcommittee will monitor actions necessitated from this review with progress reported to the board.”
The Local Safeguarding Children Board has today published its Learning and Improvement Report which sets out its responses to the reviews findings and recommendations.