THE EXECUTIVE SUMMARY

THE EXECUTIVE SUMMARY SERIOUS CASE REVIEW IN RESPECT OF CHILD K AND CHILD L AND DOMESTIC HOMICIDE REVIEW IN RESPECT OF MLK Cmmissined by Traffrd Safeguarding Children Bard and Safer Traffrd Partnership Authr: Pamela M Sheltn Independent cnsultant Date: 17 August 2012

CONTENTS Intrductin Summary f events leading t the review The Review Panel Parallel prcesses Invlvement f the families Summary f events Summary f events January 2001 - December 2010 Summary f events January 2011 20 September 2011 Analysis and cnclusins Key issues arising frm the case Pririties fr learning and change Recmmendatins and actin plans Recmmendatins frm SCR/DHR Actins frm SCR/DHR Overview Reprt Actins frm the Health Overview Reprts Individual Agency actin plans 2

Intrductin Summary f events leading t the Reviews 1. In the early hurs f Mnday 19 September 2011, MP brke int the huse f his ex-partner, MLK. She and her daughter (Sibling 1, aged 18) and 15-year-ld sn (Child L) came ut f their rms n hearing the nise, leaving her fur-year-ld sn (Child K) asleep. They saw MP climb the stairs, dwsing them with fuel frm a cntainer he carried; then retrace his steps, dwsing himself as he went. They tried t stp him but t n avail. MP then lit the fuel. Immediately, he, MLK and Child L were engulfed in flames. Sibling 1 was als caught in the fire but managed t pen a windw and was pulled ut by a neighbur wh als rescued MLK. Child L made his wn way ut, and fire fighters rescued Child K. 2. MP never regained cnsciusness. Child L had very serius burns frm which he died n 21 September. MLK als had very serius burns and died in hspital n 25 Nvember. Child K was burned frm the intensity f the heat rising int his bedrm but has since been discharged t the care f his father. Sibling 1 survived her injuries but required extensive hspital treatment. 3. The Traffrd Safeguarding Children Bard, chaired by Bb Pstlethwaite, agreed in Octber t cnduct a serius case review in view f the death f Child L and injuries t Child K. Sibling 1 was nt included as she is an adult. When MLK died, the Safer Traffrd Partnership, chaired by the Chief Superintendent in Traffrd, agreed that the death fell within the criteria fr cnducting a dmestic hmicide review. The guidance fr undertaking serius case and dmestic hmicide reviews is similar s it made sense t cmbine them in this instance. Terms f reference and the membership f the panel were agreed. The time span fr the reviews was set: frm the beginning f 2001 fr MP, at the pint his marriage ended, t 20 September 2012; and frm January 2011 fr MLK, Child L and Child K. The timescale fr cmpleting the reviews was the end f July 2012 t take accunt f the breadth f the reviews and number f agencies invlved acrss fur lcal authrity areas, including Traffrd, Manchester, Bury and Lancashire. 4. The purpse f the reviews is t establish what lessns are t be learned abut the way in which lcal prfessinals and rganisatins wrk individually and tgether t safeguard and prmte the welfare f children and safeguard victims f dmestic vilence; and agree actin t prmte change as a cnsequence. It is nt the business f the reviews t inquire int hw a child died r was injured r wh is respnsible fr the dmestic hmicide, r t reinvestigate the crime r apprtin blame. These are matters fr the crner and criminal curt t decide. The review panel 5. The members f the Review Panel are included in the chart belw. In additin, an independent plicy advisr n dmestic vilence was appinted t assist the Panel. A cnsultant frensic psychiatrist was als available t the Panel and prvided a written reprt and attended ne Panel meeting. 6. The independent authr f the verview reprt (and f this summary) is Pamela Sheltn wh attended all the Panel meetings. The independent Panel chair was Clleen Murphy. Bth have extensive experience f wrking in children s scial care, as practitiners and managers; and mre recently n an independent basis undertaking a range f assignments. Bth f them have had cnsiderable experience 3

f undertaking Serius Case Reviews. The requirement t undertake dmestic hmicide reviews dates frm April 2011 and hence few have been cmpleted. Psitin Agency Clleen Murphy Independent Chair f the Panel Assciate Directr f Manchester Mental Health and Scial Care Trust Gvernance Team Manager Safeguarding and Imprvement, Manchester City Children s Services Head f Service Multi-Agency Referral and Assessment Service, Traffrd Children and Yung Peple s Service Deputy Directr Traffrd Educatin and Early Years Service Designated Nurse, Traffrd Children and Yung Peple s Service (Traffrd Safeguarding Health Ecnmy) Designated Dctr Manchester and Traffrd Statin Cmmander Greater Manchester Fire and Rescue Service Detective Chief Public Prtectin Investigatin Unit, Greater Manchester Inspectr Plice Assistant Chief Greater Manchester Prbatin Trust Executive Divisinal Manager Greater Manchester Victim Supprt Business Manager Traffrd Safeguarding Children Bard Slicitr Traffrd Legal Services, Advisr t Traffrd Safeguarding Children Bard Parallel prcesses 7. Manchester Mental Health and Scial Care Trust, t whm MP was referred fr his mental health prblems, has undertaken an internal Serius Incident Review and the reprt was made available t the Panel. The Independent Plice Cmplaints Cmmissin has als investigated the incident and Greater Manchester Prbatin Trust has cnducted its wn Serius Further Offence investigatin. 8. The Suth Manchester Crner s Office will be hlding inquests in Nvember 2012 in respect f Child K, MLK and MP in rder t establish when and hw the parties cncerned died, and t recrd a verdict. Invlvement f the families 9. The Panel was clear that it was an essential part f the review prcess t hear the views f family members wherever pssible, as their perspective wuld prvide an additinal dimensin and different perspective t thse f the prfessinals invlved. As part f the prcess f setting up the reviews it was agreed which family members shuld be apprached and much effrt was put int establishing cntact with them. 10. The Panel Chair and Business Manager tgether made visits t the parents f MLK; the father f Child K; MP s mther; and SC1 (MP s stepdaughter and mther f Child 4). Despite cnsiderable effrt, it did nt prve pssible t see Sibling 1, the father f Child L r MP s frmer wife (MPFP). The infrmatin and insights prvided by family members has indeed given anther perspective n events. The reprts f thse visits are fully reprduced in the verview reprt; and are incrprated int the 4

analysis and cnclusins. This summary makes brief reference t them as apprpriate. Summary f events This sectin summarises the very lengthy summary f events sectin in the verview reprt. The latter is itself based n the 14 individual management reprts received frm the agencies wh had substantial cntact with MP and MLK and her family, and the cmbined chrnlgy f events. Only key events are included here. Summary f events January 2001 - December 2010 11. MP, his wife (MPFP), their tw children (Child 1 and Child 2), and MP s tw stepchildren (SC1 and SC2) were living tgether in Manchester until early in 2001 when the relatinship brke dwn. MPFP returned t Bury, initially leaving the children in the care f MP. It was at this pint that SC1 says that she (aged 13) and MP started their sexual relatinship; and that she assumed care f the children. Once MPFP had secured a tenancy, the children went t live with her. Hwever, SC1 nly stayed in Bury briefly befre returning t live with MP in Manchester. 12. MP tk what he perceived as MPFP s rejectin f him very badly; his behaviur became erratic and he said he wanted t die. He tk an verdse f tablets in March 2001 and went t Wythenshawe Hspital where a psychiatric assessment was undertaken. There was n evidence f mental illness. This incident became part f a pattern f behaviur ver the fllwing years. 13. During 2003, the GP referred MP t the Primary Care Mental Health Team but MP did nt attend the appintments ffered. This t became a pattern during the rest f his life. 14. In 2004, MP s ex-wife and mther f SC1 cntacted Greater Manchester Plice (GMP) t reprt SC1 s disclsure t her f a cnsensual sexual relatinship with MP. There fllwed a jint Plice and Bury Children s Scial Care (CSC) investigatin (SC1 having returned t live in Bury) but SC1 (aged 15) refused t cperate and there was n evidence n which t prceed. Bury judged that SC1 s mther was able t prtect SC1 sufficiently, althugh SC1 denied that the relatinship was abusive. She subsequently mved back and frth t live with MP during 2005 and 2006. 15. MP was briefly admitted t hspital fllwing a suicide attempt after the disclsure t Plice f his relatinship with SC1. 16. In 2006, the GP referred MP t the Cmmunity Mental Health Team but he failed t attend. MP sught help frm the A&E Department, claiming that he had attentin deficit hyperactivity disrder (ADHD) fr which he required medicatin. He cntinued t insist n this diagnsis, despite psychiatric assessments t the cntrary, and treated himself with illegal substances. 17. SC1 (aged 18) became pregnant t MP twards the end f 2006 and mved t her wn tenancy in Bury. Bury CSC became invlved because f her vulnerability and MP s cntinuing invlvement with her that included abusive elements. On Bury s advice, SC1 reprted the relatinship with MP t Greater Manchester Plice in Bury but made it clear that it was nt a cmplaint; rather she was cncerned that MP might abuse her child were it female. The Plice culd nt cnsider a prsecutin fr 5

underage sex because, under legislatin in frce at that time, a cmplaint had t made within 12 mnths f the alleged ffence. 18. Early in 2007, MP failed t attend hspital fr assessment f a heart cnditin. His relatinship with SC1 fluctuated between perids f separatin and recnciliatin. Scial wrkers in Bury were cncerned by SC1 s reprts f his emtinal abuse f her and requested MP t leave. He tk an impulsive verdse and was admitted t hspital vernight. He failed again t take up the ffer f cunseling frm the Primary Care Mental Health team after anther referral by his GP. SC1 mved back t live with him in Manchester shrtly afterwards. 19. Fllwing the birth f their daughter (Child 4), MP and SC1 mved in June 2007 t live with MPFP (SC1 s mther and MP s ex-wife) in Bury. This created pressures in the husehld and scial wrkers advised them firmly t return t Manchester, where they were admitted t hmeless family accmmdatin. During the next tw mnths, they twice returned t Bury t seek husing assistance but were refused and returned t Manchester. There was n liaisn by Bury scial wrkers with Children s Services in Manchester, althugh they remained invlved with MPFP and her family. 20. In August, MP had an utpatient psychiatric assessment in Manchester but n evidence f mental illness was fund and a further appintment was made fr psychlgical supprt frm the Primary Care Mental Health Team. He had a further assessment in Octber and discussed his daily use f cannabis and amphetamines t calm him dwn and treat his self-diagnsed ADHD. The cnsultant advised referral t the Cmmunity Drug Service prvided by anther Hspital Trust in Greater Manchester. MP attended at the Drug Service later in the year and was discharged fllwing a further appintment, as his drug use seemed under cntrl. 21. In Nvember 2007, at a further utpatient appintment, the psychiatrist diagnsed MP as having a persnality disrder with unstable emtinal elements. MP was upset by this utcme and strmed ut. Meanwhile, he underwent investigatins fr chest pains, which prved t be ischemic heart disease. 22. SC1 mved in August 2007 t Lancashire, she said t escape MP. She reprted her histry t staff at a children s centre and scial wrkers became invlved, having als received infrmatin frm Manchester Children s Services. Scial wrkers were cncerned by her chice f a new partner and her verall vulnerability, and s remained invlved. Cncerns increased during 2008 with reprts f dmestic vilence, and regular separatins and recnciliatins with the new partner. 23. At the end f May 2008, SC1 allwed MP [had] t have unsupervised access t Child 4. He tk her ut then sent a text saying he wuld nt return her until SC1 had ended her current relatinship. He later sent [a] nther text stating that he intended t kill bth himself and Child 4. Lancashire Plice eventually lcated them in Bury and judged that n ffence had ccurred. As a cnsequence, they did nt infrm their GMP clleagues. Hwever, there was evidence f drug-use and MP referred t his mental health prblems s fficers tk him t the lcal hspital. Clinicians fund n evidence f mental illness and referred him back t Manchester mental health services requesting an infrmal admissin t hspital. Instead, the Crisis Reslutin and Hme Treatment Team visited him: he tld staff that he had wanted t scare SC1 int nt letting him see Child 4 because he had strng thughts f killing her; he did nt want t act n thse thughts but was fearful f lsing 6

cntrl. He was unable t reassure staff that he wuld nt try t take Child 4 away again. 24. Staff decided t re-refer MP t the Cmmunity Drug Service and arrange a further psychiatric utpatient appintment via his GP. They als made cntact with Lancashire scial wrkers, wh assured them that MP wuld nt have further unsupervised cntact with Child 4, and then discharged MP frm their care. 25. The Cmmunity Mental Health Team received a referral frm the GP and deemed MP unsuitable fr their service s referred him t the Cmmunity Drug Service. The latter decided that MP s mental health prblems were the pririty s referred him back t the Cmmunity Mental Health Team. It is nt clear what happened next. 26. Scial wrkers remained cncerned abut the risks that SC1 s current partner psed fr Child 4 and, fllwing a strategy meeting, a child prtectin investigatin cmmenced. By January 2009, Child 4 s situatin was such that an interim care rder was granted and she mved t a fster hme. MP was allwed supervised cntact and requested cnsideratin fr him and his ex-wife (with whm he was recnciled) as carers fr Child 4. 27. Over the next few mnths, Plice were twice called t MP s huse due t altercatins between him and his wife after which she asked him t leave. His wife was then the subject f a Multi-Agency Risk Assessment Cnference as a result f her reprt f MP s abusive behaviur. 28. In June 2009, MP barricaded himself in an upstairs rm f his huse with a knife and threatened t use it if apprached. Plice frm GMP mved his wife (with whm MP was again recnciled) and the children ut. After tw hurs, MP emerged in a calm state. He was arrested and eventually charged with a minr ffence f criminal damage, as he had nt effectively threatened anyne. 29. The next day, MP tld his GP that he felt like kidnapping his daughter and killing her and had thughts f suicide. The GP referred him t the Cmmunity Mental Health Team, althugh did nt believe that MP had any intentin f carrying ut his threat. A clinician visited MP at hme t make an assessment the fllwing day. The incident in May 2008 regarding Child 4 was nted and referred t as a kidnapping. MP spke again f thughts f killing Child 4 because she was nt living with him. He agreed t a referral t clinical psychlgy fr help with anger management. The CMHT later discussed n tw ccasins whether MP shuld be referred fr a frensic assessment because f his ptential risk t thers and yung females in particular. N such referral was made. 30. Later in June, the independent scial wrker cmpleted the parenting assessment f MP in relatin t his applicatin t be cnsidered as a carer fr Child 4. It cncluded that Child 4 wuld be at cnsiderable risk if placed in his care. 31. In Nvember 2009, MP was sentenced t a Cmmunity Order with 12 mnths supervisin by Prbatin. His attendance at appintments was variable. As part f the infrmatin-gathering prcess, the prbatin fficer cntacted the scial wrker in Lancashire early in 2010 regarding Child 4 and learned that she wuld nt be returning hme, and als received infrmatin abut MP s disclsure t his GP f wanting t harm her. 7

32. MP tld his prbatin fficer abut his new girlfriend, MLK, but wuld nt give her name. He later said that MLK had children but refused t prvide any further infrmatin. The prbatin fficer cnfirmed with GMP that there were n recent recrded incidents f dmestic abuse invlving MP but learned f six earlier incidents relating t his ex-wife. MP later said that the relatinship with MLK had ended. 33. Over the next few mnths, MP was very unsettled: he was upset abut Child 4; he had brken up with MLK and lst his hme; he was misusing drugs and alchl and was self-harming. His mther tld the prbatin fficer hw wrried she was abut him and did nt knw what t d. In July, MP spke by phne t a mental health nurse and said he was in the md t injure r kill smene, then ended the call. In view f his histry, the nurse reprted the matter t GMP, and als referred t MP having made similar threats in 2008 twards his daughter (Child 4); and that in June 2009 he had kidnapped the child. Officers visited MP and fund him calm: he said he had n intentin f harming anyne but had felt very angry. GMP lgged the incident indicating cncern fr the welfare and mental health f an adult and a referral was made t Adult Scial Care. 34. Shrtly after this incident, SC1 (MP s stepdaughter) reprted t Plice that MP had threatened t kill her. Officers assisted her next day t cllect items f prperty she had left at MP s huse and clsed the matter as a dmestic incident. A mnth later, MP tld GMP that he felt like hurting r killing the persn wh he believed t be sexually abusing his stepsn s children. An fficer visited him, assured him that the matter was being dealt with and facilitated MP in having cntact with the Samaritans. 35. The Cmmunity Mental Health Team agreed at a meeting t undertake a risk assessment f MP. He failed t attend the appintment and they clsed the case. MP had an utstanding appintment t attend the psychlgy service in the Primary Care Mental Health Team. Summary f events January 2011 20 September 2011 36. In January, MP was driving his car in an intxicated state and cllided with several vehicles utside his huse. He refused t prvide the Plice with a bld r urine sample fr analysis. Later that mnth, he threw a frying pan twards his sn whilst in an intxicated and aggressive state, and fat splashed n his sn s girlfriend s face. This led t anther Multi-Agency Risk Assessment Cnference at which MP s unpredictable and aggressive behaviur was nted, alngside his heavy use f drugs and alchl. During this perid, the GP referred MP t the specialist alchl unit in Manchester. 37. In February, MP was sentenced t a 12-mnth Suspended Sentence Order under the Prbatin service, and was required t attend a prgramme designed fr impulsive drinkers wh exhibit angry and vilent behaviur. The prbatin fficer referred him t the Addictin Dependency Service in March; he failed an appintment at the Alchl Unit but attended the Cmmunity Drugs Service, alng with MLK and a yung child. Clinicians frm the Drugs Service infrmed his prbatin fficer f the invlvement f MLK and her child. 38. In April, MP asked GMP fr help nt t cmmit suicide after anther break-up with MLK. He was intxicated and went t hspital accmpanied by MLK. A psychiatric nurse made a full assessment; learned that MLK knew abut MP s histry f child abductin (althugh MP had threatened rather than carried ut an 8

abductin); recrded ptential safeguarding cncerns in relatin t MLK s children but nted that MP had n current thughts f harming a child. The prbatin fficer later challenged MP again t prvide infrmatin abut MLK but he refused; as did MLK when she accmpanied MP t a further appintment with the fficer, save t cnfirm that she had three children. MP then saw the prbatin fficer s manager t ask fr a change f fficer, and disclsed MLK s address. At his next appintment, the prbatin fficer said a referral wuld be sent t Traffrd Children and Yung Peple s Service infrming them f the relatinship and the ptential risk t MLK s children. 39. In May, MP was made subject t a further 12-mnth Suspended Sentence Order plus a three-mnth curfew requiring him t be at his hme address between 8.00pm and 6.00am. 40. In June, MP s applicatin t change his curfew address t MLK s hme during the week was granted by the private firm wh supervised curfew arrangements. The change went ahead withut reference t the prbatin fficer, MP s slicitr having cnfirmed the suitability f the address. MP attended at Prbatin and cnfirmed that he wuld be staying at MLK s huse n Mnday and Tuesday and she wuld cme t his huse fr the weekend. MP attended the cardilgy clinic: he had stpped taking his medicatin; his bld pressure was high; and he was referred fr pssible cardithracic surgery. 41. In July, MP brke his curfew by staying with MLK beynd the agreed times. He was admitted t hspital having taken an verdse f drugs and alchl and cut his arms; and was referred fr a psychiatric assessment. A mental health nurse undertk the assessment in hspital and a cmmunity psychiatric nurse assessed him after his discharge hme: the assessment cnfirmed that MP had an emtinally unstable persnality disrder; that there was n rle fr the Cmmunity Mental Health Team (CMHT); and, at MP s request, that the GP shuld refer him fr a specialist ADHD assessment. Later in the mnth, the CMHT agreed there was n rle fr them and referred MP fr an utpatient appintment with the psychiatrist, which was subsequently cnfirmed fr early September. 42. In early August, the prbatin fficer learned that MP had attended the Alchl Unit with MLK and Child K; and Unit staff had infrmed the schl nurse, with MP s signed agreement, because f cncerns fr the child s welfare. MP later tld his prbatin fficer that attending the Unit was a waste f time. 43. The prbatin fficer then cntacted Traffrd Children and Yung Peple Service (CYPS), as indicated t MP in the previus April, t refer the cncerns abut MP: his histry f drug and alchl misuse, dmestic vilence and mental health prblems; the sexual abuse f his stepdaughter in the cntext f his current relatinship with MLK; that he was staying at MLK s huse vernight and had regular cntact with her children; and was knwn t bth Manchester and Lancashire children s services. He sent the same infrmatin in writing. Hwever, the referral was made t a family supprt team rather than the Multi-Agency Referral and Assessment Team (MARAT) and this delayed it by a day. MARAT received an exceptinally high number f referrals that day relating t the rits in Greater Manchester, which tk pririty. As a cnsequence, the team did nt cnsider the email frm Prbatin until the next day (11 August). 44. MARAT btained infrmatin that same day frm Lancashire Children s Scial Care wh additinally advised Traffrd abut the incident in May 2008 when MP was fund t be threatening his stepdaughter and himself. This was in fact 9

Child 4. Manchester Children s Services wuld nt prvide infrmatin ver the phne and sent details the fllwing week. 45. The fllwing day (Friday 12 August), the MARAT manager decided, in the light f the infrmatin received thus far, that the team shuld make an urgent visit t MLK: t assess the extent f MP s cntact with her children, and what MLK knew f MP s histry and the risk he presented t her children. The email received frm Prbatin was frwarded t Traffrd Public Prtectin Investigatin Unit (PPIU) with a request fr any infrmatin abut MP held by GMP. They respnded the fllwing Mnday. The allcated senir scial wrk practitiner (SSW1) made n direct cntact with the PPIU at this stage because the intentin was t make an initial assessment f the situatin rather than an enquiry under child prtectin prcedures. 46. SSW1 arranged t visit MLK that afternn and asked t see her n her wn. She and anther scial wrker (SW2) arrived at the huse t find MP there alng with his mther and a friend. The scial wrkers cnfirmed that MLK wuld prefer t speak with them n their wn and the thers left, albeit reluctantly, and returned later. The scial wrkers reprted that MLK was relaxed in their presence; she listened t the infrmatin they had learned abut MP and indicated that she knew the facts althugh hearing them frm the scial wrkers made them sund different. She als said that MP justified his behaviur by saying that his ADHD meant that he was nt respnsible fr his wn actins. Hwever, she asserted that MP did nt behave with her in the way described in his previus relatinships. The scial wrkers were cncerned that MLK was thus minimising what MP had dne and the risks he psed t her children. 47. MP s daughter (Sibling 1, aged 18) then described hw uncmfrtable she felt in MP s presence, and added infrmatin abut the effect f MP n Child L (aged 15). This infrmatin caused the scial wrkers mre cncern. MLK cnfirmed that when she had tried t end the relatinship, MP had harmed himself; she als acknwledged dmestic abuse in her previus relatinships. She then referred t a family hliday, which included MP, which was due t start the next day. The scial wrkers decided that MP psed an immediate sexual and emtinal risk t the children and Sibling 1 n the basis f his sexualised cmments t Sibling 1; his cntrlling style f behaviur; MLK s wn histry f dmestic vilence that made her mre vulnerable; and her minimisatin f the risks that MP psed t her children. 48. After lengthy discussin, MLK acknwledged that MP s behaviur was unacceptable and indicated that she appreciated better the risk that he psed t her children. She signed a handwritten agreement t the effect that she wuld nt allw MP int the huse r t have cntact with the children; and wuld reprt t the Plice any threats r attempts by him t visit the hme. She agreed t cancel the hliday and understd that the scial wrkers wuld invlve the lcal Plice in ptentially remving the children if she did g away with MP. 49. The scial wrkers then invited MP back int the huse and, at MLK s request, explained t him what had happened. MP was at first very calm and then became, accrding t the scial wrkers subsequent reprt, frighteningly aggressive, at which pint they asked him t leave. MP, his mther and friend drve away in what MLK said was her car. She and Sibling 1 said that MP had had similar aggressive utbursts previusly. With MLK s agreement, SSW1 cntacted GMP. She reprted subsequently that the call taker fcused n the theft f the car rather than the safeguarding cncerns. A transcript f the call indicates that SSW1 did nt restate her primary cncerns abut the safety f MLK and her children, as well as herself and clleague, and allwed the cnversatin t fcus n the car theft. 10

50. Tw fficers came t the huse, neither f wh wuld nrmally respnd t such an incident, the summer rits having diverted many fficers away frm their usual duties. Hwever, ne fficer had recently undergne training in the wrk f the PPIU. On arrival, the scial wrkers tk the lead in explaining the situatin and the mre experienced fficer decided t speak t MLK n her wn. The fficer was reprtedly cnfused by what she cnsidered t be the cntradictry infrmatin she had picked up frm GMP recrds abut MP against what she was hearing frm the scial wrkers. MLK then tld the fficer that she felt intimidated and threatened by the scial wrkers; and had nly agreed t cmply with their requests because she was terrified abut lsing her children. She als said that MP had given her the car t drive because he was banned as a result f mtring ffences. 51. The fficer cntacted MP by mbile phne and cnfirmed that he wuld be returning the car; he was calm and cherent. The fficer said she wuld nt be prceeding with a criminal investigatin. After further discussin with the scial wrkers, she was nt cnvinced f their view that MP was dangerus. On her return t the statin, the fficer cnsulted the Detective Sergeant wh was n duty in the PPIU. On checking the recrd relating t MP, they fund nthing t justify the scial wrkers level f cncern. The clsing lg fr this incident includes reference t cncern fr the safety f persns 17 years and under s was referred n t the Serius Sexual Offences Unit, where the Sergeant recrded satisfactin that Traffrd CYPS was handling the matter. 52. MP was extremely unhappy abut the turn f events and his mther reprted that she had great difficulty in calming him dwn. Over the fllwing weeks, MP apprached his prbatin fficer; spke twice t managers in Traffrd s MARAT; and three times cntacted GMP. On each ccasin, he was seeking t clarify what had happened and seek a reslutin that wuld allw him t see MLK and the children again. T that end, he asked GMP whether he culd be arrested and dealt with fr his ffence f underage sex with his stepdaughter. On each ccasin, he received, frm his viewpint, n satisfactin and was advised t stay away frm MLK and the children. His mther has since queried why he did nt receive mre help in view f his mental health prblems and his previus negative reactin t the breakdwn f relatinships. 53. Over the next few days, the scial wrkers gathered mre infrmatin and visited MLK t check n her level f cmpliance with the agreement made at their first visit. Traffrd CYPS held a strategy meeting chaired by the MARAT manager n 18 August t discuss MLK s situatin, six days after the visit by the scial wrkers. SSW1 attended alng with the prbatin fficer and Traffrd s named nurse safeguarding children. N ne came frm the children s schls r the schl nursing service because the schls were clsed fr the hlidays. The team manager f the Family Supprt Team was unable t attend. Very late n, GMP emailed t say that n fficer culd attend - the nly ne f 19 such meetings held by Traffrd CYPS during August. Hwever, they sent an attachment with detailed infrmatin abut their invlvement with MP, including a recent incident when MP called GMP because he said he was in the md t injure himself r smene else; and the histrical incident when he barricaded himself in his hme address armed with a knife and als kidnapped his child. 54. The strategy meeting was lng and cmplex. Participants discussed in detail the infrmatin knwn abut MP, including the prbatin fficer s view that he was manipulative, cntrlling and aggressive; did nt engage well with direct wrk; and was bsessed with his self-diagnsis f ADHD, fr which he blamed all his prblems. 11

They then cnsidered MLK s ability t withstand any future advances frm MP, and cncluded that she had demnstrated her capacity t prtect her children. It was, therefre, agreed t manage the case under child in need prcedures rather than cnvene a child prtectin cnference. 55. As a result f the strategy meeting, SSW1 referred the case fr a Multi- Agency Risk Assessment Cnference, which was put dwn fr discussin n 21 September. She referred MLK t an Individual Dmestic Vilence Advisr at Victim Supprt, wh prvided immediate supprt with practical matters (such as ensuring that the lcks n MLK s huse were changed; and that GMP placed a marker n her address t indicate the need fr an immediate respnse t any calls fr assistance frm MLK); and emtinal supprt, such as understanding the insidius nature f MP s abuse f her. 56. SSW1 advised the Manchester mental health service and the GP invlved with MP abut his aggressive behaviur twards prfessinals, and that the children wuld be remved if MP returned t the husehld. She cmpleted the initial assessment and arranged the transfer f the case t the lcal family supprt team fr cmpletin f a mre detailed (cre) assessment, and nging supervisin and supprt f MLK and the children. She indicated that the new scial wrker wuld need t cntact the children s schls nce they re-pened in September. (In fact, MLK infrmed the primary schl head teacher befre the scial wrker made cntact.) She als emailed the PPIU abut the utcme f the strategy meeting althugh it had been agreed at that meeting that there shuld be a face-t-face meeting. The need t cnvene a multi-agency child in need meeting was nted. 57. GMP subsequently had cntact with MLK because f text and phne messages frm MP and, n ne ccasin a letter, which she reprted t them as advised. GMP served a ntice n MP relating t harassment. Hwever, when MP breached the ntice MLK did nt want actin t be taken against him because the messages were nt threatening and she feared MP s reactin shuld she make a cmplaint leading t his arrest. 58. At the end f August, MP was admitted t hspital fllwing a heart attack. Medical staff referred him fr a psychiatric assessment because he was agitated and wuld nt cmply with medical assessments and treatment. The fllwing evening (29 August), the senir huse fficer (SHO) n duty in psychiatry assessed MP n the ward. (The Manchester Mental Health and Scial Care Trust prvides the psychiatry service t the hspital.) The assessment was thrugh and included a statement frm MP that he had thught abut harming himself in the days prir t this admissin, including setting fire t himself, but had n mney fr petrl; he als had thughts f harming thers, namely plice fficers and scial wrkers. By the time f the assessment MP was calm; the SHO recrded n the ward ntes and her wn Trust s electrnic recrd what MP had said; and prvided advice t the medical staff abut his management n the ward; she made n mentin t ward staff r psychiatric clleagues abut the threats f self-harm and harm t thers. 59. Next day, the medical team requested further psychiatric help because MP was refusing bypass heart surgery. The (different) n-call SHO advised the dctr t assess MP s mental capacity t refuse treatment. The medical team sught further advice the fllwing day frm the n-call cnsultant psychiatrist wh arranged fr anther assessment and advised MP s psychiatrist f the cntact. There was n reference t MP s thughts f fire setting r harm t thers. MP discharged himself against medical advice withut the benefit f heart surgery r a further psychiatric assessment. 12

60. The fllwing week MP attended the earlier planned psychiatric appintment and saw anther SHO wh cnducted the interview under the bservatin f MP s wn psychiatrist. There was n evidence f thught disrder r serius mental illness. The SHO discussed the diagnsis f emtinally unstable persnality disrder and attempted t plan help fr MP. Hwever, the SHO assessed that MP s mtivatin in seeking help was t restart his relatinship with MLK. Neither the SHO nr cnsultant reviewed MP s earlier recrd and, therefre, did nt pick up MP s cmment abut setting fire t himself. 61. Events n Mnday 19 September are set ut in the first sectin f this summary reprt. Analysis and cnclusins Key issues arising frm the case 62. The analysis in the verview reprt relates t the seven terms f reference fr the review with a cnclusin at the end f each sectin. This summary fcuses n the key issues that emerge frm the analysis. The first relates t the quality f the assessments made by agencies and, in particular, the effectiveness f the assessments f risk. 63. There was evidence f thrugh assessments being cmpleted; fr example, Bury CSC s assessment f the risk t SC1 frm MP; and Traffrd CYPS s initial assessment f MLK and her family. Hwever, shrtfalls in practice were als evident. There was a tendency t dwnplay the seriusness f incidents and nt cmplete effective risk assessments such as when: There were early indicatins that SC1 and MP were having a sexual relatinship when she was a yung teenager, which were nt thrughly enugh assessed r acted upn. MP refused t return Child 4 frm the cntact visit in May 2008 and threatened her and his life. When mental health clinicians in Manchester later assessed him, he repeated the threat, which they tk seriusly. Hwever, the clinicians did nt undertake a further risk assessment as required in their wn Trust guidance; draw up a care plan fr him, in line with natinal guidance fr peple with a persnality disrder; and ensure nging versight by ne f their services. Althugh, Child 4 came t n harm, the threat was very serius and, in the view f the independent frensic psychiatrist, set him apart frm peple with an emtinally unstable persnality disrder; and was nt related t that disrder. As such, in his view, it required the invlvement f criminal justice agencies. The prbatin fficer did nt refer MP s relatinship with MLK t Traffrd CYPS until fur mnths after becming aware f its resumptin, despite MP s wrrying behaviur during this perid and having tld MP f the intentin t d s. MP made a specific threat t his GP in 2009 abut kidnapping and killing his daughter. There was again an insufficient respnse frm 13

mental health clinicians t assessing the risk f harm frm MP, including liaisn with GMP. Cnsideratin was given t referring him fr a frensic assessment f risk but this was never fllwed thrugh. It wuld have prvided clear guidance abut the level f risk that MP psed. Whilst in hspital at the end f August 2011, MP indicated his intentin t set fire t himself and t harm scial wrkers and plice fficers; and refused life-saving surgery. The relatively inexperienced senir huse fficers wh assessed him did nt seek advice frm a mre senir clleague r supervisr, and did nt appear t recgnise the significance f what MP was saying. At the subsequent utpatient psychiatric appintment, there was n reference t the histrical recrd that included MP s recent statements abut setting fire t himself and f harming prfessinal staff. Officers in the GMP Public Prtectin Investigatin Unit did nt take an verview f MP and his many presentatins t the frce, r did nt view sufficiently seriusly the emerging pattern f his threatening behaviur. They als did nt interrgate misinfrmatin abut MP s alleged kidnapping/abductin f his daughter, althugh it did nt feature as an ffence n their database. Rather, they assessed and categrised his risk fllwing individual incidents and made referrals t Adult Scial Care and Children s Scial Care. 64. The secnd key issue is the effectiveness f cmmunicatin between agencies acrss sectr and lcal authrity bundaries; and the use f histrical infrmatin t infrm assessments and the inter-agency cmmunicatin. 65. There is evidence f regular and apprpriate cmmunicatin within and between agencies: bth in cnversatins between practitiners, clinicians r fficers, and in sending emails and ther dcumentatin. This includes cmmunicatin acrss lcal authrity bundaries. Hwever, there are ccasins when crucial infrmatin was nt passed n t ther sectrs r agencies; and agencies did nt cme tgether t share infrmatin and plan hw t manage the case. In additin, there was a failure at significant junctures t make use f the available histrical infrmatin in relatin t MP in rder t analyse emerging patterns f behaviur and, crucially, instances where his behaviur deviated frm what was nrmal fr him. Lancashire Plice did nt pass n infrmatin abut the incident in May 2008 t their clleagues in Manchester, and Lancashire Children s Scial Care did nt cnvene a strategy meeting t review the risk f harm t Child 4 and ptentially ther children. Fllwing the incident in May 2008 when MP made further threats twards Child 4, Manchester Mental Health and Scial Care Trust did nt infrm GMP f the situatin and invlve them in develping a cllabrative risk management apprach fr MP. In 2009, clinicians in Manchester Mental Health and Scial Care Trust did nt pass n crucial infrmatin abut MP s further threats t kidnap and harm his daughter t GMP; nr, in August 2011, his threats t harm scial wrkers and plice fficers and set fire t himself. They did nt plan MP s care n an inter-disciplinary r multi- 14

agency basis, r prvide ther agencies with an assessment f the risk that MP psed. Mental health agencies and Children s Services in Manchester did nt review MP s histry when they received new referrals. They did nt, therefre, recgnise and respnd t the emerging pattern f his behaviur but dealt with each incident as a new event. Crucially, Manchester Mental Health and Scial Care Trust did nt take accunt f the threats made by MP in August 2011 at his next assessment early in September. The Prbatin Trust recgnised the cmplexity f MP s needs and apprpriately referred him t services aimed at addressing his alchl and drug prblems and mental health difficulties. It did nt cnsider whether a planned crdinated respnse frm the varius agencies wuld have been mre successful in supprting MP. MP did nt reach the threshld fr being managed under Multi-Agency Public Prtectin Arrangements and this undermined a multi-agency planning apprach. MP did nt have a serius recrd f ffending but his range f difficulties in relatin t alchl and drug misuse, his emtinally unstable persnality disrder, dmestic abuse and sexual abuse f a minr made fr a txic mix that required a multi-agency apprach: t share infrmatin, assess the level f risk f harm and agree a plan fr managing him. Traffrd CYPS did nt hld a child in need meeting in a timely fashin (it had nt been arranged by 19 September 2011) despite the serius nature f MLK s situatin and absence f key agencies frm the strategy meeting. The draft status f the Children in Need Plicy suggested that children in need cases were nt viewed r managed with the same degree f urgency r pririty as that given t cases managed under child prtectin prcedures. 66. The third key issue is the knwledge within agencies f the indicatrs and impact f dmestic abuse, in particular at the pint f separatin. 67. There is evidence f a sund knwledge base abut dmestic abuse within Children s Services, the Prbatin Trust and Greater Manchester Plice; but a lwer level f knwledge within Health services. Hwever, Health agencies within bth Traffrd and Manchester have cmmenced actin t increase staff awareness and prvide prmpts fr asking patients abut the pssibility f dmestic abuse. Actin taken t prtect MLK and her family by the scial wrkers and an individual dmestic vilence advisr frm Victim Supprt fllwing the visit in August 2011 was prmpt, wide-ranging and entirely apprpriate. Hwever, the fcus f attentin was whlly upn MLK and her family and n attentin was given t MP s needs at what was a critical juncture. 68. The independent frensic psychiatrist said that the enfrced separatin f MP frm MLK and her family wuld have been a serius lss t him, and wuld have triggered an emtinal crisis that exacerbated his persnality disrder, including impulsivity and frequency/presence f suicidal and/r hmicidal ideatin. MP s mther described in vivid terms the adverse effect f the separatin n MP, and is 15

critical f the manner in which the scial wrkers handled the matter, particularly in view f his mental health prblems. 69. Agencies did nt give due cnsideratin (indeed any cnsideratin) t the effects f the separatin upn MP; they fcused upn him nly t the extent that he psed a threat t MLK and her children. This was cmpunded by subsequent missed pprtunities t respnd t his bvius (in retrspect) high level f distress, frustratin and grwing sense f injustice that was translated int threats f serius harm against self and thers. MP ceased t cunt; n ne listened carefully t him r heard what he was saying. The respnse by agencies t MP after 12 August was insufficient. Pririties fr learning and change Assessment f risk 70. There are examples within mental health services and children s scial care f failures t make assessments in respect f MP n the basis f histrical infrmatin as well as the current situatin. Incidents were treated as new events with n regard t prir infrmatin. Individual incidents may nt ccasin a strng respnse but the cumulative effect f incidents f the same behaviur, r uncharacteristic nature f the behaviur cmpared t histrical incidents, shuld alert practitiners and clinicians t undertake a thrugh review; and reach a judgement, based n an analysis f the evidence, n the level f risk indicated. 71. Bury, Lancashire and Manchester children s services did nt undertake thrugh enugh assessments f the risks faced individually by SC1 and Child 4 at different junctures in their lives. In each instance, there was insufficient regard t the case histry and an underplaying f the seriusness f the current risk. 72. Manchester Mental Health and Scial Care Trust clinicians did nt have sufficient regard t the specific threats made by MP n mre than ne ccasin t harm Child 4. These incidents shuld have led t a further risk assessment and t a specialist frensic assessment f the risk that MP psed. In additin, the Trust shuld have decided whether r nt MP s threats were related t his mental disrder, advised GMP accrdingly and agreed a cllabrative risk management apprach. The Trust was made aware f MP s enfrced separatin frm MLK by the scial wrker but clinicians did nt take accunt f its effect upn MP when assessing him after that date. In additin, they did nt cnsider the significance f MP s statement abut setting fire t himself and his threats made twards scial wrkers and plice fficers; and did nt pass n this infrmatin t GMP r Traffrd CYPS. 73. MP was rightly categrised as a vulnerable adult by the Public Prtectin Investigatin Unit (PPIU) within GMP n the basis that he was a risk t self. Althugh lacking the benefit f an assessment frm Manchester Mental Health and Scial Care Trust abut the risk he psed t thers, nevertheless the PPIU had accrued a bdy f intelligence relating t MP s threats t harm thers. Hwever, this intelligence was nt assessed r given due weight; in particular, incrrect infrmatin (regarding the alleged kidnapping f Child 4) that ptentially indicated an even higher level f risk t thers was nt interrgated. At n time did the Unit seek expert mental health advice. Actin taken n the basis f individual and cumulative incidents was nt sufficient: it required cllabratin with ther agencies t ensure that infrmatin was shared; an assessment f MP s risk f harm t thers made; and jint plans fr his management agreed. 16

74. MP was desperately seeking help fllwing his last, enfrced separatin frm MLK but n ne heard him. The fcus stayed n MLK and her children, and there was much psitive wrk undertaken t supprt and prtect her and her family. In this respect, natinal guidance des nt assist agencies in having due regard t the perpetratr. MP s needs were verlked, despite the research finding that the perid fllwing separatin represents a mre dangerus time fr the victim, and this ultimately prved catastrphic. The respnse t MP mirrrs ther research indicating that agencies ignre the rle f men despite the crucial part they play in families lives whether beneficial r nt. Multi-agency cperatin 75. Manchester Mental Health and Scial Care Trust has n specific service prvisin fr peple suffering frm a persnality disrder. As a cnsequence, MP was referred between teams and disciplines with n ne service assuming respnsibility fr planning his care. Such practice is utwith natinal guidance and failed MP. 76. The multi-agency public prtectin arrangements (MAPPA) did nt apply t MP because his level f ffending did nt reach their threshld. Hwever, there has t be a means f managing by way f multi-agency planning individuals wh fall belw the criteria fr MAPPA but present a risk t self and thers n the basis f a full analysis f their histry and current status. 77. Manchester Mental Health and Scial Care Trust failed t wrk with ther agencies thrugh inter agency meetings in rder t share infrmatin and plan the management f MP. Such inter-agency meetings require a higher pririty within the Trust. Equally, Trust clinicians were nt invited t the strategy meeting in August 2011 despite their substantial invlvement with MP. 78. There were instances f children s services underplaying the risk f harm that MP presented and failing t hld strategy meetings t share and mitigate that risk. 79. The draft status f Traffrd s Children in Need Plicy undermined its standing with and acceptance by the relevant agencies. In turn, this devalued the status f the categry f child in need. It presents a significant risk t planning fr and managing cases that are serius but deemed t fall just belw the threshld fr instigating child prtectin arrangements. Hwever, the plicy has been finalised and accepted by the Traffrd Safeguarding Children Bard during the curse f this review. 17

Recmmendatins and actin plan 1. Traffrd, Manchester, Bury and Lancashire Safeguarding Children Bards and the cmmissining bdy fr mental health services in Manchester must take immediate steps t ensure [1] that staff understand the crucial relevance f the case chrnlgy t an assessment f the current situatin; and [2] that recrd-keeping arrangements in the Bards cnstituent agencies facilitate access t the histry f a case. In additin, the Manchester Mental Health and Scial Care Trust must draw up an agreement with the University Hspital f Suth Manchester regarding its prvisin f mental health services, including access t and maintenance f patient recrds. 2. The Manchester Mental Health and Scial Care Trust must, as a matter f urgency, reinfrce its advice t clinicians abut threats by its patients t harm thers, and ensure that such advice is heeded and apprpriate actin taken, including instigating strategy meetings with Greater Manchester Plice and Adult r Children s Services. 3. Greater Manchester Plice shuld review the practice f the Public Prtectin Divisin and supprt fficers [1] t recgnise patterns f incidents that indicate an escalatin r changed directin in an individual s behaviur; and [2] in the light f an assessment, take steps t mitigate any risk by means f strategy meetings and multi-agency planning. 4. The Safer Traffrd Partnership must review the respnse f agencies t individuals with a cmplex range f prblems wh pse a risk f harm t self and/r thers including, in particular, perpetratrs f dmestic abuse. 5. Traffrd Safeguarding Children s Bard must take immediate steps [1] t implement its Children in Need plicy fully and [2] cnsider what cntinuing rganisatinal supprt is necessary t ensure that implementatin is and remains effective. Overarching Actins (frm SCR/DHR Overview Reprt) Traffrd Safeguarding Children Bard (TSCB) 1. Message regarding the imprtance f chrnlgies t g t all staff 2. Each agency t cnfirm t TSCB that recrd keeping arrangements facilitate access t the histry f a case. 3. Child In Need Plicy t be apprved, placed n TSCB website and implemented. 4. Develpment Day t review implementatin f the Children in Need Plicy and rganisatinal supprt. Actins frm Develpment Day t be agreed 5. Perfrmance Framewrk t be revised t ensure that effectiveness f Children In Need plicy is maintained Manchester Safeguarding Children Bard (MSCB) 1. MSCB t ensure that the key recmmendatin re relevance f case chrnlgy is presented t the Manchester Mental Health Clinical Bard - as cmmissiners f mental health services in Manchester 2. MSCB t seek assurance frm all partner agencies that recrd keeping arrangements facilitate access t the case histry. 18