By Sam Rkaina, Local Government Reporter
A TODDLER who drowned in a pond after being neglected by his family was failed by many of the agencies that were supposed to help him, a report has revealed.
Two-year-old Daniel Marshall Rees-Smith drowned in his alcoholic grandmother Hilary Rees’ back garden in Hanham while his parents Charlotte Rees-Smith and Andrew Marshall drank at a local pub.
Rees had passed out on the sofa, having drunk around eight pints of cider before taking Daniel home with her.
All three relatives were given suspended prison sentences at Bristol Crown Court on Thursday for their roles in his death last June. Click here to read a report of the court sentencing.
A serious case review into Daniel’s short life has shown that authorities were well aware of problems with his family before he was even born.
But chances to deal with them were missed due to repeated shortcomings by a number of agencies including social services, Bristol’s youth offending team and Bristol City Council Children and Young Peoples Services.
Investigations were begun but not followed up, cases were closed before it was clear problems had been solved and assessments were not thorough enough.
The councillor in charge of a committee responsible for monitoring the city council’s services for children last night described his case as “an accident waiting to happen” and said the agencies involved in his case and others involving vulnerable children “must do better” in future.
A review of Daniel’s case found allegations of domestic abuse and alcoholism involving the family were not followed up, meetings to assess Daniel’s level of need did not take place and different agencies dealing with the family did not work together as well as they should.
The family had a history of incidents with the police, including Daniel’s grandmother being arrested for drink driving while her pregnant daughter was a passenger, and a number of reports of domestic violence.
Bristol’s Children and Young People’s Services team did not look at how a final warning given by police to Daniel’s mother for cocaine possession would affect her suitability as a parent nor how he could be affected by reports of his grandmother’s alcohol and domestic abuse.
These allegations were also made by Daniel’s father during a custody battle, when he also claimed the boy’s mother was neglecting him, the report found.
But the government Children and Family Court Advisory and Support Service (Cafcass) failed to make the required checks with other agencies or investigate the father’s allegations.
More than a dozen organisations had contact with Daniel’s family in the few years before his death, including Avon and Somerset Police, Great Western Ambulance Service, child care services in Bristol and South Gloucestershire and the two Bristol hospital trusts.
All contributed to a serious case review, held by the Bristol Safeguarding Children Board, an independent body that co-ordinates different organisations that work on child protection.
Safeguarding boards always carry out such reviews when a child dies and abuse or neglect is suspected to be a factor.
The board made six recommendations for “lessons to be learned” from Daniel’s experience, including developing a better understanding of how alcohol abuse in families can affect children’s welfare.
The report concludes that “even with hindsight, it is difficult to conclude whether the child’s death was predictable”.
It adds: “The death could have been prevented by whichever adult was responsible for his care at the time.”
But in summarising the events that lead to his death, the report exposes the failings of some organisations, despite the efforts of others to draw attention to the problems.
Great Western Ambulance staff, for example, referred the family to Bristol CYPS after visiting Daniel’s mother’s flat because he had a fever.
The report states: “The ambulance staff were concerned about the state of the flat.
“There were cat faeces on the floor and Daniel was seen to be in unhygienic conditions”.
A social worker did visit but “the assessment was not as thorough as might be expected”, according to the report.
No contact was made with other agencies who had been dealing with the family, nor the father.
Some agencies did not take further action because they were under the impression the family’s problems were not severe enough, according to the report.
It said: “The Cafcass author identified that a referral to children’s social care should have been made following the father’s allegations of the mother’s neglect of the child.
“One of the reasons for the failure to make a referral was the perception that these concerns would not meet the children’s social care threshold for accepting a referral.”
Concerns are also raised about the workload of a number of the agencies involved in the case.
The report states: “The council’s social work team had high caseloads at the time and had difficulty in transferring long-term work to another team.
“The child’s case was assessed as being low priority.
“During the whole period the social worker saw the child on one occasion. Referrals to services did not take place.
“The case was closed despite evidence which suggested the child’s situation was not improving.
“Cafcass failed to follow through safeguarding checks and did not complete an adequate risk assessment.
“Lack of resources and high workloads were a factor in the management of the case at the time of their involvement.
“There were serious pressures on the health visiting service during the period covered by the serious case review.
“This meant that four different health visitors were involved with the child.
“The impact was that there was not a chance to build up a trusting relationship with the family.”
The summary of the report can be seen on the Bristol City Council website, and a full version is due to be released in the next few weeks.
Councillor Alistair Watson, the chairman of the city council’s children’s services scrutiny commission, has called on agencies involved to act on the recommendations made by the board.
Conservative Westbury-on- Trym councillor Mr Watson said: “This really is a very sad and sorry tale.
“Given the facts which have emerged concerning Daniel’s lack of care and the circumstances surrounding his tragic death, this looks like an accident waiting to happen.
“Whilst it is easy to be wise after the event, it seems that there were plenty of warning signs known to health visitors and other support workers in the months beforehand, which should have led them to take a more rigorous approach to secure his safety.
“Given the mounting evidence of neglect over a sustained period of time, most people will find it incredulous that little Daniel was left in the care of such woefully inadequate persons.
“However loving an environment, there are obvious risks for anyone being brought up in a drug or alcohol fuelled environment.
“Lessons must be learnt from this tragedy if we are to prevent any repetition of this failure to protect a vulnerable child.
“In future, the council’s various family agencies must do better and, for this reason, I welcome the new guidance issued by the Bristol Safeguarding Children Board.”
Timeline of events running up to Daniel’s death
– THE year before Daniel was born, South Gloucestershire Children’s Social Care was contacted by his mother’s school with concerns about her welfare.
Police informed SGCSC Charlotte Rees-Smith was repeatedly running away from home. Her parents were reported to be drunk when the police visited the house, which was in poor condition. There was evidence of an abusive relationship between her parents and a report that Hilary Rees had assaulted her daughter.
– SGCSC completed an initial assessment and Charlotte was offered sessions with an adolescent support worker, but the case was closed within a few months.
– Hilary Rees was stopped for drink driving while her pregnant daughter was a passenger. Charlotte tried to stop the police from arresting her mother and she was arrested as well.
– Charlotte’s midwife referred her to Bristol Children and Young Peoples Services as she needed support with parenting skills, housing and benefits.
Bristol CYPS assessed Charlotte and Daniel’s father Andrew Marshall’s capacity as parents.
But risk issues were not considered and the case was closed before Daniel was born, with no plan to monitor progress.
– The Youth Offending Team failed in its duty to complete an assessment after Charlotte received a final warning for cocaine use. Her mother told YOT her daughter “did not want any support, because lots of agencies were already involved” and the case was closed.
– Daniel was born a few weeks later. The day after leaving hospital, the police were called to a domestic abuse incident between Charlotte’s parents. Daniel was present when the police visited but they did not share this information with SGCSC.
– A few months later Daniel’s parents split up. The police were called when his mother reported Andrew Marshall had failed to return him after a visit and claimed he had threatened to harm himself. No other action was taken.
– The couple were seen by a Children and Family Court Advisory and Support Service (Cafcass) family court advisor. Marshall claimed Rees-Smith neglected their son and that her mother Hilary Rees was an alcoholic. But custody was given to the mother and Cafcass did not investigate the allegations.
– The couple got back together and were visited by a health visitor twice over the next few months. He was meeting his developmental milestones and had had his immunisations. Good attachment was observed between the baby and both his parents.
– After turning one-year-old, Daniel was taken to hospital suffering from a high temperature and fever. Ambulance staff were concerned about the state of the family flat. There were cat faeces on the floor and Daniel was in unhygienic conditions. The ambulance staff referred the case to Bristol CYPS.
– An initial assessment by a social worker noted the condition of the home was unsuitable for Daniel. But “the assessment was not as thorough as might be expected”, according to the case review. No contact was made with other agencies such as the health visitor. The father was not contacted.
– Charlotte lost a college placement because she did not attend and as a result Daniel lost his daycare place. The mother had a lot of debts, believed she was suffering from depression and drinking heavily.
– The social worker discussed the case with their team manager but the agreed plan to complete a review of Daniel’s level of need did not take place.
– The case was closed shortly afterwards on the understanding that the mother was using services like a young mother’s project and Barnardo’s – but there is no evidence that she actually was.
– Over the next few months leading up to Daniel’s death, his father returned home. A different health visitor visited three months before his death, and a new assessment was completed.
– This was followed up with GP appointments the parents kept. Daniel was eating and drinking well and no concerns were raised.
– The health visitor made a referral to Barnardo’s home visit service and raised concerns about the mother’s mental health, cleanliness in the flat and safety issues. Follow up visits were made to monitor progress.
– The last visit was with a Community Family Worker from Barnardo’s but this was shortly before Daniel died.
– The day before Daniel died at her home, his grandmother Hilary Rees was receiving treatment for health problems and told nurses she was drinking again. She was seen to be looking unkempt and smelling of alcohol early in the morning.
Responses to the report
Bristol City Council
ANNIE Hudson is the head of Children and Young People’s Services for Bristol City Council.
She said she agreed with findings of the serious case review including that “it is difficult to conclude whether the child’s death was predictable”.
Ms Hudson stressed that lessons would be learned, in particular about the potentially destructive effects of alcohol abuse on families.
The council receives hundreds of calls every day about children who are at potential risk and those risks have to be weighed up all the time.
She said: “The serious case review has not concluded that if XYZ had been done there would have been a different outcome, I don’t think there’s the evidence to say that.
“The key is to make good assessments and working efficiently with other agencies. Some of what happened was not of the high standard we would expect.
“In terms of what was known then, the child was not identified as having significant child protection needs. I think there’s a job to be done with children where there are concerns; we have to ensure there is consistent good sharing of information.”
Ms Hudson stressed the council was not making cuts to the frontline social services staff but would have to monitor case loads.
She said: “In a very tragic way this demonstrates the importance of having very strong multi-agency services in Bristol. There are many vulnerable children in Bristol and many receive good services.
“Protecting vulnerable children should be a priority for any community.”
Cafcass (children’s legal service)
KEVIN Gibbs, the head of service at the agency Cafcass, said: “Cafcass was involved in this case for three months in 2008, prior to the Daniel’s tragic death in 2010, in relation to a dispute between his parents, who later reconciled.
“Our number one priority is always children’s safety.
“Since that time in every case, where there is a dispute between parents about where a child lives, we check the court application for safety issues within 24 hours of receipt and request police and local authority checks within three days. This means that we are receiving and acting on important safety information about children much more quickly.
“Many more children are being identified as being in need of help and protection and we are determined to ensure they receive the help they deserve.
“Despite rising demand, all of the children whose cases have been referred to us in Bristol have a dedicated family court adviser helping to make sure they are kept safe.”
South Gloucestershire Council
A SOUTH Gloucestershire Council spokesperson said: “The South Gloucestershire Safeguarding Children Board has been working closely with Bristol Safeguarding Children Board to contribute fully to the serious case review, which was set up following the tragic death of a Bristol child.
“We accept all the recommendations made in the report and we had already taken steps to implement some of the recommendations of the review.
“We, along with all the agencies involved, have agreed to an action plan to ensure lessons learnt from this case are used to improve safeguarding policies and practice, particularly between local authorities in instances where families live across both districts.
“For example, if we receive a domestic violence report from the police about an individual and they are not resident in South Gloucestershire, as standard practice we will alert the authority where this person lives to make them aware of the incident.”