Council criticised over death of child on special guardianship order

Joe Lepper
Wednesday, February 22, 2017

A children's services department has been criticised for a raft of failures in their handling of the case of an 18-month-old girl, who was murdered after being placed with a family member through a special guardianship order (SGO).

The legal guardian of Keegan Downer, who suffered more than 150 injuries, has been convicted of murder. Picture: West Midlands Police
The legal guardian of Keegan Downer, who suffered more than 150 injuries, has been convicted of murder. Picture: West Midlands Police

A serious case review (SCR) by Birmingham Safeguarding Children Board into the murder of Shi-Anne Downer by her guardian Kandyce Downer in September 2015, found that although her death could not have been predicted her ordeal "might have been prevented by more professional involvement and supervision".

Following her death, Shi-Anne, who was also known as Keegan, was found to have more than 150 scars and bruises and had also suffered brain and spinal injuries. Kandyce Downer was sentenced to life last year and told she must serve at least 18 years in jail.

The SCR is particularly scathing about Birmingham City Council's decision to opt for a SGO in Shi-Anne's case rather than seriously consider other options such as adoption.

It also details how Shi-Anne "was almost invisible to professionals" after she had been placed with Kandyce Downer, adding "there is only a little bit of information from a single visit by the health visitor and then a short mention by education on her time in pre-school".

Birmingham Safeguarding Children Board's independent chair Penny Thompson said: "I believe that unfortunately this case reflected "group think" where the general consensus seemed to be that a special guardianship order (SGO) was the right thing to do.

"There was a superficial assessment by an external agency commissioned by the city council; little challenge on behalf of Shi-Anne and her lifelong interests; poor information exchange; insufficient discussion between involved agencies, and too much focus on Kandyce Downer's wants rather than the child's needs."

Thompson said that since Shi-Anne's death the government has taken action to ensure children are not placed at risk due to inappropriate SGOs. In March last year SGO regulations were overhauled to put a greater focus on investigating risks to the child.

Last year, Birmingham Perry Barr Labour MP Khalid Mahmood called for the city council to suspend the use of SGOs until the SCR into Shi-Anne's death had been completed.

Thompson added that she had been impressed with changes at Birmingham City Council's children's services since Shi-Anne's death.

"When I visited the new service I was struck by the strong grip on practice and decision making," she said.

The council's children's services has been rated as inadequate since 2009 and is set to be taken over by an independent trust in April 2018.

Despite once again handing the department its lowest grade, in November last year, Ofsted did note that there had been significant improvements in its looked-after children's services.

Birmingham City Council's director for people Peter Hay said: "This is a terrible tragedy and we have been clear all along that the best response we could make to Shi Anne's death was to comprehensively change our practice.

"We have already looked into how we handled this case and the special guardianship order that resulted in the placement of Shi-Anne with Kandyce Downer.

"Within the city council, we have revised and improved the guidance about how to identify the most appropriate option for SGOs, and we no longer commission external assessments, instead doing them solely in-house.

"In cases where an SGO has been granted, they will remain 'open' as a 'child in need' for at least three months after the date of the order."

He added that unannounced visits now take place to people where a SGO has been made and staff have been offered further training around granting such orders.

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