A review into the murder of 18-month-old Keegan Downer, published in February, found that flawed assessments and decision-making had led to her death after she was placed in the care of a special guardian. Keegan, whose birth name was Shi-Anne, suffered more than 150 injuries while in the care of Kandyce Downer and died in September 2015, eight months after Birmingham City Council made the special guardianship order (SGO).
The review found that her death could have been prevented if the placement had been better supervised but that she had become "almost invisible to professionals" after the SGO was made.
It also found that the authority had prioritised SGOs over adoption "irrespective of the circumstances of the child". This was in part due to the impact of the Re B and Re B-S court cases, which were widely perceived to have raised the bar for adoption orders. However, the quality of the SGO assessment was "striking in its superficiality" compared to adoption placement assessments.
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