Serious Case Review: Special Guardianship Surrey Safeguarding Partnership (September 2020) Family M Serious Case Review

When completing Special Guardianship assessments, it is important that you keep up to date with any serious case reviews, in order to ensure that your practice and any sgo assessment you complete, continues to be robust.

I will outline briefly the findings of this Serious Case Review regarding Family M, who were living in Surrey. The case highlights that there was also county crossover, there were also two other Local Authorities involved, highlighting difficulties around information sharing with information not being passed over in a timely manner.

The serious case review is about children who were living under Special Guardianship with a relative who were removed from one situation where they were likely to suffer significant harm to another where they experienced severe abuse. This is distressing news for Special Guardianship assessment, which has become a popular option for child to remain living within their families.

The serious case review highlights that these children were “failed by a system that did not consistently hear their voice and fully explore and understand the meaning of their behaviour and effectively work with the complexity of their lives and circumstances”. An area that Local Authorities are starting to become much more aware of, is in taking on the voice of the child, and I have seen this with several Local Authorities providing wider training for staff in this area. It is important and necessary, whenever possible for social workers to take the child’s views into account when making decisions about their lives.

Special Guardianship and Kinship care assessments are always a very difficult area of practice. What the findings highlight is the importance of checking information and not taking for granted what information is already there.

Let me outline what is meant by this.

In respect of the Special Guardianship Orders and practice thereafter, it seems that thinking was unduly influenced by the assumption that previous court proceedings had granted Residence Orders and the suitability of The Perpetrator and his wife had been thoroughly assessed

What this implies, is that the Special Guardians had held Residence Orders (now called Child Arrangements Orders) and therefore this may have meant that SGO assessment of risk of them had been lowered. It appears that a professional view may have been taken that the applicants holding previous orders lessened concerns and therefore a flawed view of risk.

What does this mean for your Special Guardianship (SGO) assessment?

When undertaking an SGO assessment, even if the applicants you are assessing, hold previous orders or maybe even had a positive kinship assessment prior, you should still do your own due diligence and verify and check out information provided as far as possible.

You should not make general assumptions based on the history provided but you should make every effort to explore and understand the history around those circumstances.

But what happens after the sgo assessment, continues to highlight the difficulties around Special Guardianship Support.

Once the children were placed with The Perpetrator and his wife, “any behavioural problems were too readily attributed to early trauma, confusing the analysis of the signs and indicators that were also evidence of current harm.”

This is a further common factor that you may come across in Special Guardianship placements.

How do you understand the behaviour of children who are traumatised?

How much of this behaviour is attributable to their new placement circumstances and how much is from their past?

serious case review girl unhappy

It is only in speaking to the children can a clear understanding be provided. Many schools also offer counselling, and this may be another safe place where children are able to talk and discuss what is happening in their placements.

It is not easy to understand these factors within the space of a short SGO assessment and that is why there is a need to ongoing special guardianship assessment support so that areas like this can be further explored and understood.

A further factor in the review, was that the applicants were able to groom the professionals involved. The findings discusses how the Perpetrator’s narrative enabled this to happen, by providing a  “consistent narrative that he and his wife were “courageous and brave in taking on the children,” “were brilliant” with the children, “child focused” and “lovely people”.”

I know that I have heard these terms before when completing a special guardianship assessment, both from the applicants and their personal references.

How do we as social workers extract what is grooming behaviour?

How do we know when a couple who appear to have this readiness and selflessness, have ulterior motives?

As social workers, the risk is that we may lower our instincts around comments like this. The risk and what is clear, is that this has resulted in errors of thinking arising out of this type of grooming behaviour and one which assessors need to remain alert.

Many family members come forward with very similar narratives as to their motivation.

The question therefore for assessors will be how to know what is grooming and what is a genuine Special Guardianship carer?

What I am concerned about with this information, is that not all prospective Special Guardians are out to groom and abuse. There are good people out there and there are good special guardianship carers. As assessors, our job is to find those special guardianship carers.

But this case does highlight that abuse can happen within Special Guardianship placements and that assessors need to continue to risk assess these placements robustly.

special guardianship assessment serious case review child holding hand

Key Points from the Serious Case Review Family M Surrey in relation to Special Guardianship

The serious case review Finding Three is the one most relevant to Special Guardianship and kinship assessments, and I would recommend reading the finding in full report for yourself.

My summary of finding three in relation to special guardianship assessment is as follows: –

Voice of the Child and Impact on Each Child’s Individual Needs.

Your assessment should look at the needs and impact of all children in the household. Your assessment should include an understanding of each child’s specific needs and their current lived experiences. This is an important factor when matching the child with the Special Guardianship arrangement. This could include speaking to a child on their own, observing them in the placement, gaining views from schools, health visitors etc. We know that even non-verbal children, can express their views, simply by observation and how they interact in the environment.

The findings indicate that children in this particular SGO placement, were being placed in succession as the need arose.

However each new placement was not being analysed as to how this was affecting the children already in placement. It highlights that it would have been given that by the time the 6th Child was placed, that this would be having an impact on the special guardianship placement.

Understanding the context of Special Guardianship and other legal orders

You need to have a good understanding of the meaning of Special Guardianship orders and also other orders when considering the permanency of a child. This is a challenge in this area of work where social workers are still learning about this special guardianship orders and how it works in practice.

What is clear is that there needs to be a development of expertise within local authorities and in the training of social workers and other professionals to further understanding around Special Guardianship.

Verification of self reported information

You need to ensure that information provided is not just self reported and that information is verified as far as is possible. This may mean taking up of personal references, school references, employment references, any voluntary roles and ex-partner references etc.

An area raised has been around Local authority checks and the quality of the information provided. You should ensure that local authority checks when completed are done so carefully and fully.

I have had some local authority checks, which when returned no information was known about the applicants. However, as I was aware that there should have been information, due to past history and LA involvement with regard to a family, I was able to return to the relevant agency to challenge this. But we don’t always know this information and therefore to overcome this, you should try to provide as full details as possible regarding applicants when requesting checks; for example any aliases they were known by, address history held, details of any children of the applicants.

Why this is important is because Local Authority files in the past were often not linked with family relationships, therefore providing this information will help in you obtaining as accurate information as possible.

Better information sharing across health and schools.

Information sharing across health and schools was a further area that was highlighted and you need to be aware of this when undertaking checks with these agencies.

The findings indicate that the GP and schools also had little understanding of Special Guardianship. “The GP had very little contact with The Perpetrator or his wife and there was nothing on their medical records to cause alarm when they were contacted by the social worker carrying out the Special Guardianship Order assessment in respect of Child 6. This GP did not have any records alerting them to The Perpetrator’s previous referrals to specialist services due to alcohol, overdose and self-discharge from hospital in 2006. The GP was also not aware of the meaning of a Special Guardianship Order and assumed that The Perpetrator and his wife would be thoroughly checked by the local authority in the same way that foster carers would be and have the same level of social work involvement.”

Similarly, the school had a lack of awareness of the children’s legal status and meaning of Residence Orders and Special Guardianship Orders.

The findings also highlighted that information leaflets in simple to understand language, jargon free needs to be provided for agencies to enable their understanding. I think we could all do well to be jargon free, especially when gathering important information from other agencies.

Understanding of Re B and Re: B-S when making decisions to place within the family.

What is clear from this is that children should not be placed in a family placement if there are sufficient concerns about the placement. The findings highlight that there was misunderstanding around the nothing else will do principle when making decisions around Special Guardianship and family and friends’ placements.

The review states “decisions were driven by a focus on the positive benefits of placing children within Family M Serious Case Review Final September 2020. One practitioner described being influenced at the time by their interpretation of judgements in the Court of Appeal which stressed the need to only place children for adoption when “nothing else will do”. This interpretation, which was not challenged by managers within the Local Authority concerned, did not take account of the fact that an underlying message from these judgements was also the importance of thorough evidence informed assessments. In addition, a later judgement Sir James Munby, referred to the ‘widespread uncertainty, misunderstanding and confusion’ which has arisen since the decisions in Re B and Re B-S. He confirmed that: Re B-S was not intended to, and has not, changed the law. It has not set any higher hurdle for placement orders. Sometimes adoption is in the best interests of the child and, where that is the case, the courts should not shy away from making a placement order. Children should not be kept with their birth families if it compromises their welfare.”

This last statement is one to remember when completing Special Guardianship assessments and deciding on the permanency options for a child.

Children should not be kept with their birth families if it compromises their welfare”.

special guardianship serious case review hand holding childs hand

What would have made a difference for Family M SGO assessment?

Since this matter with Family M occurred, the Special Guardianship regulations have been strengthened which means that the assessment of prospective special guardians now also ensures that they can fully meet the needs of the child through until adulthood.

In addition, there was a new requirement to report to the court on the relationship between the child and the prospective special guardian(s), how they will help the child overcome the impact of any previous abuse or neglect, and how they will manage any risk to the child from the relationship between the special guardian and the child’s birth parents.

The strengthening of the regulations are important in completing these risk assessments and you should ensure that you cover these areas fully within your special guardianship assessment.

Before we end, a final area worth raising is

Shortcomings around timescales for completion of Special Guardianship Assessment.

One of the areas, highlighted here at is the rushed timescales which does not allow practitioners the time for reflection and critical thinking.

It is so important to have time to stop and consider whether the applicants narrative reflects what is happening, this is often taking place in a very charged and difficult situation.

The dilemma for SGO assessors as you may realise is therefore quite a complex one.

Assessors should also use supervision and have time for reflection to take on board information regarding information gathered within the special guardianship assessment. Time to do this is often in short supply and continues to present risk in this area of work.


If anything, your key understanding from this serious case review, as with all serious case reviews, should be the importance of analysis of information gathered when making decisions that will affect a child’s life under special guardianship.


Special Guardianship Info –  Giving SGO a Voice

The Full Report can be found at

Serious case review Family M [full overview report].  

Surrey Safeguarding Children Partnership
Jane Wonnacott

Publisher Surrey Safeguarding Children Partnership (2020)

Abstract : Serious harm and sexual abuse of children whilst living with a relative under a Special Guardianship Order. The review concerns six children, of whom four were removed from one situation where they were likely to suffer significant harm to another where they experienced severe abuse. The children had moved from another local authority area and were placed with the perpetrator and his wife. Behavioural problems were attributed to early trauma; this was magnified by the perpetrator’s ability to create a narrative that he and his wife were “courageous and brave” in taking on the children.

Findings include:

The need to share information across the multi-agency network; practitioners need to be equipped to undertake assessments which include hearing the voice of the child, understanding the meaning of a child’s behaviour, and maintaining professional curiosity; friends and family assessments should always include consideration of the impact of placement on all children in the household.

Recommendations include: ensure that there is a focus on the voice and lived experience of children in assessments and interventions; consider the child’s history, the history of their care givers and the motivation underlying their application to look after the child; the Safeguarding Children Partnership should work with partner agencies to develop a strategy on recognising and working with child sexual abuse within the family; and agencies should evaluate their supervision systems and provide an opportunity for practitioners to analyse in complex family situations.

Special Guardianship Info –  Giving SGO a Voice