Special Guardianship Serious Case Review Overview Report: Megan.

Special Guardianship and serious case reviews are two words, within the work of kinship and special guardianship care, are words that we would not want to see together.

The reality is that children placed in Special Guardianship arrangements to keep them safe have in some instances still been subjected to further and ongoing abuse in these new arrangements.

However, we must remember, that not all Special Guardianship placements are abusive. It is also important to hold onto the thousands of SGO orders that are granted and where children are thriving with family members.

When serious case reviews are completed on special guardianship arrangements, what assessing social workers need to take from these, is to consider how to improve practice. And ensure that children are safe in special guardianship placements, by looking back at what happened so that practice can be improved.  

serious case review sgo megan

The serious case review of Megan, a five year old girl in Gloucestershire, makes for harrowing reading and the review describes her circumstances as “dickensian”. This seems unbelievable to consider that with all our knowledge about safeguarding and working together, that this has happened.

But it is happening. The serious case review considers several areas where the circumstances for Megan could have been different. That is if professionals had made different decisions.

I recommend that you read the Serious case review, Megan, in full but I will sum up the findings here, only in relation to the aspects regarding Special Guardianship.

I will explore what this means when you are completing your Special Guardianship Assessment and what you need to consider when completing SGO and kinship assessment.

Background Information: Megan’s life story and family background

In 2009, Megan was born almost eight weeks premature. At the time of Megan’s birth there were professional concerns about her birth mother’s capacity to care for her. As a result, Megan was made subject of a Child Protection Plan (CPP) under the category of neglect, along with her half-sibling, Charlotte.

In February 2010 the concerns remained, and the Local Authority initiated care proceedings and Megan became a Looked after Child (LAC). Interim Care Orders (ICO) were granted for both Megan and Charlotte with a direction that assessment work would be undertaken in a residential setting. Following an intense assessment, their birth mother was deemed unable to care for either for Megan or Charlotte.

Charlotte was placed on an SGO with her Paternal Grandmother (PGM). A Social Worker (SW) explored whether Charlotte’s PGM could also take Megan, but this was not possible. Megan remained in foster care whilst a number of viability assessments were completed by a SW with other family members. They continued to search for a suitable permanent carer for Megan and to conduct DNA testing to establish who her father was. The long-term plan for Megan at the time was adoption or placement with family members.

Special Guardianship Assessment of Paternal Grandmother

DNA testing established that person C was Megan’s biological father. A parenting assessment, decided Megan would not be placed with C as a viability assessment deemed him unsuitable to care for Megan, but she should be placed with his mother, the PGM.

Care proceedings for Megan were already underway when her father was identified. It is reported the SW felt under immense pressure from the court timescales and line management to identify another family member. Court proceedings for both Megan and Charlotte had been ongoing for 50-weeks and was over the agreed 26-week time limit set. The SW was mindful of the Family Justice Review (2009) which had highlighted care proceedings drift and delay for children. The SW felt C’s father, the PGM, was a likely applicant for an SGO and a better option for Megan because it would ensure she kept contact with her mother and her half-sibling Charlotte which an adoption order would potentially sever.

sgo serious case review assessment megan

These are the findings about the Special Guardianship Process

1.Concerns about the relationship between Megan and the PGM

Megan’s foster carer provided, through the LAC Review process, written concerns regarding the sporadic contact between Megan and her PGM who was being assessed for an SGO. The foster carer was of the opinion as Megan did not have a pre-existing relationship with her PGM, she was showing separation anxiety.

Given this concern to find a relative at such a late stage, the SCIE review reports the IRO felt the courts would make a decision on the SGO and would be in favour of it. The IRO was clear he had a responsibility to ensure other permanency plans were considered but the court process dictated timescales and he thought his reviews were therefore not so influential. He also felt it was not unusual for a child who was moving out of a placement to show separation anxiety or for a foster carer to express concerns, especially if the carer was also hoping the child could stay with them for longer.

Questions/areas for you to consider if you were completing a similar SGO assessment

-During SGO assessments you need to question and challenge plans that are being made for children, just because a professional has made a decisions does not mean that this is necessarily the best one for a child.

-The SGO assessor could have could have asked the foster carer any further questions about Megan’s needs and the behaviour she was displaying. Was this behaviour seen in other areas as well i.e. at school

-You should maintain open professional curiosity when trying to understand behaviour. The IRO and SW hypothesise was that Megan’s behaviour was due to separation anxiety and did not explore alternative hypothesis any further.

Processing Information late in the proceedings

Megan’s paternity was discovered very late during the proceedings. The PGM was 37 years old at the time and had not had time to assimilate being a grandparent having a primary school aged child herself.

It is evident the SW did not request extra time from the court to enable the PGM to consider the implications of taking on another child under an SGO. The court appointed Guardian advised accordingly that the PGM herself was worried about the speed of the assessment and the SGO.

As Gloucestershire Council were not requesting additional time from the court, the appointed Guardian wrote to the solicitor to ask the court for a delay because the PGM was concerned about bonding with Megan.

What you can do during your SGO Assessments: Do not rush Special Guardianship Assessment, even when the timescales are out, you need to raise issues to your legal team and request additional time to complete a robust and thorough assessment that takes into account the needs of the child and also the Special guardian and their family.

Caseload and impact on SGO Assessment

The SW advised he was holding a very high case load and was also mentoring newly qualified SWs. The SCIE report highlights senior line management was adamant court deadlines were met as the Local Authority had been deemed inadequate for safeguarding by Ofsted. Apparently, this was added pressure and an apparent morale issue amongst SWs within a culture that allowed managers to sign off reports for SGO cases from SWs they trusted without seeing them, in order to save time.

What you can do during your SGO Assessments: You should raise caseload within supervision. Special Guardianship reports should never just be signed off by your manager, and you have a responsibility to challenge poor practice within the organisation.

Presentation of the SGO applicant and what this may mean

The PGM during the processes of SG assessment was noted to be ‘emotionally flat’ at times by the SW and also by a health visitor (HV) engaged with Megan’s case. Visits to the home were not comprehensive in their observation of the layout of PGM’s home. Introductory sessions between PGM and Megan were held in an unsuitable room for play, taken up almost entirely with a table. There was no challenge to meet elsewhere as the full extent of the house was unknown by most professionals although it was tidy and sparse there was little evidence of PGM’s own child, Paul, being there. Paul was not seen by practitioners or assessed as to the likely impact on him having Megan permanently living with him and his mother and should have been part of the overall assessment.

What you can do during your SGO Assessments: You should also observe the home where the child will be cared for. You should arrange to observe other children in the household with the prospective Special Guardianship applicant. You should arrange to speak to children of the applicant on their own, where possible.

Assessment of motivation of Special Guardian applicant

It is also reported PGM had financial difficulties which would have been significant considering the additional expenditure of having Megan reside with her. She declared herself bankrupt in 2010. Consideration of the additional pressures of a child with additional needs and possible financial motives for taking on an SGO were not considered as part of the assessment. Regulation 12 of the Special Guardianship Regulations 2005 (relevant and in place) shows the overall assessment for PGM’s assessment , for Megan’s Page 9 of 31 SGO, was not thorough. GCC are now addressing issues regarding applications for financial support for SGOs.

What you can do during your SGO Assessments: You should ensure that you fully understand the SG applicant’s motivation. Additionally, you should make a full assessment of support needs and importantly a full financial assessment must be completed.

SGO serious case review megan

Further details of what happened for Megan during the Court process

In January 2012, Gloucestershire Family Court Proceedings directed that Megan be placed with the PGM on an Interim Care Order (ICO) with a view to an SGO to be made at a later court hearing. Megan (who was two years old), moved into PGM’s three-story property in February 2012. During the following period Megan’s birth father C also came to live in the home as he had split up from a previous partner (not Megan’s birth mother Amanda). PGM’s partner K moved in whilst Megan lived there. The PGM’s older daughter, Megan’s Paternal Aunt (PA), was also a regular visitor to the home. She was to become the fourth defendant in a criminal trial but was the only defendant who was subsequently found not guilty of any offences against Megan.

In April 2012 the Court granted the SGO to PGM with a Contact Order attached (The Adoption and Children Act 2002 allows SGOs to be granted with Contact Orders attached). This was to ensure Megan saw her sibling Charlotte on a regular basis. There had previously been some concern surrounding Megan not being taken for contact with Charlotte by PGM (possible lack of engagement issues and not considering Megan). PGM did not like these meetings and felt she was being looked down upon by Charlotte’s PGM. A decision to grant the SGO without any professional challenge was made. PGM felt she was ‘doing this for her son.’ The fact she was a new grandmother, with no previous relationship with Megan was not explored.

Areas of note regarding the above processes :-

  • The viability assessment of the PGM for the SGO was completed too swiftly (only nine weeks after PGM was identified as a relative) due to court timescales and pressure on the SW, her team and the IRO LAC process.
  • There was no attempt to request the court to extend the time considering the late identification of a family member to be considered for the SGO.
  • There appears a lack of support being provided to the PGM following the SGO.

It is not clear if the PGM fully understood the enormity and permanence of what the SGO involved?

Professional practice and the actual assessment process was therefore below the standard expected.

Practitioners were of the apparent predisposition of keeping a child with the family wherever possible and believed the SGO would inevitably be agreed by the Court, a preconceived practitioners’ assumption, in any case.

Initial Family and Friends Care Assessments: a good practice guide (2017) Staying Put: good practice guidance states, “In assessing the suitability of a child living with a relative or friend or other person connected with the child as an alternative to care proceedings, local authorities will need to consider what support might be required to enable the arrangement to be successful, whether informal or by way of special guardianship or a residence order.”

Whether family members and friends are caring for a child or young person who would otherwise be looked after, who is already looked after, or is returning from a care placement, it is essential that proper recognition and effective support are given. This is to ensure that the carers are able to safeguard the child and promote his or her welfare, and so achieve their full potential.”

Considering the concerns from the Foster Carer (FC), Health Visitor and the appointed Guardian as well as the concerns of the PGM; her reported ‘flatness’; who felt the whole process was being rushed, together with her financial difficulties, the outcome of PGM’s assessment was seriously flawed.

The whole process notwithstanding was over the normal prescribed time limit set, including the LAC review opinion, it is suggested the assessment was not completed to a professional standard of practice, failing to consider all the concerns and issues in the ‘best interest’ of Megan.

The SW and professionals were over optimistic about PGM’s capacity to parent another child and care for Megan and that PGM wanted Megan to know her natural mother.

The SW believed the PGM had some empathy for Megan retaining a relationship with Amanda and Charlotte, with contacts arranged between PGMs, even though Megan’s PGM did not like the meetings.

The SCIE reports “There was a very strong and shared professional perception, based on experience, that an SGO would always be granted because they were the preferred option of the court and therefore quick and less robust assessments and reviews were all that was required.” This review agrees with this finding.

The SGO application report provided by the SW for the court was also reviewed. It was too optimistic of PGM and did not fully outline the underlying concerns and comments from professionals and PGM herself which should have been identified within GCSC supervision and discussed with the SW prior to completion.

Despite the lack of a pre-existing relationship (SGO 2005 Regulations) with Megan, it is possible that the minimum of assessment was carried out to satisfy the court. Given no request for extension was made we do not know, due to the circumstances of identifying PGM late in the care proceedings, whether a Judge may have, in the best interest of Megan, allowed an extension? No attempt was made to request an extension despite the fact that there would have been a strong argument for such an extension given the issues identified by this and the SCIE report.

The findings from this review and the recommendations made propose that the assessment of SGO applicants should include an extra level of safeguarding to take away the presumptions, optimism, and worry of professionals meeting timescales in order that a thorough assessment is conducted.

Assessments need not only to consider the short and medium term, but the long-term period of caring for Megan and other children and young people for the future.

Summary of Contributing SGO factors in Megan case

· SGO assessments were completed by the children’s team who were allocated to the child.

· SGO carers had no relationship with the SGO team who were going to support her longer term.

· The family came forward late in the proceedings and the relationship with Megan was not established.

· SGO Support plans were not quality assured by the team responsible for supporting SGOs.

· PGM had not previously engaged in contact with other children and did not engage in support or with professionals.

 · There was no SGO training for SGO carers who were going to be caring for traumatised vulnerable children.

 · There was a lack of knowledge available about SGOs (including Health and Education) and what it means for carers legally and in relation to future support and help available and what support and oversight is required.

· There was no testing of the arrangement.

Here’s what Gloucestershire Council have done since this serious case review:

· SGO carers received training delivered by an experienced SGO carer.

· Information leaflets and packs are available for potential carers before and during the assessment process are made available.

· Assessments are completed by social workers who are experienced in kinship care and are aware of the support likely to be required in the short/medium and longer term based on their experience of supporting carers.

· The assessments and support are held in a specialist team who manage all friends and family arrangements and support.

· All SGO arrangements have 4 visits per year following the granting of the order. This is not statutory, but the majority are complying.

· Monthly support groups for SGO carers facilitated by a family support worker from the specialist kinship team are held.

 · There is an annual SGO get together ‘picnic in the park.’

· An SGO newsletter is sent to all SGO carers who can also access fostering carers training.

· Consultations with a social worker and child psychotherapist is available to the SGO to help them care for and understand the needs of the children in their care.

· GCC fund pre-school and nursery for children in SGO arrangements ensuring they have a range of professionals involved in their care and allowing the carer to work and or ‘recharge their batteries’ with a variety of initiatives such as holiday activities, an annual review of the support (postal) of SGO arrangements.

Other keypoints made in the Serious Case Review with regard to Special Guardianship

 · The 26 weeks court timescales is insufficient time to complete quality assessments taking into consideration that these are permanent arrangements which are life long and involve some of the most vulnerable and traumatised children. There is a need to extend the completion time by at least 12 weeks but have a legal team who support professionals to extend this where required. It should be child led not court led.

· FGC should be used at the earliest point in the process, so family members are identified earlier and the support around these arrangements are agreed and reliable.

· GCSC considers kinship fostering as a positive long-term option. Children’s social work teams and Legal generally will not consider this as an option even for a period of time to test and ensure the placement is the best option for the child. Professionals would like this to be a preference in many arrangements.

· Children’s views are not taken on board in the decision making and often they have not met or have an established relationship with them.

· The period of transition needs be more child focused and consider the research and knowledge we have about children attachments and trauma.

· There needs to be a contingency plan for the child if the SGO assessment is not positive.

· Children’s social workers need to think about the long-term suitability of the placements as opposed to ‘they are there now and doing really well’. Children’s SW often make a decision about the placement before the assessment is completed forgetting that the carers need to be better than good enough when you consider the needs of the children and the impact of their early childhood adversities.

· Social workers need to be confident and provide evidence to rule the potential carers out in the early stages of stage 1 and 2 viability assessments.

· Improved collaboration between the children’s teams, legal and kinship team.

· If the SGO assessment is negative but the child social worker plan is still for an SGO they need to ensure the support plan is robust and mitigates all risks and concerns raised by the assessor who completed the assessment and not ask for the assessment to be changed.

Special Guardianship Info –  Giving SGO a Voice

You can find full details below of this Serious Case Review report :Megan

A serious case review overview report: Megan.  

Gloucestershire Safeguarding Children Board
David Byford

Publisher Gloucestershire Safeguarding Children Board (2020)

Abstract Neglect and abuse of a 6-year-old girl over a number of years. Megan was placed in the care of her paternal grandmother in 2012 via a Special Guardianship Order (SGO). Megan was neglected and physically abused by her father, her paternal grandmother and her grandmother’s partner. Megan was brought to hospital ‘acutely unwell’ and staff found her covered in bruises. Megan was removed from her grandmother’s care in 2015. Her father, grandmother and partner received substantial custodial sentences. An initial case review was carried out by the Social Care Institute for Excellence (SCIE) in 2017. This review reassesses the 2017 report. Ethnicity or nationality not stated. Learning includes: need for practitioners to improve their awareness and personal knowledge in being able recognise and identify the signs and symptoms of all child abuse; the voice of the child was not effectively captured at the time considering the subsequent disclosures Megan made; agencies should have robust record keeping and management systems in place; a consistent lack of professional curiosity and scrutiny displayed in the assessment of child protection concerns; too much optimism when conducting the SGO application of parental grandmother’s capacity to care. Recommendations: Gloucestershire County Council Children Social Care to develop a safeguarding pathway for the application of family members for Special Guardianship Orders. The process will include utilising a Family Group Conference and to apply for an interim Kinship Foster Placement to allow safeguarding to remain in place whilst a detailed viability assessment of the prospective guardians’ capabilities is conducted.

Other resources Read full overview (PDF)

Citation Byford, David and Gloucestershire Safeguarding Children Board (2020) A serious case review overview report: Megan. Gloucestershire: Gloucestershire Safeguarding Children Board.

Special Guardianship Info –  Giving SGO a Voice