A superficial assessment by an outside agency led to tragic toddler being placed in the care of her killer, an inquiry has concluded.
But the serious case review into the death of 18-month-old Shi-Anne Downer - also known as Keegan Downer - also found that she became ‘almost invisible to professionals’ who only visited her once between her placement and death.
Shi-Anne died in September 2015, beaten to death by Kandyce Downer, a distant relative into whose care she was placed by social workers. Kandyce was sentenced to life in prison for the murder.
The review has concluded that Shi-Anne was barely considered after the decision to issue the special guardianship order was taken. “The voice of Shi-Anne was regularly missed” it states.
Instead they focused too much on the demands of Kandyce Downer - a single mum-of-four at the time she took Shi-Anne in.
The report found that no one could have predicted that Kandyce, who appeared to be a caring mother to her own children, would turn into a child killer, but that risk factors were evident more visits and regular checks might have set alarm bells ringing.
Follow updates from the report below.
Kandyce Downer - toddler killer trial
Key Events
'Insufficient checks' - The crucial paragraph in report
This is the crucial paragraph which says that while there were insufficient checks, that no-one could have predicted how Kandyce would turn from being an apparently loving mother to her own children, to a ‘brutal attacker’ and child murderer. The report states:
“The review author is firmly of the opinion (albeit based on hindsight) that Shi-Anne should never have been placed with Kandyce Downer, due to
a) Kandyce Downer not really fitting the criteria to be awarded an SGO,
b) the flawed and incomplete assessments.
“As Mrs Justice Patterson says above, there is no evidence why Kandyce Downer changed from that loving mother into the brutal attacker.
“As a result of this the author feels that Shi-Anne’s death couldn’t have been predicted.
“It is felt though, that if there was a Supervision Order in place (as long as implemented effectively) or in particular, what the review author sees as a significant event when Kandyce Downer became pregnant again (including thebreakdown of her relationship) an assessment of the risks posed by this additional stress to the household, that the opportunity for Kandyce Downer to carry out these assaultscould have been prevented by the involvement of professional action and curiosity into the life of Kandyce Downer and the children, in particular Shi-Anne.”
Report chair: "Council has improved"
Chair Penny Thompson CBE, continued:
“As a result of this and other cases, national guidance on the use of special guardianship orders has been altered to be more robust, and in Birmingham practice and management has fundamentally changed.
”The checks for special guardianship orders, when a child is place with relatives, were much more relaxed than those for full adoption but have now been strengthened.
“This tragic case has informed the improvement of services in Birmingham and will go on to contribute to the training and culture of learning that our Safeguarding Partnership is committed to.
“It also provides lessons for all areas, and I hope will inform the improvement of assessment, planning and child-centred practice, nationally.
“Whilst nothing can bring Shi-Anne back; she will not be forgotten.”
Chair of new report on its findings
Chairwoman of the Birmingham Safeguarding Children Board Penny Thompson CBE, who led the serious case review, said:
On behalf of all the agencies that sit on the Safeguarding Board I would like to express our deepest sympathies to Shi-Anne’s birth family, the foster family who cared so well for her before she was placed with the Special Guardian, and all those who knew and loved her.
“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.”
City Council stops use of outside agencies to assess SGOs
Local authority editor Neil Elkes has been assessing the report this morning....
Birmingham children’s services has already reviewed and updated its procedures to prevent a repeat, it says.
A key issue was that they farmed out the Special Guardianship Order assessment to Minster Social Work Ltd who gave a positive assessment.
The social worker assigned to Shi-Anne the case was absent from work between July and September 2014 during some of the most crucial decisions around the Special Guardianship Order.
The city council has already stopped the use of outside agencies to assess SGOs and updated its procedures around this.
There are also concerns raised around the lack of information sharing between social workers, GPs and health visitors
NSPCC: 'Motivation for guardians must be explored'
THe NSPCC has released a statement on today’s report.
A spokesman said:
No child should have to endure the horrific abuse that Shi-Anne was subjected to during her tragically short life.
“It is clear that the process of making Kandyce Downer responsible for Shi-Anne via a Special Guardianship Order was deeply flawed, with a disturbing lack of assessment and scrutiny.
“It is vital that the child remains at the heart of all decisions that professionals make.
And someone’s motivation for wanting to take responsibility for a child must be rigorously explored, to ensure the child will be safe and brought up in a loving environment.
“We would urge anyone concerned about a child – whether it is something they have seen at the school gate or unusual behaviour – to contact the NSPCC helpline on 0808 800 5000, as it could save a life.”
City council reviews procedure
Birmingham City Council after the death of Shi-Anne reviewed their procedures.
The council also provided assurance to the review that they are making the necessary improvements through the provision of position statements against each key area of work they had identified.
The key areas they identified are including:
- Now completing all SGO assessments in house
- The SGO procedures have been updated and guidance produced about ensuring the assessments are thorough and include all relevant points, also identifying the most appropriate permanence option for children.
- They now keep cases where an SGO has been awarded open and notify relevant agencies that an SGO has been granted, so they can be flagged on their systems, and also ensure support and supervision is provided for a number of months.
These changes are incorporated into the council’s Individual Agency Summary Report presented to this review.
What was missed by social workers
The following issues in the review author’s opinion were not taken into account when placing Shi-Anne with Kandyce Downer.
- Shi-Anne had been removed at birth and therefore had no pre-existing relationship with any member of her extended family.
- None of Shi-Anne’s older siblings had contact with their birth parents, so what would be the reason for Shi-Anne to have it?
- None of Shi-Anne’s older siblings wanted contact with her and none appeared to be planned for the future.
- If Shi-Anne was to be brought up within the extended family, how would her relationship to her birth parents and siblings be explained to her, especially given the above?
- The birth mother’s wish was that Shi-Anne was not cared for within the extended family. Why was this not apparently considered?
REPORT: The risk factors which could have set alarm bells ringing
Moving into the report...
In foster care Shi-Anne was regularly visited and was up to date with development checks and immunisations before being moved in with Kandyce Downer. After that Shi-Anne was not brought in for further checks and immunisations and there was no follow up to find out why.
The report states that alarm bells should have been ringing over Kandyce Downer’s suitability and ability to look after Shi-Anne.
Risk factors included:
She was a single mother with four children already.
There were two historical episodes of domestic abuse
A period of stress leading to time off work
A new partner and an unplanned pregnancy. The report states:
Recognising this might have led to an assessment and offer of support once all the factors were put together”
What is an SGO?
SGO stands for Special Guardianship Order (SGO).
It was this arrangement which saw Keegan (Shi-Anne) moved into Kandyce’s home.
Special Guardianship is where you take on the responsibility of caring for your grandchild until they are 18 years of age
An SGO is not as clear cut as adoption as the child retains a link to their parents.
On the SGO regarding this case assessment Penny Thompson said:
It was weak assessment, it wasn’t challenging.
To be fair to the organisation they were given a short-period of time to do it.
She said that there were also lessons for the courts, health services and education services who had contact with the Downer family.
Natioinal policy on SGOs has been strengthened - says service's chief
Peter Hay, director of children’s services said:
This is a terrible tragedy and we have been clear all along that the best response we could make to Shi-Annes 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.”
He said that natioinal policy on SGOs has been strengthened as a result and locally the council is now carrying out all assessments in house. He added:
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.”
“A number of other improvements have been made as a direct result of this case including unannounced visits to people who have been granted an SGO and more support available to them.”
'Flaws in the system need eradicating'
Before the report was released cabinet member for children’s services Brigid Jones said:
My thoughts are with everyone who knew and loved Shi-Anne.
While nothing we do will bring her back it is important that changes are made where there were flaws in the system. We have made such changes and we now have far more robust procedures in place.
While Shi-Anne’s terrible death could not have been predicted we know that she should not have been placed with Kandyce Downer.
I full expect that the lessons from this case will inform better assessments and practive around SGOs not just in Birmingham but nationally.”
Foster carer had raised concerns
Before we outline the findings of the report here is a short recap of some of the concerns raised in the murder trial...
Keegan’s then foster carer had raised concerns with social services that Downer may have had a financial motivation before the child’s handover, but the guardianship order was granted.
- In the three months before her death Keegan was not seen by any health or social services professionals and she was also taken out of her nursery in June.
- It also emerged during sentencing that Downer had tried to secure custody of Keegan’s older sister, but she was already setlled with her foster family.
- However, it was the council who approached child killer Downer to see if she would be interested in caring for Keegan when she was born.
