Two damning serious case reviews into the deaths of Dylan Tiffin-Brown and Evelyn-Rose Muggleton have been published today – and concerns remain for the future.
On 15 December 2017, shortly after his second birthday, Dylan Tiffin-Brown was rushed to Northampton General Hospital in an ambulance.
Despite all attempts to save the young boy’s life, he died of cardiac arrest.
His small body contained high levels of several drugs and it had multiple bruises and injuries.
His father, Raphael Kennedy, who had only met his son for the first time 10 weeks before, was later convicted of his murder.
Two months prior to his death, during a police raid of his father’s flat, Dylan was found in the presence of drugs and was believed to have been left alone for long periods.
No director can promise the same thing won’t happen again.
Sally Hodges, director of children’s services, Northamptonshire County Council
Police officers referred the case to Northamptonshire Children’s Services and a multi-professional strategy meeting was held two days later. It was decided that the threshold had not been met to show that the boy was “suffering or likely to suffer harm”. Rather than urgent action being taken, a plan was made to assess the family further.
During this period, extended family members raised concerns about Dylan’s father with the local authority up to eight times. One of these reports was said to have been made before the police raid.
In the month of Dylan’s death, an independent reviewing officer involved with separate legal proceedings connected to the family, sent information to the social worker dealing with Dylan’s case which showed that Kennedy was still having unsupervised contact with his son. The officer noted at the time that no observations on Dylan’s welfare had been recorded on his file since October.
48 hours later Dylan was dead.
Late last April, in the nearby town of Kettering, the mother of one-year-old Evelyn-Rose Muggleton headed off to work, leaving her baby in the care of her partner, Ryan Coleman.
Later that morning, Coleman rang her to say that Evelyn-Rose had fallen off the bed and was unresponsive. She called an ambulance and rushed home. When she arrived, her daughter was floppy and not breathing.
Paramedics quickly arrived and took her to hospital. They noticed she had marks on her neck and face.
A CT scan showed that the baby had bleeding and swelling on her brain.
Over the next few days, her condition deteriorated and she died on 29 April.
His small body contained high levels of several drugs and it had multiple bruises and injuries.
Coleman’s account of what happened to Evelyn-Rose didn’t match her injuries and he was later convicted of her murder.
The man had moved in with the family the previous May, shortly after meeting Evelyn-Rose’s mother. Despite being just 21, he had a significant criminal history, including violence. While at the family home, a number of reports were made to the police by neighbours about suspected drug activity at the property.
Evelyn-Rose’s older siblings had previously been subject to child protection plans because of domestic violence in the home. During this time the family had three social workers. The first social worker who dealt with the case was off sick for a period of time, leading to a lack of recorded visits or follow-ups. Despite knowing that the mother was pregnant with another child, a second social worker failed to even discuss this with her during his visits. Then, when he suddenly left, his replacement decided to close the family’s case.
Today, two serious case reviews have been published into the children’s deaths.
The findings are damning.
In Evelyn-Rose’s case, it is noted that there were “missed opportunities” by a number of agencies involved with the family. On one occasion, her eldest sibling was taken to hospital with three head injuries on the same day, but no referral was made to the multi-agency safeguarding hub.
The report into her death says that the family’s case with Northamptonshire’s Children’s Services had been allowed to “drift with little attention being paid to the children’s welfare”.
In Dylan’s case, the investigation found that the lack of observations made in his file by social workers and other staff had “seriously undermined” his safety and that the multi-agency strategy meeting had failed to “fully appreciate the significance of [his father’s] chronic history of domestic abuse and history with the police for drug-related offences”.
It also found that “local strategic level factors” had impacted on children’s services in Northamptonshire at the time. They included a high turnover of staff, large numbers of agency staff, high caseloads, and significant levels of sick leave.
Speaking to Byline Times this morning, Keith Makin, chair of the Northamptonshire safeguarding children board, who carried out the reviews, said he could not understand how children’s services didn’t piece together warnings from family members and the evidence from police.
“As an independent person looking at the case, I can’t grasp what happened at that point,” he said. “I just can’t understand it. Something fundamentally went wrong.”
Sally Keeble, Labour candidate for Northampton North, recently highlighted five troubling cases involving children’s services in the area. She says that members of Dylan’s family have also shown her text message exchanges between them and the council in which they made repeated warnings about the child’s father.
“For some unaccountable reason, these warnings were not acted upon,” Ms Keeble said.
She is now calling for the leader of Northamptonshire County Council, Matt Golby, who was cabinet member for children’s services at the time of the two deaths, to resign.
Today’s news comes just days after Byline Times reported on serious concerns that social workers in Northamptonshire, the first local authority to effectively declare itself bankrupt in decades, still have about the way children’s services are being run.
They spoke of pressure to close cases too quickly, continued problems with the recruitment and retainment of staff, and demoralised workers. One described working in the county as being similar to an abusive relationship.
As an independent person looking at the case, I can’t grasp what happened at that point.
Keith Makin, chair of the Northamptonshire safeguarding children board
“They [managers] tell you over and over again that everything is fine,” they said. “It’s like being in an abusive relationship. It’s gaslighting.”
Byline Times asked the new director of children’s services at Northamptonshire County Council, Sally Hodges, how she felt about these concerns.
“It’s fair to say we still have a way to go with our improvement journey,” she said. “There are a lot of outstanding things to be achieved and we know that it takes a considerable amount of time to turn things around. What I can say is that there is the will to see these improvements take effect.”
When asked if she had confidence in the leadership of Mr Golby, given his role in children’s services at the time of the two cases, she said: “I am acutely aware of his support for the improvements we are making. He is heavily involved.”
Despite all the talk of improvements, neither Mr Makin or Ms Hodges could confidently say that the same failings that were made in Dylan and Evelyn-Rose’s cases could not happen again.
“I’m confident we’re doing everything we can to make sure that staff and services are as strong as they can be,” Ms Hodges said. “But no director can promise the same thing won’t happen again.”