Professionals failed to prevent Keanu William’s death, report finds

London: Doctors, social workers, police and nursery staff collectively failed to prevent the death of a two-year-old boy who was beaten to death by his mother after months of horrific cruelty, a serious case review has found.

A “significant” number of chances were missed to intervene and stop Rebecca Shuttleworth, 25, from abusing Keanu Williams, who died days after he was seen with burns, bruises and marks.

Published in Birmingham on Thursday, the independent review said the failings were familiar. Agencies had failed to communicate internally and with each other; staff had been too willing to believe a parent’s explanations; there had been a lack of professional curiosity. Once again, the focus on the child had been lost, it said.

The review comes just two weeks after a similar one on Daniel Pelka, the four-year-old boy tortured to death by his mother and stepfather in Coventry. That review concluded Daniel became invisible to teachers, health professionals, social workers and police.

Findings in the Keanu Williams report will lead to further calls for a change of culture within agencies responsible for the care of children to ensure their focus is always on protecting young people.

Shuttleworth was jailed for life in June and was told she will serve at least 18 years before being considered for parole.

During her six-month trial at Birmingham crown court, a jury heard that 37 external marks were found on Keanu’s body after his death in January 2011. He had bruising to his lower chest, abdomen and back and had suffered a fractured skull.

A postmortem examination identified “tramline” bruising consistent with the boy having been struck with an object such as a stick or rod with some force. A fist-sized tear was discovered in part of the child’s abdomen, which had caused substantial bleeding.

Shuttleworth’s partner, Luke Southerton, 32, was convicted of one count of child cruelty an assault on Keanu but cleared of murder. He was given a nine-month suspended sentence.

The serious case review report on Keanu said that Shuttleworth’s chaotic lifestyle she moved addresses frequently, was sometimes homeless and changed partners regularly made helping the family challenging. There was no time when Keanu had a permanent home with his own cot, belongings and toys.

But the review, presented to the Birmingham safeguarding children board, concluded that it could have been predicted that Keanu was likely to suffer significant harm and should have been subject to a child protection plan on at least two occasions to address concerns that he was being physically harmed or neglected.

It said, “Professionals in the various agencies involved collectively failed to prevent Keanu’s death as they missed a significant number of opportunities to intervene and take action. They did not meet the standards of basic good practice when they should have reported their concerns, shared and analysed information and followed established procedures for child protection investigations and a range of assessments including medical assessments and child protection conferences.”

The review revealed that in November 2009 Keanu was the subject of a core assessment. A conference on his case concluded that he did not need a child protection plan but was a “child in need” requiring support, such as a nursery place.

According to the review: “The outcome of the child protection conference led to a loss of focus on Keanu because the child in need services moved the attention towards practical matters, such as the provision of a nursery place.”

Keanu was taken to hospital and a GP on a number of occasions but Shuttleworth explained away his injuries as “bumps and falls due to unsteadiness”. She once claimed: “Keanu falls over nothing”. On the last occasion, just before Christmas 2010, Keanu was taken to the accident and emergency department of a hospital with bruises to his eyes, forehead, back and feet, and burns to his right foot. Shuttleworth claimed he had burned his foot on a radiator while sleeping.

A police officer and social worker went to examine the flat but the injuries were put down as neglect rather than wilful neglect, and no effective action was taken. “This was not only a missed opportunity but a significant failure by all the agencies involved to act to protect Keanu,”

the report concluded.

The boy was seen by nursery staff early in 2011 with a number of marks and bruises on his chest, stomach and back, and was described as distressed. But he was not referred on to other services and clear guidelines and procedures were not followed as staff again believed Shuttleworth’s explanations. Keanu died four days later of multiple injuries sustained over months.

The review concluded there was a lack of focus on Keanu.

“A number of the issues which have arisen in this review are also familiar themes in serious case reviews nationally, such as: poor communication between and within agencies, a lack of analysis of information, a lack of professional curiosity in questioning information, a lack of confidence among professionals in challenging parents and other professionals, shortcomings in recording systems and practice, professional over-optimism rather than to ‘respectfully disbelieve’, dealing with events as one-off episodes.”

It makes a series of recommendations to 13 organisations named in the report, saying the case “illustrates the dangers of becoming side-tracked into dealing only with the practical day-to-day matters of the adult family members and responding to events without analysing the available information and without seeking clarification”.

“When the impact on the child of the nature of care provided is not considered by professionals, and the accumulation of events over a period of time are not taken into account and reviewed, the child focus is lost.”

Shuttleworth herself spoke to the review team. She spent her childhood in care and expressed “some surprise” that Keanu was not taken from her when he was born. She said she was appealing against her sentence so could not talk in detail about the case.