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Birmingham publishes first full Serious Case Review

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Birmingham City Council has been handed an 18-point action plan following the death of Khyra Ishaq who was starved by her mother and stepfather after being taken out of school.

The Birmingham Safeguarding Children Board (BSCB) today published its 180-page serious case review on the 2008 tragedy, which is the first such report to be made fully public on the orders of education secretary Michael Gove.

The review found Khyra’s death was “preventable” and paints a picture of local agencies failing to fully share information between each other that could have saved the girl’s life.

In particular it pointed to too great an emphasis on processes for dealing with children taken out of school for home education – as was Khyra’s case – rather than on their overall welfare, adding that safeguarding concerns expressed by the school had not had been accurately recorded.

The report notes that if connections had been made between missed care appointments, weight loss and an “obsession with food” among Khyra’s siblings, health professionals would have acted more promptly to help.

Among the review’s 18 recommendations are a review into better cross-agency working and a requirement that social care staff should demonstrate an understanding of the Common Assessment Framework.

The final recommendation is for the city council to launch an awareness-raising campaign aimed at underlining the safeguarding role that residents can play. A failure of many neighbours to act on concerns about Khyra and her siblings emerged shortly after her death.

Hilary Thompson, chairwoman of the BSCB, said: “The serious case review concludes that although the scale of the abuse inflicted would have been hard to predict, Khyra’s death was preventable.

“The report identifies missed opportunities, highlighting that better assessment and information-sharing by key organisations could have resulted in a different outcome.”

Education secretary Michael Gove said the report confirmed that all the agencies in Birmingham failed to protect Khrya and that he expected to hear recommendations on reforming arrangements for home-educated children in the near future.

“Clearly lessons need to be learned by the tragic events in this case, and I will consider the letter I expect to receive from Birmingham shortly, to see what changes need to be made to the existing arrangements,” he said.

Today’s serious case review is likely to serve as a benchmark for the publication-in-full of other such reviews into tragedies.

Neither Khyra nor her mother are mentioned by name in the report, and staff are also not referred to by name, however they could be identified by job to those who knew the schools and other such institutions involved.

In cases where references are made to several staff working in similar roles, they are identified by condensed job-title and a number – such as ESW1 (Education Social Worker 1).

The full serious case review can be read here.

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