Assessments within children’s social care in relation to Star Hobson who died aged just 16 months old were not fit for purpose, the Child Safeguarding Practice Review Panel has stated.
The review of Star’s death, alongside the death of Arthur Labinjo-Hughes, found that assessments did not enable the identification of risks to Star and a plan for mitigating those risks.
“The practice framework underpinned by the Signs of Safety methodology was reduced in practice to the use of a formulaic list and rating scale and did not lead to a better understanding of risks and protective factors for Star,” said the review.
“Assessments needed to move beyond superficial judgements and imprecise language, to the position where all available information was used, triangulated and analysed in order to understand what was happening to Star,” the review added.
Unsettled life
Star was murdered on 22nd September 2020. Savannah Brockhill was sentenced to a minimum of 25 years for murdering Star while her mother Frankie Smith was initially sentenced to eight years for causing or allowing Star's death. However at the Court of Appeal, three senior judges considered the case and extended the original term by four years after Attorney General Suella Braverman said eight years was “unduly lenient”.
Star’s mother Frankie Smith was 17 years old when she became pregnant, was young for her age and struggled academically. Star’s father had been in care and was living in supported accommodation but remained in contact with his parents. He was in regular contact with both a transitions social worker in Adult Social Care and a Personal Adviser from the Leaving Care team.
Star had a somewhat unsettled life after her birth, moving households frequently and with times when people other than her mother were looking after her full time. Health visitors and nursery nurses were not aware of the extent of disruption in Star’s life and found her to be developing as expected.
Frankie’s relationship with Star’s father was “on and off” both during the pregnancy and immediately after her birth. The relationship finally ended when Star was four months old although arrangements were then made for Star to have regular contact with her father at his parents’ home.
Domestic Abuse
Frankie Smith met Savannah Brockhill around October 2019. Savannah was 26 years old and worked as a security guard. It is now apparent that Savannah had a history of domestic abuse with a previous partner and was made subject to a Restraining Order in 2015.
There are consistent reports from family and friends about the change in Star after Frankie began her relationship with Savannah. There were also reports that Frankie was seen with bruises, possibly caused by Savannah, and that Savannah seemed to be controlling her – including restricting Star’s contact with other family members.
In January 2020 a domestic abuse organisation was working with a friend of the family who often looked after Star. The friend was worried about abuse in Frankie’s relationship with Savannah and Savannah’s physical chastisement of Star.
Following a written referral, the police made a welfare check and a social worker completed a child and family assessment, having seen Star at a home visit. The final assessment did not report any child protection concerns but the main need identified for Star was accommodation for her and Frankie. A letter was sent to the Housing Department and the case was closed to children’s social care.
Between February and April 2020, Frankie asked Star’s great-grandparents to look after Star as she could not cope after her relationship with Savannah broke down. Star thrived while with her great-grandparents until April 2020 when, without any prior warning or discussion, Frankie removed Star from their care as her relationship with Savannah had resumed. Frankie and Star went back to live at Star’s grandmother’s house and Frankie stopped all contact with Star’s great grandparents. Paternal grandparents saw Star for the last time in March 2020, after which point they were also denied contact.
Concerns
During May 2020, family members became increasingly concerned about the way that Savannah was treating Star. Star’s great grandmother made a referral to children’s social care on 4th May 2020 which resulted in an unannounced visit the next day. Frankie told the social worker that she felt the referral was malicious as Star’s great grandmother did not approve of same sex relationships. No visible injuries were seen, Star’s grandmother said she had no concerns and agreed to supervise contact between Star, Savannah and Frankie for the duration of the assessment.
Star’s father contacted the Emergency Duty Team in June to say that he wanted to send some pictures of bruising on Star’s face that had been sent to him by a relative of Star. He was given the contact details of the allocated social worker and advised to call 101 which he did.
A police officer spoke to Star’s grandmother and another relative of Star at their home and then visited Star and Frankie, who had moved to live at Savannah’s home. The police officer observed three bruises to Star’s face which Frankie said had been caused by Star banging her head into a coffee table. Alerted by the police officer (who was concerned that accounts of how the bruising occurred were not consistent), the Emergency Duty Team and police safeguarding team agreed that a Child Protection Medical was needed. The medical examination was conducted the same day and concluded that the injuries were consistent with the explanation that Star’s mother had given of an accidental injury. Star was discharged from hospital into the care of her mother.
Bruises
The single agency child and family assessment was completed and the case closed on 8th July 2020 with a note that the concerns were unsubstantiated and the original referral from great grandmother was recorded as malicious, the report said.
Star was being looked after by a family friend in August 2020 and another friend of the family was there and noticed bruises to Star’s face which looked like finger marks. The friend took a video and sent it the next day to Star’s uncle. He shared the video with Star’s maternal great grandfather. Star’s father also saw a copy of the video and contacted the police on 31st August but when the police tried to visit the home but were told that Star was with Frankie and Savannah in Scotland.
The following day Frankie called the GP to say that Star had cut her lip when falling off cobbled steps and it was “swollen, oozing red and green stuff and split open.” The GP surgery was about to close for the day and the GP asked Frankie to call NHS 111. A safeguarding note was entered on the file.
Star’s great grandfather contacted children’s social care the following day as he had now seen the video of the bruises. Two days later the social worker visited Star, Frankie and Savannah at Frankie’s home address. The social worker did not have a copy of the video showing the bruising to Star that had prompted maternal great grandfather’s concerns or the photo of bruising that had been sent to the police.
However, the social worker noted that the home was clean, warm and tidy and there was a “good attachment” between Frankie and Star. Frankie “happily stripped Star” and bruises were seen but perceived to be consistent with normal bruising. The referral was once again deemed to be malicious and concerns were not substantiated.
Frankie rang the GP the same day as the social worker visit because she had noticed blisters on Star’s tongue, something she had forgotten to mention in the call to the GP that morning. The GP offered to see Star immediately but Frankie said this was not possible as they were in the car on the way to Doncaster. The GP told her they must access an emergency appointment at Doncaster and advised Frankie to ring NHS 111 to arrange this.
“From early September 2020 it is clear that Frankie Smith and Savannah Brockhill acted to prevent professionals and family members from coming into contact with Star. A GP called Frankie on 7th September and she said that Star was now back to normal. After this, no professional saw Star or had contact with Frankie Smith before Star’s murder on 22nd September 2020,” said the report.
“Photographs taken during this period and recovered as part of the police investigation show a sad child with many bruises on her legs, arms and face. These photographs are in stark contrast to earlier photos of the happy child taken by her extended family. CCTV footage on September 13th, when Star was in the sole care of Savannah, showed the child being physically assaulted by Savannah with 20 separate blows to the head and body recorded over a period of two hours,” the report added.
Fractures
The final cause of death was an abdominal haemorrhage caused by blunt force trauma. A post-mortem found evidence of a recent skull fracture approximately ten days before Star’s death; re-fracturing of her right tibia approximately three – seven days before; and multiple injuries to the scalp, forehead, cheek and back - stark evidence that Star had been physically assaulted on numerous occasions in the weeks and months leading up to her death.
The report concludes:
- Professionals had only a limited understanding of what daily life was like for Star, beyond a superficial assessment from “one off” visits, which did not build on any historic information known by each agency.
- Assessments did not explore the family context and interaction between family members, most specifically in relation to concerns raised about how Star was being treated.
- Star’s wider family members were not listened to. The growing weight of concerned voices speaking on behalf of Star should have prompted professionals to reconsider the escalating risks to her.
- Domestic abuse between Savannah and Frankie was cited by referrers to children’s social care in January and May 2020 but this was not assessed in the respective single agency assessments.
- Assessments within children’s social care were not fit for purpose and did not enable the identification of risks to Star and a plan for mitigating those risks.
- The responses to the referrals with concerns about Star were significantly weakened by the lack of formal multi-agency child protection processes, especially strategy discussions and consideration of whether Section 47 enquiries should be initiated.
- Bradford children’s social care service was a service in turmoil in 2020, where professionals were working in conditions that made high quality decision making very difficult to achieve.
- The scale and depth of systemic problems in Children’s Services in Bradford was highlighted by the Education Secretary’s decision to place children’s social care in Bradford into a not-for-profit trust in January 2021 which, the review says, had a substantive and material impact on the quality of practice and decision making about Star.
- The volume of work and significant problems with workforce stability and experience, at every level, meant assessments and work with Star and her family were too superficial and did not rigorously address the repeated concerns expressed by different family members.
- There were undoubtedly multiple fault lines in multi and individual agency practice arrangements in Bradford in 2020, some of which are unique to that area. These contributed to the practice issues identified by this review.
The overriding recommendation of the review is the establishment of Multi-Agency Child Protection Units
Read Arthur’s story here.
