Child must be the main focus in any child protection case, SCR warns

Serious Case Review into the death of Ellie Butler warns that professionals should not be distracted by hostile behaviour from parents


All agencies should remember the importance of focusing on the needs of the child throughout any case, the Serious Case Review into the death of Ellie Butler has warned.

Ellie was aged 6 years and 10 months when she died in October 2013. In 11 March 2014, her father Ben Butler was charged with the murder of Ellie and also faced a charge of child cruelty. On 22 April 2014, her mother Jennie Gray was charged with intending to pervert the course of justice and also faced a charge of child cruelty. Last week Ben Butler, was given a life sentence for Ellie’s murder. Gray, was given 42 months for child cruelty and her part in a “cynical” cover-up of their daughter’s death.

However the Serious Case Review into Ellie’s death warns that all agencies should reinforce the importance, throughout their work, of focusing on the needs of the child at the centre of a case and good practice in the direct recording of the child’s voice should be adopted.

The SCR by the London Borough of Sutton’s Local Safeguarding Children’s Board also warns professionals that when they are working with parents who are resistant and hostile, they should not be “deflected or distracted by parental behaviour” and should focus on assessing the potential risk posed to children in these families by emotional abuse or neglect.

“The adequacy of multi-agency training in this topic should be assessed,” the SCR adds.

Ben Butler had a history of alcohol-related injuries, assaults and fights as well as a history of depression. He had a long history of offending, including a 3 year 11 month prison sentence for armed robbery with violence and witness intimidation, charges of ABH and an assault on a pregnant ex-girlfriend.

In February 2007, when Ellie was a baby, she was taken to Epsom and St Helier Hospital after Butler noticed that she was “suddenly soft and limp”. The hospital team found Ellie had sub-dural haematomas (a collection of blood on the brain as a result of a head injury), retinal haemorrhages and suffered seizures. A child protection investigation found that the injuries were not accidental and in March 2009, Butler was found guilty of GBH in respect of Ellie’s injuries and was sentenced to 18 months in prison.

In June 2010, the Court of Appeal quashed Butler’s conviction for GBH on the basis of new expert medical evidence which raised areas of doubt. In July 2012, the High Court Hearing overturned the previous Finding of Fact, which meant the parents were found not to be culpable of involvement in Ellie’s injuries and had suffered a miscarriage of justice.

Sutton Council was required by the court to send a letter to all agencies who had worked with the family to inform them of Butler’s quashed conviction and exoneration.

Christine Davies CBE, Independent Chair of the Sutton Safeguarding Children Board, said: “The serious case review concluded that the Family Court’s decision to exonerate Ben Butler of harming Ellie in 2007, combined with its subsequent order for agencies to be sent a letter to that effect, had a very significant impact on how agencies could protect his children from that point in time onwards.

“Ben Butler’s exoneration and the Judge’s statement about him being a victim of a miscarriage of justice had the effect of handing all the power to the parents. This coupled with the assessment made by Services for Children to support Ellie and her sibling to be cared for by their parents were critical factors,” she added.

An Independent Social Work Agency S4C was appointed to carry out an assessment of Butler and Gray with a view to the rehabilitation of the younger sibling Child S to Ms Gray after the judge stressed that any “assessment or work to be done would be doomed to failure if it were to be managed by the Local Authority”.

However S4C was not made aware of Butler’s history and despite their work with the family, and Ellie and her younger sibling being returned to Gray, a number of events came to light including:

  • Gray presenting at St Helier hospital with both children who were hungry.
  • Gray became pregnant and presented at Chelsea and Westminster Hospital for gynaecological investigations with the younger child, saying there was no one to care for the child while she was in hospital.
  • The relationship between Gray and Butler broke down and they separated.
  • Butler refused to deal with children’s services.
  • The family’s home went into rent arrears.
  • Gray was again admitted to Chelsea and Westminster Hospital on 27 March 2013 with bleeding attributed to a termination of pregnancy. She gave false information, including denying that she had children or that she had previously been in that hospital.
  • There was an allegation that Gray had been raped reported to the Multi Agency Safeguarding Hub in April  2013 although no supporting evidence was brought forward.

S4C concluded their work with the family in March 2013 and submitted a report to Children’s Services dated 12 April 2013 which was generally very positive regarding the development of the relationship between the children.

However, the parents continued to be resistant to any Children’s Services involvement and contacts and most professional contacts with Ellie and the family during the last months of her life were with universal services including the school, school nurse, health visitor and housing. Ellie died in October 2013.

The SCR concluded that this case was particularly unique due to the numbers of agencies involved, the levels of resistance from the parents and the use of an independent social work agency. It said: “Despite a significant range of concerns and worrying incidents (albeit below the threshold for statutory intervention) being documented by agencies before and after Child D (Ellie) went to live with the parents, the effect of the court judgement and exoneration, combined with the parents refusal of any voluntary engagement with support services, meant that no intervention that might have made a difference was possible.”

“The Judge in the High Court case pronounced with perhaps undue certainty that the parents’ previous patterns of behaviour would change. She said: ‘Now they have been unburdened from the shadow of findings against them… they are going to change’.”

“Sadly this did not turn out to be the case,” the SCR concluded.

The Serious Case Review is available here.


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