With City Council committees last night lasting around 5 hours and finishing around 11pm, doing an update on the events there was not possible yesterday, but I feel it appropriate to discuss today the debate over the Significant Case Review and Independent Review into the circumstances into the tragic and terrible death of Brandon Muir - without doubt the major - and most serious - matter to be discussed by city councillors in a very long time. You can read the report to the City Council's Policy & Resources Committee by clicking on the headline above. During the debate, I made the following points :"Over the last few days, I can only say, I have been dismayed at the speed with which some have rushed to accept the findings of the Serious Case Review into the circumstances surrounding the death of Brandon Muir.
“Gaps and inaccuracies” made by all the agencies charged with the protection of children throughout Dundee are indeed acknowledged in the body of the Serious Case Review, but in reading the recommendations, I was struck that these read more like a basic course in social work rather than some innovative working practices not heard of before.
May I make clear, this is not a criticism of the reports authors, who have clearly conducted a very searching and detailed inquiry but they must surely have been frustrated with their findings that even basic office procedures, such as minute taking at important meetings, were not observed.
For instance, I refer to recommendations on Case Conferences, item 11.1.1 (on page 46). ‘All agencies must ensure the most up to date information is available to the case conference’
Does it really take reports such as these to advise anyone attending such an important meeting that they should be in possession of up to date information?
I think that I will not be the only person who, having read the reports, was deeply concerned at the apparent lack of preparedness in relation to the Initial Referral Discussion on 28th February 2008, some 17 days before the death of Brandon Muir.
If these recommendations regarding recording of case notes and minute taking at meetings were not already being carried out by the agencies involved, questions must asked, if not - why not?
The Serious Case Review painted a picture of an inadequate system where proper recording of case notes was something of an exception rather than a rule and “little or no managerial oversight of work” existed (to quote Para 3.3.9 on Page 8). Why such a system – or perhaps I should say “non system” – would have been allowed to develop must now be subject to our scrutiny.
Much comment has also been made over the last few days about whether the shocking, violent, death of Brandon Muir could have been ‘predicted’.
May I make clear, this is not a criticism of the reports authors, who have clearly conducted a very searching and detailed inquiry but they must surely have been frustrated with their findings that even basic office procedures, such as minute taking at important meetings, were not observed.
For instance, I refer to recommendations on Case Conferences, item 11.1.1 (on page 46). ‘All agencies must ensure the most up to date information is available to the case conference’
Does it really take reports such as these to advise anyone attending such an important meeting that they should be in possession of up to date information?
I think that I will not be the only person who, having read the reports, was deeply concerned at the apparent lack of preparedness in relation to the Initial Referral Discussion on 28th February 2008, some 17 days before the death of Brandon Muir.
If these recommendations regarding recording of case notes and minute taking at meetings were not already being carried out by the agencies involved, questions must asked, if not - why not?
The Serious Case Review painted a picture of an inadequate system where proper recording of case notes was something of an exception rather than a rule and “little or no managerial oversight of work” existed (to quote Para 3.3.9 on Page 8). Why such a system – or perhaps I should say “non system” – would have been allowed to develop must now be subject to our scrutiny.
Much comment has also been made over the last few days about whether the shocking, violent, death of Brandon Muir could have been ‘predicted’.
The author of the Serious Case Review came to the conclusion that it could not have been. Only in as much as none of us can see into the future – I agree that, indeed, it could not have been predicted.
The more pertinent question is whether it could have been prevented. The Serious Case Review states there was ‘little opportunity to prevent the fatal assault’ on Brandon. The key to this would seem to have been that with the information available at the Initial Referral Discussion meeting, whilst there were ‘serious concerns’, there ‘were no red lights’ and immediate removal of Brandon to a place of safety was not considered necessary. This of course was the missed window of opportunity that would have changed the turn of events.
The author also raised the benefit of hindsight. It is my belief the decision to remove a child to a place of safety must be based on whether the decision makers charged with the responsibility of that decision, with certain information before them, would consider the child to be at risk. Yet the report does not actually tell us what information was brought to the table at the meeting on 28th February 2008, so we are unable to question what information caused ‘serious concern’ but not a ‘red light’. In light of the disastrous consequences that ensued, surely we must be asking if the threshold for a ‘red light’ should be lower than whatever information was presented at that meeting on 28th February.
The more pertinent question is whether it could have been prevented. The Serious Case Review states there was ‘little opportunity to prevent the fatal assault’ on Brandon. The key to this would seem to have been that with the information available at the Initial Referral Discussion meeting, whilst there were ‘serious concerns’, there ‘were no red lights’ and immediate removal of Brandon to a place of safety was not considered necessary. This of course was the missed window of opportunity that would have changed the turn of events.
The author also raised the benefit of hindsight. It is my belief the decision to remove a child to a place of safety must be based on whether the decision makers charged with the responsibility of that decision, with certain information before them, would consider the child to be at risk. Yet the report does not actually tell us what information was brought to the table at the meeting on 28th February 2008, so we are unable to question what information caused ‘serious concern’ but not a ‘red light’. In light of the disastrous consequences that ensued, surely we must be asking if the threshold for a ‘red light’ should be lower than whatever information was presented at that meeting on 28th February.
So - perhaps scrutiny should now be made of the criteria or guidelines for the categorisation of cases as a result of Initial Referral Discussion meetings. When does a case become a “red light”; when not, and are the criteria that lie behind this adequate and robust.
Mindful of the restriction of time for me to speak, I can only say that the reports have left me with many more questions than answers.
Suggestions that elected members should scrutinise these reports in detail at an all party committee have been met with some resistance and I would make the point that any unwillingness to allow proper, detailed scrutiny will be viewed by a concerned public as being a wholly inadequate handling of, and response to, this report, - by Dundee City Council.
At this committee, members have – in terms of Standing Orders of the Council – the ability to ask a couple of questions and limit contributions to 4 minutes. Further, there is no opportunity to call witnesses to this meeting. It goes without saying that all will agree with accepting the recommendations from Professor Wilson and Mr Hawthorn but in terms of a proper response by Dundee City Council to these reports, failure to bring these reports to an adequate and public scrutiny process would be unsatisfactory, inadequate and not acceptable in terms of properly scrutinising a catastrophic failure of service delivery.
I would further suggest that councillors should be afforded a further meeting with the authors of the reports in order that they may ask further questions thrown up by the reports. I am in agreement with Bailie Borthwick that only 90 minutes to read such an in-depth and complex document prior to meeting with the reports’ authors was woefully inadequate. It is only now that having read and digested the information in the reports that serious questions can be raised with the reports’ authors.
The answers to these questions are nothing more and nothing less than Brandon’s family and, indeed, all citizens of Dundee deserve."
My call for a further meeting with the reports' authors was agreed to but, overall, the response of the council administration - in failing to agree to further and proper scrutiny of the reports - has been extremely disappointing and concerning. It is vital that the City Council responds properly and adequately to the very serious issues raised by these reports.