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Summary: Child services in Hertfordshire place a 4-year-old girl with her natural father who is taking psychiatric medications. He exhibits behaviour that may or may not have been related to the medication: agitation, anxiety, and sudden, impulsive, uncontrolled outbursts of anger. The case is referred for a review. The reviewers mention the medication, but the bias to assume it was a positive is so strong that the medication is not even identified. In this way, a potential contributing factor is simply ignored in the search for answers.
13 May 2015
A man has been found guilty of murdering his four-year-old daughter by beating her to death.
Alexa-Marie Quinn had 66 injuries including a bruise from her stomach to her ankles when she died in March 2014, St Albans Crown Court heard.
Carl Wheatley, 31, from Hatfield, Hertfordshire, admitted manslaughter but the jury rejected his plea of not guilty to murder on the grounds of diminished responsibility.
He will be sentenced on Friday.
The court heard Wheatley had convinced social workers he could look after the girl at his home in Queen Bee Court and was awarded custody of her three months before she died on 12 March last year.
The jury was told Wheatley beat Alexa with “hard, sustained, persistent hitting” after losing his temper. The blows were delivered with such force that fat deposits entered her bloodstream and blocked her lungs.
A pathologist found she died from “extreme blunt-force trauma”.
Alexa had been removed from her mother’s care some years earlier and had been living with foster parents in Bedfordshire before moving in with her father.
The supermarket worker was also fighting for custody of a three-year-old boy, who cannot be named in order to protect his identity.
Prosecutors said he wanted custody in order to claim more benefit payments.
During the trial, the jury was told psychiatrists diagnosed Wheatley with multiple mental health disorders.
Prosecutor Christopher Donnellan, QC, said Wheatley dialled 999 on the morning of the fatal attack but by the time paramedics arrived it was likely Alexa had been dead for hours.
Det Ch Insp Jerome Kent from Hertfordshire police, said: “Alexa-Marie suffered horrific injuries at the hands of her father, a man who should have been protecting her.
“Not only did he cause her such significant injury prior to her death, he failed to seek any help for her, leaving her to suffer.”
In welcoming the verdict, Jenny Coles, director of children’s services at Hertfordshire County Council, said: “There will be an independent review of all the agencies involved in looking after Alexa-Marie by the Hertfordshire Safeguarding Children Board.
“We are keen to see its results and will welcome any recommendations about any improvements to our services and in our work with vulnerable children and their families.”
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Hertfordshire Safeguarding Children Board Serious Case Review: Sophie
Edi Carmi and Jane Wonnacot
2.1.1 This serious case review concerns the death of a four year old girl killed by her father in March 2014. This was less than three months after she moved to live with him following the decision at Luton County Court to grant him a Residence Order. The child’s father was convicted of her murder in May 2015.
2.1.2 The child, called Sophie for the purposes of this review, was one of a sibling group of three children. Sophie was born in Hertfordshire, where there were concerns for the children in the family because of domestic violence incidents relating to the mother’s partners. This included a violent incident with Sophie’s father, which was reported to police and children’s social care. Mother was advised by children’s social care to separate from Father.
2.1.3 Mother and siblings moved to Bedford Borough and from this point there was only one further contact with Sophie’s father whilst Sophie lived with her mother.
2.1.4 Bedford Borough Council removed all three siblings from their mother in March 2012, due to mother’s continuing chaotic lifestyle, substance misuse and domestic violence in the home. An interim care order was obtained and Sophie and siblings placed together with foster carers in another unitary authority.
2.1.5 When care proceedings are initiated, other family members must be considered as potential alternative carers; consequently Sophie’s father was located, expressed a wish to be her carer and became subject to an assessment. By this point he had been involved in another relationship and had another child, called Joe for the purposes of this serious case review. The father and Joe’s mother lived in Hertfordshire, but did not live together. Joe lived with his mother, but had regular contact with his father.
2.1.6 This review relates to a complex set of circumstances involving two family groups, two local authorities and foster carers residing in a third area. One of the local authorities is a large shire county and the other two are unitary authorities covering much smaller geographical areas.
3. Evaluation of What Happened
3.2.7 The assessment was completed in September 2013 and recommended that Sophie should move in with her father. The assessment was limited in its scope, relied largely on self reported information and observation of the father/child relationship in supervised contact. It did not address all the questions in the letter of instruction, did not gather information regarding Father’s history of domestic violence and involved limited triangulation of information provided, as could have been obtained through discussion with father’s ex partners and relatives (see 4.3 for further discussion).
3.2.8 Father’s solicitor had requested a report of Father’s mental health from the team responsible for his treatment. This was undertaken by a locum psychiatrist, who whilst not knowing Father previously, provided a highly relevant report to the proceedings (see 4.3 for further discussion).
3.2.9 The content of this report should have called into question Father’s ability to manage stress, describing how he became so angry that a colleague overheard and knocked on the door to check on the ‘safety’ of the psychiatrist. Father’s anger continued to such an extent that the psychiatrist felt ‘intimidated’ by him. When the psychiatrist tried to end the interview, Father would not leave. The psychiatrist’s colleague joined the interview to calm Father down. This took 45 minutes. It is of note that the accounts that Father gave during this interview were inconsistent, and the anger was partly his response to challenge on such inconsistencies.
3.2.10 What is surprising is the apparent insufficient scrutiny of this report by all those involved in the legal proceedings. This was partly because it was filed late, after the assessment of the independent expert. However, the report ends with a judgement that the prognosis for Father was good on the basis of his stable employment and consistent use of medication in the previous year. It has been suggested that this positive prognosis may have contributed to the lack of full consideration of the implications of the content; however, that statement referred to the prognosis of Father’s mental health (the purpose of the report) as opposed to his parenting. In fact the cautionary suggestion of possible psychological input to help him work on his difficulties ‘in a deeper way’, mentioned with this prognosis, should have alerted the reader to the need for further assessment.
4. Findings and Recommendations
4.3: All parties in the Court arena failed to appropriately consider the implications of the September 2013 psychiatric report, and consequently did not argue for a delay in the final hearing so as to develop a care plan better able to meet Sophie’s needs.
4.3.4 Significant information was received near the end of the legal proceedings on 10.09.13.and should have, but did not, cause constructive delay. This new information was contained in a report from a psychiatrist (in the service providing Father with treatment) in response to a request by Father’s lawyer for a report on Father’s mental health. The report mentioned Father being agitated and anxious, changing his account frequently, becoming angry and it taking 45 minutes to calm him down. Most significantly, the psychiatrist referred to being intimidated himself by Father’s behaviour.
4.3.5 Such information should have caused immediate alarm bells: if Father was able to intimidate an adult male professional by his behaviour, his risk to a child was of great concern. However, although the social worker and her managers did see the report, the contents were not seen as alarming at the time. This appears to the independent serious case review authors to be surprising. Social workers and managers in both Bedford Borough Council and Hertfordshire County Council told the authors that their understanding at that point was there should be no delay in making the Final Order and it is likely that this will have impacted on the lack of detailed consideration given to the report’s contents.
4.3.6 A further reason for the report being insufficiently considered was its conclusion of a good prognosis of Father’s mental health (see 3.28 – 3.2.10), which may have mistakenly been confused with his parenting prognosis. Whilst this was a report about his mental health, and not about his parenting, the content indicated further consideration was needed about his ability to parent a young, disturbed child, who may test a parent’s abilities to the limit.