Mistakes were made, but Rio Smedley's death 'could not have been prevented'
AN INVESTIGATION into the murder of two-year-old Rio Smedley has revealed there were “missed opportunities” but that his death could not have been prevented.
Rio died in April, 2012, as a result of a cardiac arrest after he was attacked by his mother’s partner, Daniel Rigby, who was later jailed for life.
The youngster’s mother, Kirsty Smedley, was jailed for four years for allowing or causing the death of a child.
Today, Bolton Safeguarding Children Board has published its serious case review (SCR), which examines the roles of all agencies involved and the lessons to be learned.
The review painted a tragic picture of Rio, of Cheriton Drive, Breightmet, being brought up against a background of “shadowy” unknown males, the risk of domestic violence, neglect, and anti-social behaviour in a family dependent on benefits.
Rio - called "Child J" in the report - was described as a boy who “presented as healthy and was a little chunky”.
He was chatty but not overfamiliar with workers, a quiet and contented child, who was quite shy when first meeting people but who enjoyed playing with his toys and would engage in play after a while.
He was said to have a warm relationship with his mother.
But the review also found Rio’s emotional and developmental needs were being compromised in his family.
A number of opportunities were missed by agencies to provide support to the family, which could have led to more “positive outcomes” during his life.
The SCR panel found the death was neither predictable or preventable — and there was no evidence available either at the time, or in hindsight, that Rio could have experienced physical abuse from any of his carers.
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The only time the authorities were aware of Smedley’s relationship with Rigby was when she told them she had been assaulted by him.
She told authorities that she was no longer in a relationship with him — and would not pursue the charges as the stress was “affecting her health and pregnancy”.
In fact, she had sent 250 text messages and tried to phone Rigby 186 times when he was on bail, but Bolton Children’s Social Work were not notified.
The specialist PPIU — police public protection investigation unit — domestic abuse investigator recommended Rigby be charged after a risk assessment.
But the decision not to prosecute was not passed back to investigator and as a result the PPIU was not able to reassess any risk or to inform other agencies of the decision when Rigby was on bail.
Just two days after Rigby was bailed, Smedley made a 999 call to say that Rio had fallen down the stairs had injured his head while under the care of Rigby.
Paramedics arrived on the scene within six minutes and tried to resuscitate him, but Rio was pronounced dead in hospital.
The review identified issues about charting the family’s progress, an “over reliance on plans to put in place support mechanisms” given that Kirsty Smedley had a pattern of not working with services once her immediate needs had been resolved and “an acceptance” that she was a “positive and protective factor” in relation to the children, without full assessment of her parenting capacity.
It added that on at “least one occasion” the case was closed prematurely and there was an “over-optimism” about Kirsty Smedley’s ability to maintain improvements.
The review also noted the fact that she planned to drop the charges does not appear to have been “accorded adequate weight in terms of assessing her capacity to safeguard her child”.
It added that had the agencies, particularly children’s services, fully understood the family history, particularly Smedley’s pattern of “disengaging from services”, it would have raised greater concerns about her potential to work with them.
The report said her actions suggest that she was primarily focused on meeting her needs rather than focusing on any impact renewing her relationship might have had on her children.
Rio’s half-sister lived at her grandmother’s because of Kirsty Smedley’s — referred to as Adult P — failure to “prioritise her needs” and there was evidence to suggest the children’s development was being affected.
Although this, coupled with other incidents, including a fire at the house when the child was being cared for by inappropriately young babysitters, triggered the intervention of services, they were not serious enough to take legally enforced action.
The panel stated that it accepted that given the resources and the thresholds for intervention, child protection would not necessarily have been the right course of action, but added it was not clear why Rio's situation was not comprehensively assessed.
It added: “There was an underlying pattern of neglectful behaviour by Adult P.
“This was not a case of serious chronic physical neglect and it is perhaps this which made it difficult to recognise."
The serious case review concluded: “A clear conclusion has been reached by the panel and the independent author of this review that Child J’s death could have not have been predicted and as such would have been very difficult to prevent.
“The review has identified a number of opportunities missed.
“However, whilst these identify areas for improvement it would be significantly overstating the case to presume that had any or all of these opportunities been taken up Child J’s death would have been prevented.”
Bolton Council’s director of adult and children’s services, Margaret Asquith, said she sympathised with the family.
She said: “We wish first to send our sincere sympathies to the family and we realise the publication of this review will bring back many tragic memories for them.
“The serious case review found that Child J’s death could not have been predicted or prevented, but made recommendations to further improve practice and develop services.”
THE serious case review has made a number of recommendations for improving safeguarding for each agency involved in the review.
Agencies involved in the review were Greater Manchester Police, Bolton children’s services, Bolton NHS Foundation Trust, Bolton PCT, Bolton at Home, Greater Manchester Probation Trust and Action for Children.
Other agencies which contributed were Affinity Sutton Housing, North West Ambulance Service, Greater Manchester Fire and Rescue Service, Wigan Chldren’s Social Care, and Wigan Youth Offending Team.
Recommended improvements include:
- the sharing of information and communication between agencies
- the way in which agencies record information
- the development of better templates, tools and training for several agencies in dealing with domestic abuse.
The review also posed a series of “challenges” for all agencies involved with the family.
These were to consider:
- whether there could be any improvements in multi-agency responses to safeguarding children in cases of domestic abuse.
- whether the multi-agency approach to neglect is providing an acceptable level of service to those families and children at lower levels of need and to ensure effective and shared responsibility of agencies in ‘stepping up’ and ‘stepping down’ as levels of need change.
Bolton Safeguarding Children Board says it has accepted all of the review recommendations for Bolton and is working to ensure all areas for action are fully implemented.
Mike Tarver, chairman of Bolton Safeguarding Children Board, said: “On behalf of the safeguarding board I’d like to express our sincere condolences to the family involved in this tragedy.
“We commissioned the review to see if there were any lessons to be learned to improve interagency working and safeguarding for children.
“We welcome the review panel’s recommendations and have developed a comprehensive action plan.
"We will be monitoring and reviewing this regularly to ensure that all the Bolton agencies involved have effectively implemented these actions.”
TOWN hall chiefs said that appropriate action was taken throughout Rio’s life and that he usually appeared well looked after, cared for and in a clean environment, so was never judged to be at risk of harm.
Smedley was offered and provided with support from children’s centres and a family intervention project.
They said she had to choose to take the support, and they could not force her to do so — and in some cases she did accept it.
Officers also said serious incidents, such as a fire when "inappropriately young" babysitters were looking after six-week-old Rio, triggered an immediate high-level response and a visit from social workers.
During Rio’s life, five "child action" meetings were convened.
Children’s services officers said that there were a number of objective indicators coupled with professional judgement which would lead to a child being put on the child protection register.
However, the main test for this was whether the child is at risk of harm and there was no evidence that Rio was - and he suffered no injuries in the weeks before his death.
They added they would further look at services to make them more attractive to families, so they would engage with them.
Early years intervention will also be reviewed.
Smedley has said she had ended her relationship with Rigby and had previously ended a relationship in which there was said to be a risk of domestic abuse with a previous partner.
In that case it had been agreed the partner would not have unsupervised contact with Rio, and Smedley would call the police if she felt at risk.
Margaret Asquith, director of children’s services, said: “We have already taken steps to implement the recommendations to improve where we can, safeguarding of children in Bolton.”
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