Systems, people and the death of Khyra Ishaq

27 July 2010 by Jennifer

Detailed, referenced analysis of the evidence given in court when Khyra Ishaq’s siblings were taken into care, taking into account some other sources already available prior to today’s release of the Serious Case Review relating to her death.

Introduction and context

Khyra Ishaq died of starvation in May 2008, in Birmingham, England. She was seven years old. Since then, her name and story have been used in various places to create anxiety around home-based education – and the laws relating to it – because she wasn’t in school for the last weeks of her life.

But the laws which social workers needed in order to save Khyra’s life already exist. Social Services took on investigating the children’s welfare, after two reports from other professionals – then let it drop without even completing a basic “Initial Assessment”. Other people were worried about Khyra and her siblings too.

This article was written between February 2010 and today, i.e. before the Serious Case Review (SCR) was published. The SCR (which is due out today) may well provide more insight than has been available to me so far. But even before the SCR, there was a fair bit in the public domain about how the tragedy came to happen. So I thought it was worth releasing this interim analysis now, in the hope that it’ll help to inform subsequent commentary.

I want to write this keeping Khyra in mind as a person, so I’m taking the liberty of borrowing this beautiful picture of her (I’m not sure who took it originally).
Photo of Khyra Ishaq. A young Black girl is smiling at the camera. She has baby teeth and brown eyes. She is wearing a black headscarf. She looks happy.
::a moment of respect::


Some time early in 2010, a report was put into the public domain from the court case where Khyra’s surviving siblings were taken into care.1 From that account, we have more facts now than when her story was first reported.

I’ll quote at length from that, and also from the very useful Government document Working Together to Safeguard Children 2006,2 which I’ll sometimes abbreviate WTtSC.

(I’m using a colour code for the quoted documents, as there are so many of them in this article. Court report, Government guidance and similar official pronouncements, Other sources/ commentators. All bold type is mine, to make it easier to skim-read. Footnote numbers are bold where the footnote contains discussion, and non-bold for references.)

I’ll start by considering some of the surrounding discourse…

Point-scoring with her name

Some people have cited Khyra Ishaq’s death as a terrible warning against allowing parents to take care of their own children without professionals overseeing them.

Back in October 2009, Maggie Atkinson had recently been named as the new Children’s Commissioner for England. Interviewed by the Children, Schools and Families Committee, she was asked about non-school education and the (now considerably discredited) Badman Review. In her answer, she treats Khyra’s name as her trump card:

I have absolutely no doubt that the vast majority of families who choose electively to educate their children at home are doing so for entirely right reasons, for entirely honourable, fair, just, creative and admirable reasons. But I would give you two words, and they are the first and second names of the child who died – Khyra Ishaq.

(By the way, if you follow the link to read the rest of Ms Atkinson’s answers to the Committee, please note that her account of home ed law 20 years ago is inaccurate. In fact she had neither the right nor the duty 20 years ago to “go into [the] premises” of electively home educating families, though she may well have mistakenly thought that she had, as perhaps did some of the families.3)

In April 2010, The Times contributed their own misleading description of Khyra’s life:

At the moment Britain has among the most liberal [home education] laws in the developed world and does not require parents to register or be inspected.

Khyra Ishaq, the seven-year-old girl who starved to death at the hands of her mother and stepfather in Birmingham, was supposedly being home educated by them.

“Supposedly being home educated”? True in the sense that the Local Authority (LA) had her listed in that category by the time she died. But even while the children were all still in school, there had been reason to doubt that they were safe in their mother’s care.

As the Victoria Climbié Foundation put it,

Home education was a small aspect of this case. It is clear that there were numerous occasions where social workers and the agencies involved could and should have spotted and intervened to help Khyra much, much earlier.

Their headline sums it up:

“Home Education did not kill Khyra; Agency Failings did”

Birmingham blame game

In an article from March 2010 entitled Khyra Ishaq and the scandalous blame game, journalist Paul Dale points out Birmingham Council’s attempt to use home ed law as an excuse – here alluding to “cabinet children, young people and families member” Les Lawrence and children’s director Tony Howell.

A week ago, the pair told a press conference there was nothing more that could have been done by social services or education officials to save Khyra.

This was because Khyra had been removed from school by her mother to be educated at home, and under English law local councils have no right to demand entry to a house in order to make sure a child really is being educated.

That is true, but totally irrelevant in this case, and it didn’t take Mrs Justice King, the judge presiding over care proceedings involving Khyra’s brothers and sisters, to see through such a ludicrous excuse. As Mrs Justice King pointed out, social workers could at any time have insisted on seeing Khyra, talking to her in depth and conducting an initial assessment, they simply chose not to do so.

One of the great unanswered questions surrounding the Khyra Ishaq case is why the council became sidetracked on the issue of her education, when common sense should have suggested that information from teachers about the state of Khyra and her siblings – always thin, cold and so hungry – warranted a full social services investigation.

Another question is which bright spark dreamt up the home education excuse, and why on earth did anyone think the council would get away with it?


Perhaps Coun Lawrence and Mr Howell did not read Mrs Justice King’s coruscating assessment, or maybe they assumed the report would never come into the public domain?

But it did come into the public domain: the report he’s talking about is the very same thing I allude to in my intro, Birmingham City Council’s application for a Care Order for Khyra Ishaq’s surviving siblings.

The Court report

Here we encounter in print someone who was genuinely trying to establish the facts, Mrs Justice King.

The report makes very sad reading. But if you can face it, it does shed a lot of light on Khyra’s death and what happened to lead up to that. (I don’t quote here the most harrowing aspects of her life and death; my focus is on what was known outside the family at the time, which might have saved her. If you want the full details, you can always follow the link to the whole document.)

Invitation for input

This is probably a good point to say that my analysis of what led up to Khyra’s death is based primarily on

  • a careful reading of the Court report, plus
  • conversations I’ve had with other people about the report, plus
  • other things I’ve read in the course of trying to understand the implications of it.

I’m not a social worker myself and never have been.

It’s therefore quite possible that someone with different background knowledge might pick up on implications that I missed, or be able to say “actually at this point what ought to have happened is that“, or “such-a-thing is common, this other thing is unusual”. If you can shed more light, please do comment.

Also, as I’ve acknowledged above, I’ve not yet seen the Serious Case Review at the time of writing this.

Now to the sequence of events…

First signs

Khyra died in May 2008. The first signs of something amiss had come more than a year before her death:

52. On 20th March 2007 the mother had a meeting with Mrs J B from G P School about K who had been caught stealing food at school on two occasions. …

53. It was agreed between the mother and the school that K would be seen by another teacher, L H, to talk through why she was stealing. There is a note about that meeting which is deeply disturbing. K throughout it was obsessed with food and to being what she referred to as “a good girl.” She spoke of getting nice porridge if she is good and horrible porridge if she is bad.

M is Khyra’s brother, a year older than her; he was at a different school due to his autism and other special needs.4 The first incident described here took place in September 2007, around eight months before Khyra’s death:

58. … A teaching assistant in M’s class recorded her shock at how much weight M had lost over the summer. In her written evidence she described him as “really thin and like a child from Ethiopia.” She spoke of him being weak and tired and the weight still “dropping off.” …

59. Just before Christmas 2007 the mother told M’s school escort that he was not to be allowed breakfast at school, only fruit. This made M cry.

60. M’s class teacher, A Q, gave evidence. He is a teacher of considerable experience and was a very impressive witness. He spoke of M’s obsession with food which went he said beyond the obsessive behaviour one can see from time to time in children on the autistic spectrum. It was, he told the court, “the expression on his face that made the staff so sure it was not autism but hunger. You learn to read the children. None of the other children were ever as hungry as he was.” Mr Q told me quite openly how, seeing how hungry M was and knowing of the mother’s embargo on chocolate and second helpings, he arranged for the cook to give him extra large portions rather than seconds. On one occasion Mr Q caught M taking an apple core out of the bin so he found some fruit to give him.

Z is Khyra’s brother about two-and-a-half years older. He was at the same school as her. There were concerns about him too:

78. An incident occurred one day when the children were having fruit at break time and Z was seen taking extra fruit. When asked about it he said he was hungry and was told he could certainly have extra food but must ask.

79. A few days later Miss W [Z’s class teacher] saw Z as she described it “frantically stuffing his pockets with fruit” from a fruit box in the playground. Miss W demonstrated this graphically in the witness box, showing the court by using both hands being used again and again to put fruit into the pockets with a desperate intensity. Miss W was sufficiently concerned on that occasion that she wrote a so called ‘concern report‘ and passed it on to the pastoral worker at the school, Mrs. D. Miss W also spoke to Miss C [one of Khyra’s teachers] and discovered that she too had concerns about K and food. Mrs D, the assistant Head teacher of the school and in charge of pastoral affairs, was told of this also.

80. Z was obsessed with food. He was found loitering around the dining hall with a view to going back in to get another meal. …

Not all the concerns were about food and hunger. At a meeting around November 2007,

70. … Miss C told the mother that K was hungry all the time and spoke of the petty thefts. The mother was angry and said K had stolen food before. She went on to say that K “wets her pants on purpose in front of her” and that she had sent her to school in the same pants in order to teach her a lesson. “Can’t you smell the stench?” she asked Miss C. Miss C described herself as having being speechless at what was being said and that the mother was unconcerned and seemed unable to realise what she had said.

December 2007 and later

Khyra and her older siblings Z and L stopped going to school in December 2007.5 B, the three-year-old, stopped going to nursery around the same time. A and M were still in school: A at secondary school, and M at his “special school”.

61. After Christmas Mr Q became more alarmed. M was holding up his trousers with his hands because he had lost so much weight and the staff, on Mr Q’s instructions, started to look for marks on his body when he was undressing for swimming. He raised his concerns with the Deputy Head and the matter was transferred to the school nurse. She weighed him and noted that his weight was between the 25th and 50th centile having been previously on the 75th and that the mother was restricting his diet.

A Daily Mail article from 2009 describes one of the children being examined by a doctor in January 2008. If the article’s correct, then from the age and gender, the child must have been M. The doctor was “Dr Suraj Ahmed … an assistant specialist in community paediatrics”.

Weighing 22kg, the boy was below the average weight for his age.

Dr Ahmed said: ‘I pointed this out to (Gordon) and said that he appeared not to be getting enough calories. I suggested that he might benefit from seeing a dietician but she was not keen on that. She was against it.

I can’t vouch for the accuracy of this story; I suspect it’s based on Dr Ahmed’s evidence from the trial of Khyra’s mother and stepfather for Khyra’s murder, but I haven’t seen a transcript of what was actually said in evidence.6

This doctor’s examination is never referred to in the Court report. Was the doctor at all worried about M at the time? Was anything said to Social Services?

64. … Ten days before K’s death M’s teacher made another referral, describing him as “thin, weak, tires easily, feels the cold easily. Whenever food is available he will constantly ask for more.” …

That paragraph is ambiguous in not spelling out to whom the teacher made this referral. In context (and recalling that the doctor’s examination is not documented in the Court report), the word “another” suggests to me that this may have been a second referral to the Deputy Head and/or the school nurse, i.e. within M’s school. At no point does the Court report seem to suggest that the staff of M’s school made a referral to Social Services.

What’s clear, however, is the nature of the teacher’s concern.

Neighbours too had noticed the children:

111. Some time in February 2008 the mother went round to a next door neighbour’s where a Polish family called W lived at the time. When the door was answered the mother was at the door and it is accepted was angry and accusing a family member of the W’s of feeding K behind her back. She said a thin, underfed child, K, was brought to the door and that JA joined them. K pointed to the daughter of the house and said that she, the daughter, had been giving her bread. Mr W is clear that no-one had given K bread but said that there was no fence between the gardens and they used to put bread out for the birds. He could only guess that it was that bread that K was eating but was too afraid to admit it to her mother.

JA was the mother’s partner – not the children’s father, though.

The children’s father was living abroad by that time; he’s since been quoted as saying that he had expressed his concerns anonymously to Social Services after becoming alarmed by the mother’s behaviour, but, to paraphrase, didn’t want to rock the boat too much for fear of losing all contact with his children. But he doesn’t come into the care proceedings transcript, except in this little bit of context:

4. At the time of K’s death in May 2008, the mother and father had long since separated. The Father was living in Spain with his new wife and their two children. Mother was living in the former matrimonial home with all six children together with a man called JA who I will refer to as either “the Intervenor”7 or “J” which is how the children knew him.

Again, it’s not in the Court report, but another Guardian newspaper article from February 2010 mentions the observations of a different neighbour, from about two months before Khyra died:

8 March Amandeep Kaur, who lived nearby, sees Khyra dressed in underwear in the back garden of her home. She was later to tell police that it was a cold morning and the “abnormally thin” child was whimpering.

Birmingham Safeguarding Children Board said in February 20108 that

… the police investigation identified at least 30 individuals … who could have intervened and made a difference.

It is alarming because it was clear to us that many people in the community had concerns but did not feel able to share them with the many agencies that are there to help.

But for now, let’s go back in time to December 2007, when three of the children stopped coming to school.

First approach to Social Services

192. The concerns of the Deputy Head teacher, J B [hereafter Miss B], had reached such a level by the time the three children had been withdrawn from school that on 19th December 2007 she made a referral to social services. Miss B’s point of contact there was the referral officer R C [Miss C]. Her written referral centres on the food issues outlined earlier in the judgment in relation to each of the children.

Note that there are two people in the Court report both referred to as “Miss C”, and both of them appear in this article too. (Presumably surnames were given in the original; some full names are also given in various newspaper articles, but I’m sticking to the Court’s initials here.) One, Miss A C, was a schoolteacher of Khyra’s, and the other, Miss R C, was the Social Services initial point of contact for this kind of referral. From now on in the article, I’m talking about the latter.

Miss C said that Social Services wouldn’t take it on:

194. Miss C’s evidence was that in having “scrutinised” the information provided by the school, the view was taken that as the school already had a working relationship with the family it would be better for them to continue with their work rather than their department intervene which might “antagonise the situation.” Miss C therefore contacted Miss B to say that the case did not warrant an assessment.

This decision and explanation seem to me puzzling. I gather that sometimes, the information provided in a referral isn’t clear enough to convey the reality of the situation, but this doesn’t seem to have been the case here. The judge comments in summing up:

232. … The school’s referral was unequivocal, it was issues over the children being hungry, thin and cold which were of concern, …

Working Together to Safeguard Children clearly states:

2.125 Staff in schools and FE institutions should not themselves investigate possible abuse or neglect. They have a key role to play by referring concerns about those issues to children’s social care, providing information for police investigations and/or enquiries under s47 of the Children Act 1989, and by contributing to assessments.

In other words, it wasn’t the school’s place to investigate neglect; so when Miss C said “continue with their work”, what work did she mean?

And in what sense did the school have “a working relationship with the family”?

At any rate, Miss B (the deputy head) did visit the house herself. She rang Miss C again to report her continuing concern. Miss C again said that Social Services would not take it on, and instead recommended that Miss B get the police to do a “safe and well check”; this too happened.

In the interests of not overloading readers with unnecessary detail, I’m going to relegate those two visits to a footnote,9 because neither made a difference to the overall situation.

Miss B’s comments seem to show a gap in understanding at this time between the social workers and the school:

199. … Miss B said that in any event such a [safe & well] check would not have allayed her concerns as given the history she felt that it was necessary to know what each child looked like on a day to day basis.

Miss B’s reasoning may have been that the sight of a child alive on one occasion didn’t prove anything about their long-term wellbeing – and if so, I agree. I don’t understand why the social workers recommended a one-off “safe and well check” rather than investigating the signs of ongoing neglect.

Anyway, this wasn’t the most crucial episode, so I’ll move on.

The second referral

207. On 28th January 2008 a liaison meeting was held at G R P School. Miss R M, an educational social worker attended the meeting. The school expressed their concerns for the children, describing them as being “at risk“. They told Miss M of their unsuccessful referral to social services before Christmas.

Miss M tried visiting and phoning the family, but got nowhere either. The mother pretended to be out, and on 30 January when Miss M rang up,

209. … simply shouted over her and was not listening.

So it must have been 30 or 31 January when

210. … Miss M then spoke to Miss C at social service.

211. Following her conversation with Miss M, Miss C recommended the carrying out of what is known as a CAF, that is to say a Common Assessment Framework assessment. This is low scale intervention where local agencies (other than the local authority work), with families in order “collaboratively to resolve any issues they face”. Miss M said in evidence that she told Miss C in terms that she did not think that such an assessment would work as the mother would not co-operate and the whole basis of a CAF assessment is co-operation. Miss C agreed to discuss the matter with her manager.

In other words, Miss C from Social Services recommended a CAF, which could be initiated by Miss M in her role as “educational social worker” or by the school, and would not necessarily involve Social Services.

This was inappropriate, since (to quote a helpful page from Salford City Council)

1.5 The CAF is not for when there is concern that a child may have suffered or may be at risk of suffering Significant Harm.

(The CAF is more about helping people to access services, and ensuring that several different agencies aren’t all repeating the same kind of assessment with people in the same family. It’s supposed to help people not to have to jump through the same hoops over and over to get support.)

Miss M pointed out that a CAF wouldn’t even work, anyway, because Khyra’s mother was extremely unlikely to cooperate, and (unlike child protection investigations), it’s up to the family or child to decide whether to start a CAF process.

Miss M’s powers and duties

In understanding Miss M’s role, I think it’s important to note that an “Educational Social Worker” is not what most people imagine from the words “social worker”. In some LAs, the same job is known as Educational Welfare Officer, which is perhaps a bit less misleading. An EWO or ESW is usually part of the Education Department rather than Social Services, and in most LAs, they needn’t have a social work degree (though not all “ordinary” social workers have that either).

An article on the Connexions careers site quotes Deborah Bell, an ex-school-teacher and now (or then) “Principal Education Welfare Officer” for the London Borough of Hillingdon, giving an outline of her job:

This department covers a whole range of issues like bullying, exclusion, school attendance, child employment and school-aged parents.

From Birmingham City Council’s current web page on the Education Welfare Service (EWS):

When a young person has a record of absences, or has stopped going to school altogether, Education Welfare staff work with parents and carers, school staff and other agencies, including the Courts, to restore attendance.

I haven’t seen a job description for Miss M’s actual job, but from the job title, it seems likely that a lot of her time would have been spent on this kind of anti-truancy work.

Birmingham EWS also has a role in child protection:

The Education Welfare Service takes lead responsibility for the Local Authority in matters of Child Protection. EWS provides the link to the Birmingham Safeguarding Children Board (BSCB); provides written guidance notes to schools; provides advice, guidance and practical support in cases of child protection referral; co-ordinates information for Designated Teachers in schools; co-ordinates training courses through Birmingham LSCB and the Health Education Unit.

But note what’s not there: it’s not the responsibility of the EWS, or of any individual staff member there, to investigate abuse or neglect. Miss M – unlike social workers with a child protection remit – would not have had the legal power to insist on seeing the Ishaq children, however concerned she was. Her safeguarding duty in Khyra’s case would have been to report any welfare concerns she had to Social Services, which she did.

In fact, paragraph 211 shows Miss M spelling out to Miss C the reality of the mother’s non-cooperation. Miss M wanted Social Services to take on the case (i.e. beginning with an Initial Assessment). From the chronology, it seems it may have been this conversation which eventually swayed Social Services to accept the referral.

(I’ve seen/heard a couple of instances of people implying that Miss M was mistaken in not visiting the family again herself.10 But on the evidence currently available to me, it looks to me as though she’s one of the few people involved who did do her job well, and even helped other people to do theirs.)

Social Services take it on

226. … on Thursday 31st January, Miss C and her manager reconsidered the referral that had been made to social services and Miss C contacted Miss M. She said that they would carry out what is known as an Initial Assessment on the I family. …

That’s a very important bit – because the Initial Assessment is what ought to have happened and then didn’t.

Note that the assessment was to be of the whole family – all six children, including the two still in school.

In the next part, look out too for the phrase “Section 47” or “s47” – a formal enquiry following concern that a child is “suffering or likely to suffer significant harm“.

The nature of an Initial Assessment

The most useful explanation I’ve found so far about Initial Assessments comes from Working Together to Safeguard Children.

Here, “LA children’s social care” doesn’t mean a separate department; it’s roughly equivalent to saying “Social Services in their work with children”.11

5.37 The initial assessment is a brief assessment of each child referred to LA children’s social care, in which it is necessary to determine whether the child is in need, the nature of any services required, and whether a further, more detailed core assessment should be undertaken (paragraph 3.9 of the Framework for the Assessment of Children in Need and their Families (2000)). It should be completed by LA children’s social care, working with colleagues, within a maximum of seven working days of the date of referral. The initial assessment period may be very brief if the criteria for initiating s47 enquiries are met. <snip>

5.39 The initial assessment should be led by a qualified and experienced social worker. It should be carefully planned, with clarity about who is doing what, as well as when and what information is to be shared with the parents. The planning process and decisions about the timing of the different assessment activities should be undertaken in collaboration with all those involved with the child and family. The process of initial assessment should involve:

  • seeing and speaking to the child (according to age and understanding) and family members as appropriate

  • drawing together and analysing available information from a range of sources (including existing records); and

  • involving and obtaining relevant information from professionals and others in contact with the child and family.


5.43 In the course of an initial assessment, LA children’s social care should ascertain:

  • is this a child in need? (s17 of the Children Act 1989); and

  • is there reasonable cause to suspect that this child is suffering, or is likely to suffer, significant harm? (s47 of the Children Act 1989).

So an Initial Assessment of all six children would have included speaking to the children, and would have brought together the concerns of the various staff from two different schools who were seriously worried about the health of Khyra, Z and M.

It seems to me this would have turned up enough “reasonable cause to suspect… significant harm” – if, indeed, the documented concerns from Khyra’s school weren’t already enough. (Working Together to Safeguard Children makes clear that neglect in itself may be “significant harm”.12)

Unless something else had then gone wrong at Social Services, this would have led to a Core Assessment under section 47 of the Children Act 1989, and to intervention in the children’s lives.

(Here, it may be helpful to consult the flow charts on pages 142 to 148 of Working Together to Safeguard Children 2006, summarising referral, initial assessment, child protection plan and child protection conference, etc.13)

Now let’s see what actually happened…

Did Miss G need consent from the mother before talking to school staff?

228. On the same day, 31st January 2008, the case was allocated to a social worker called A.G. On 1st February Miss G endeavoured to contact Miss M with a view to arranging a joint visit to the house to discuss with the mother the completing of an Initial Assessment in respect of the six children. Miss G subsequently told me in evidence that whilst an Initial Assessment does mark the acceptance by social services of a referral it still requires the consent of the parents before any enquiries can be made about the children from third party agencies such as the school and the health services.

229. It now seems to be common ground that this was a misunderstanding on her part and no such consent is required although parents are asked to consent/co-operate with the assessment as a whole. The social worker therefore intended to go to the home at 36, L R and ask the mother to complete the relevant consent forms enabling enquiries to be made.

So Miss G believed that she must obtain parental consent before making enquiries at the children’s schools. This seems to me one factor in Khyra’s death, inasmuch as Miss G must have believed she wasn’t allowed to initiate contact with M’s school. (To recap, M is Khyra’s slightly older brother who went to a “special school”, and concern about his weight had first been noted at school after the summer holidays in 2007.)

On the other hand, it’s clearly nonsensical to suggest that the social workers needed the mother’s consent to consult the staff of Khyra’s school, who had already made the first referral; and information sharing doesn’t arise in the context of interviewing the children themselves. So in my view, this mistake wasn’t the main factor, only a contributing one.

Ambiguous information on obtaining consent

The report says “It now seems to be common ground that this was a misunderstanding on her part”.

I agree insofar as it appears Miss G certainly did have the legal right to make enquiries at M’s school without the mother’s consent. Both Working Together to Safeguard Children and Information Sharing: Guidance for practitioners and managers14 agree that public interest can override the absence of consent where there’s a risk of significant harm.15

However, I’m not sure to what degree this misunderstanding originated with Miss G, versus to what degree she was misled by ambiguous information from elsewhere in the system.

A form called an Initial Assessment Record is available from the old DCSF web site.16 A note on this form states:

Parental permission to contact other agencies should be obtained unless permission seeking may itself place a child at risk of significant harm.

Asking for permission didn’t itself place the children at risk – they were already at risk – so that exception would seemingly not apply. Perhaps this note is where Miss G got the idea that she must obtain the mother’s consent?

That note closely resembles a paragraph from Working Together to Safeguard Children:

5.34 Parents’ permission, or the child’s permission where appropriate, should be sought before discussing a referral about them with other agencies, unless permission-seeking may itself place a child at increased risk of significant harm.

But there’s a significant difference: WTtSC says the parents’ permission should be sought, whereas the paraphrase on the form says it should be obtained. If WTtSC is correct, then the form is wrong and misleading.

In trying to understand the facts of this myself, I also happened upon a page on Surrey County Council’s web site with this instruction:

3.2 The process of Initial Assessment should involve:

  • <snip>

  • Seeking parental consent to the Initial Assessment and agreement to contact other professionals as appropriate depending on the level of risk to the child and using ‘Consent form for an Initial Assessment of my child and Family’ (Form SCS35).17 Establish if full consent or partial consent is given and record on Initial Assessment Form

Considerably further down that page in section 8, we get information about when the absence of consent may be overridden. But I can see how, from that summary taken alone, someone could easily get the initial impression that parental consent was necessary. I wonder if Miss G had read something similar.

The 7-day limit

229. … When Miss G contacted Miss M’s office she discovered that she had in fact left the department and that a new educational social worker, S S, was now dealing with the case. Unfortunately very shortly after referral was accepted and the case allocated to Miss G she went on annual leave and did not return until 18th February.

This delay too was poor practice at Social Services. WTtSC says (as quoted above) that an Initial Assessment should be carried out

within a maximum of seven working days of the date of referral.

Given that Miss G was about to go on leave (though we’re not told here exactly how soon), it seems to me problematic that she was ever allocated the case in the first place.

But again, this in my view was not the key mistake which led to Khyra’s death.

Mr H visits

Mr H, the Local Authority’s one-person elective home education division, visited on 8 February 2008, accompanied by Mr L, a “senior educational social worker”.

212. … the purpose of the visit was to ensure that the children were receiving “an efficient full time education at home.”

They were allowed into the house but did not see (or ask to see) the children.

It’s this small episode of the story which might, on the face of it, suggest a need for stronger legal powers to interfere via the LA’s home ed people. But if Mr H had had safeguarding concerns, his duty would have been to inform Social Services – who, as we see, were already aware of the family. His remit was education.

(Mr L seems to me a peripheral figure. Like Miss M, he’s not a social worker in the commonly-imagined sense of the term. He seems to have been sent out simply as “backup” to Mr H, following Miss M’s advice to Mr H that he take a second person with him.18 Paragraph 225 seems to confirm this; Mr L speaks of Mr H’s procedure and claims no role of his own in the matter.)

Risk factor confusion

230. On 18th February Miss G wrote to the mother telling her that a referral had been received from educational welfare. She said that the concern related to her having withdrawn the children from school and that so far as they were aware the children had not been seen by any professionals since December 2007. The mother was told in the letter that on 21st February at 3 o’clock a joint visit would be undertaken by her together with S S the new educational social worker.

This letter illustrates the way in which genuine risk factors can be obscured by the red herring of home-based education.

Yes, the children were at risk. But the key warning sign was not the withdrawal from school, nor the “not being seen by any professionals” for a few months. That’s true of lots of children, and it usually isn’t (or, at least, ought not to be)19 cause for concern.

The key warning sign was that even before that happened, people were noticing they were (a) thin, (b) desperate to get food and seemingly “obsessed” with it.

Plus, according to one teacher, the mother had said she deliberately sent Khyra to school in knickers the child had earlier urinated in.

A brief glimpse of three of the six children

Back to the visit of Miss G and Miss S, on 21 February 2008 (still over two months before Khyra died):

231. The visit was as unproductive as that of Miss B and the police. The mother eventually answered the door but would not allow them into the house.

232. Miss G, standing on the doorstep, tried to tell the mother about the initial assessment and that it would centre around educational issues. Miss G told the court in her written material that as the referral was, as she put it “of an educational concern as opposed to a child protection concern“, that was how she had phrased it to the mother when she saw her on 21 February 2008.

This showed a fundamental misunderstanding of the nature of the referral on Miss G’s part. The referrals did indeed come from the school and an educational social worker but they were not educational in nature. The school’s referral was unequivocal, it was issues over the children being hungry, thin and cold which were of concern, concerns shared by Miss M once she had spoken to the school and had been exposed in the telephone call on 30th January to the mother’s aggression and irrational response to her visit.

233. Miss G wrongly told the mother that her consent was necessary in order for the initial assessment to be carried out. When it became quite clear to her that the mother was not going to give that consent she told the mother that they would leave so long as the children were seen.

234. Initially the mother refused to bring the children to the door but eventually brought, I am satisfied, L, K and Z to the door.

235. There is some disagreement in the detail of this meeting as between Miss S, Miss G, the mother and JA, who was present for part of it. The detail matters not as what is incontrovertible is that the visit was made, the mother and JA refused to allow them entry to the house and refused to co-operate with any assessment. Although three of the children were brought to the door they did not on any level engage with Miss G or Miss S and hovered at the back behind their mother and were seen only for a matter of minutes. When requested to say who he was, JA refused.

236. It goes without saying that during the course of this visit Miss G did not get to the stage of the mother signing the form which she says would have permitted investigations to have been made of third parties. At the conclusion of the visit Miss G told the mother that as an assessment had been opened, she needed to see the other three children. The mother said A was asleep and the other two were at school. Finally the mother agreed for Miss G to return to the house at 4 o’clock the following day in order to see the three other children. By the time the social worker got back to the office the mother had already rung to say that Miss G was not to go the following day to see the children.

Working Together to Safeguard Children includes a helpful box (on page 113) entitled Initial assessment and enquiries: ten pitfalls and how to avoid them. The second pitfall is:

2. Not enough attention is paid to what children say, how they look and how they behave.

(Incidentally, this is not cutting-edge research; the “pitfalls” list is from a book published in 1998.20)

The list’s authors advise,

Ask yourself: Have I been given appropriate access to all the children in the family? If I have not been able to see any child, is there a very good reason, and have I made arrangements to see him/her as soon as possible? How should I follow up any uneasiness about the child(ren)’s health or development? If the child is old enough and has the communication skills, what is the child’s account of events?

Depressingly, in the Ofsted report of July 2010,21 listening to children is still mentioned as a problem area for Birmingham:

30. … The quality of the [initial] assessments is variable … Insufficient attention is given to seeking and responding to the views of the child or young person.

The social workers let it drop

237. Miss G spoke to her manager about the mother’s refusal to allow her to go and see the other three children. Miss G said in evidence that as they knew that Education Otherwise was involved, they agreed between them that another visit to see the other children would not be necessary and that as the referral had specifically concerned the three children they had in fact seen at the house that day, they would abandon any further attempt to see them. Had the referral of G P and Miss M been treated as it should have, that is to say as having raised child protection issues as opposed to merely issues of school attendance, it is hard to imagine that such a view would have been taken.

(Note that “Education Otherwise” here doesn’t refer to the charity of that name, but according to the Court report22 is another name for the LA’s one-person home education division. On the current Birmingham Council website, it’s given its more common name of Elective Home Education (EHE) or “home education”.)

Here we see what, in my view, was a genuinely key role of non-school education in this tragedy: as an element which the social workers failed to place in its proper context. Because the social workers somehow conflated life-and-death safeguarding concerns with educational concerns, they grossly misjudged the seriousness of the case and effectively abdicated responsibility for the children.23

The aforementioned Initial assessment and enquiries: ten pitfalls and how to avoid them casts an interesting light:

3. Attention is focused on the most visible or pressing problems and other warning signs are not appreciated.

Ask yourself: What is the most striking thing about this situation? If this feature were to be removed or changed, would I still have concerns?

The children’s educational status was not, in fact, the “most pressing problem”. But it seems to me quite possible that in the social workers’ eyes it was the most “visible” or “striking” feature of the case.

As Paul Dale describes it in his article,

the council became sidetracked on the issue of her education, when common sense should have suggested that information from teachers about the state of Khyra and her siblings – always thin, cold and so hungry – warranted a full social services investigation.

Of course any case might be mishandled if the social worker in charge of it failed to grasp the significance of the original referral information. But was Miss G perhaps also influenced by a perception that Mr H (the council’s EHE person) now had responsibility for the children’s wellbeing? How exactly did she and her supervisor lose sight of the safeguarding concerns?

Back to the narrative:

239. Miss G took the view that she had seen the children and even though it was only brief “nothing had stood out.”

240. This visit was in itself was insufficient for the purposes of even an initial assessment. The Department of Health’s Framework for Assessment known and referred to as The ‘Lilac’ Book, provides the framework which informs such assessments. Paragraph 3.1 of the ‘Lilac’ Book sets out a list of enquiries which “may be undertaken.” The only mandatory enquiry is seeing the children. The paragraph says in terms that “as part of an initial assessment the child should be seen. This includes observation and talking with the child in an age appropriate manner.”

241. … Miss G told me that despite the history, a child protection investigation would only have been triggered if she had seen the children on their own and they had made a ‘disclosure’ or she had not been allowed to see the three children subject to the referral.

(Here, too, Miss G seems to have misunderstood: neither of these circumstances is a necessary element in “reasonable cause to suspect that this child is suffering, or is likely to suffer, significant harm”.)

242. With respect to Miss G, that rather begs the question; had she seen the children or any of them as is expected and anticipated in an Initial Assessment she may have had more information, if only from the children’s physical appearance, that would have led her to conclude that a child protection investigation was necessary.

This reasoning makes sense in the light of medical evidence:

182. Professor M looked at the photographs of K in the context of the mother [claiming] that K lost virtually all the weight in the last week of her life. Looking at the photographs taken the day she died he said “this would not occur in the last few weeks. It would take many months. She has suffered from extreme emaciation. There is complete loss of subcutaneous fat and muscle wasting not just on the buttocks which go first but in all four limbs. The bony prominences are made even more prominent by the complete lack of abdomen.”


191. I am satisfied in accordance with all the medical evidence that K died of pneumonia secondary to severe malnutrition and that all the other children suffered from malnutrition to a greater or lesser extent.

We know that M already appeared strikingly thin even by the previous September.

I wonder too what the children would have told the social workers if asked in private. (Some abused children keep the abuse a secret, but we know from the school teachers that Khyra and her sibling Z had readily admitted how hungry they were.)

243. As it was, even though an Initial Assessment is deliberately designed to be a brief assessment which is not too onerous a piece of work for social services to undertake, it was not completed but simply shelved without even speaking to the children’s schools from where the anxieties had stemmed and the referral had been made.

This seems to me the key turning point: Social Services could have made all the earlier smaller mistakes, and yet still saved Khyra’s life if they’d kept going with the promised Initial Assessment, and where it would have led.

244. The Initial Assessment was abandoned on the basis that Education Otherwise in the form of Mr. H was now to be involved. Miss G accepts that she at no stage spoke to Mr. H and that she herself agreed with the decision to abandon the assessment. She accepted that she knew the detail of the school’s concerns before the visit to the house and said in evidence that she thought in hindsight that “perhaps the welfare issues should have been considered in more detail.” In so far as I can see it, the welfare issues were not considered at all and should have been at the forefront of any social work enquiries about this family.

245. Miss G concluded her evidence by saying that as no further work was to be done on the case on the basis that Education Otherwise would be involved; her recommendation had been for the case to be closed. It was awaiting formal closure when, as she unfortunately phrased it, “this incident occurred.” The incident to which Miss G refers is the death of K.

Analysis from the Guardian and the Judge

The report closes with some analysis by the Judge, based in part on the submission of the Guardian. (The “Guardian” here is not the newspaper of that name, but a court-appointed social worker acting as an advocate and representative of the child.24)

246. The Guardian has submitted to the court that K’s death was preventable. It was. Initial and core assessments are carried out by social services department according to the Framework for Assessment of Children in Need and their Families, referred earlier in this judgment as the Lilac Book. The guidance says “In practice this means in planning, preparation and coordination with professionals in other agencies in accordance with the principles in 1.23.”

247. Paragraph 1.23 sets out the principles which should guide inter-agency, inter-disciplinary work with children in need.

248. The guidance goes on in paragraph 1.51 to say: “Understanding what happened to a vulnerable child within the context of his or her family or a local community cannot be achieved as a single event. It must necessarily be a process of gathering information from a variety of sources, making sense of it with the family and very often with several professionals concerned with the child’s welfare.”

249. At paragraph 5.43 the guidance says: “When a child has special educational needs or is disabled the schools and educational psychologists will have important information about the child’s development, the level of understanding and the most effective means of communicating with the child. This information should be sought before the beginning and the end of the assessment.”

250. The Guardian submits that it should have been clear to social services what their role and that of the educational welfare services were when they received the initial referral from G S. The Guardian says that faced with the mother who was reported to be unco-operative and aggressive towards the professionals and a man who when seen by the professionals consistently refused to provide details of his name (and this court would add also the refusals to allow professionals into the house or to speak to the children) the Guardian submits that the appropriate course for the local authority should have been to consider a section 47 Children Act enquiry, that is to say

“(1) Where a local authority

(a) —

(b) have reasonable cause to suspect that a child who lives or is found in their area to be suffering or is likely to suffer significant harm,

the authority shall make or cause to be made such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.”

252. I agree with the Guardian’s analysis. Social services, despite the concerns of the school and the unco-operative attitude of the mother when they visited the house, decided to rely on Mr H and the educational social worker and abandon their own investigations.

Child protection was not a responsibility which Social Services could legitimately get rid of to someone else. Working Together to Safeguard Children puts it like this:

2.17 Where a child is at risk of significant harm, children’s social care staff are responsible for co-ordinating an assessment of the child’s needs, of the parents’ capacity to keep the child safe and promote his or her welfare, and of the wider family circumstances.

In other words, Social Services could not legitimately “rely” on Mr H to do their job, which in any case he had neither the training nor the legal powers to fulfil.

Back to the Judge’s analysis:

253. As a result of each professional carrying out his or her own duties in isolation, information was not passed on and relevant connections were not made. The most glaring example being that if only anyone had asked, they would have discovered that both M’s school and the other children’s schools had largely identical concerns.

254. It seems extraordinary to me that no alarm bells rang with social services when the mother cancelled the appointment for A, B and M to be seen by Miss G. A referral had been accepted which, contrary to Miss G’s initial evidence, related not only to education but to serious welfare issues and Miss G on her own account was aware of the issues which had been raised by the school. Put at its baldest, at the very least a proper initial assessment should have been completed. The children had been withdrawn from school and the mother thereafter had been reluctant (at best) to allow the children to be seen. Added to this there was an unknown male in the house with the six young children in circumstances where he was refusing to identify himself.

255. The court is acutely conscious of the enormity of the task faced by these or any other social workers. It is also conscious that none of the professionals involved between January 2008 and May 2008 have had the benefit of legal representation or the opportunities of making submissions to this court. A serious case review is currently being conducted and no doubt the social services and educational welfare involvement will be analysed in a way that is not open to this court. It is no part of the function of this court to second guess their findings.

256. The fact remains however that M’s school was seriously concerned and the school of L, Z and K were voicing their concerns about these children, in particular their concerns relating to their belief that the children were not being fed properly. The schools did all they could to bring their concerns to the attention of the relevant authorities. These concerns were not taken sufficiently seriously and were not adequately investigated.

The role of the schools

On what’s documented here, I think it’s overstating the case to say that both schools did all they could.

2.123 Education staff have a crucial role to play in helping identify welfare concerns, and indicators of possible abuse or neglect, at an early stage. They should refer to those concerns to the appropriate organisation, normally LA children’s social care, contributing to the assessment of a child’s needs and, where appropriate, to ongoing action to meet those needs. – WTtSC25

As far as I can tell from the report, the staff at M’s school – although caring for him as best they could within the school environment – didn’t pass on to Social Services his alarmingly quick weight loss, the incident where he took the apple core from the bin, and their awareness that the mother was restricting his diet. Perhaps that referral, from a separate and professional source, of another child in the same family (and without the distraction of home education) would have made some difference to Social Services’ handling of the case.

But it’s certainly clear that the staff at Khyra‘s school made their fears known. They communicated both with Social Services (in writing and several times by phone) and with Miss M. The school staff stopped pursuing the matter only after Miss M had reported back that Social Services were taking it on.

The Judge on responsibility

259. K’s death was caused by and is the responsibility of her mother and the Intervenor, but on the evidence before the court I can only conclude that in all probability had there been an adequate initial assessment and proper adherence by the educational welfare services to its guidance, K would not have died. Merely looking at the photographs of the house and the conditions in which the children were living confirms in my mind that had social services even seen the bedroom in which the children lived or the manner in which they were fed, they would undoubtedly have intervened.

In paragraph 259, I think Mrs Justice King is, to some degree, following the social workers’ mistaken impression by laying responsibility on what she calls the “educational welfare services”. (This would presumably include Miss M, Mr H and/or the EWS department as a whole.)

I think there were anomalies in how the educational enquiries were treated;26 but Miss M, the “educational social worker” first involved, did report to Social Services the events leading to her concerns, correctly carrying out her key safeguarding duty. As I commented above, paragraph 211 shows Miss M actively pushing Social Services to recognise the realities of the case.

Like Miss M and the children’s teachers, Mr H had a professional duty to report any safeguarding concerns which arose in the course of his EHE job. As it happened, it was other people who raised concerns; but even if he’d had some too, it was still Social Services’ responsibility to follow up the concerns.

I would say simply “in all probability, had there been an adequate initial assessment, K would not have died.”

Parallels with the deaths of other children

The Victoria Climbié Inquiry Report (from Parliament’s Health Committee in 2003)27 says this:

From Maria Colwell in 1973, to Jasmine Beckford and Tyra Henry (both in 1984), Kimberley Carlile (1986), Leanne White (1992), and Chelsea Brown in 1999, the deaths of these children all share many points of similarity. The pattern does not even end with the death of Victoria; since that time there have been at least two more high profile cases (Lauren Wright in 2000, and Ainlee Walker in 2002). In many of these cases the child has been the target of abuse from an adult who is not the natural parent (typically a step-father). While the particular circumstances of each case are different, there are also areas of considerable similarity. In particular, the following features recur time after time:

  • Failure of communication between different staff and agencies.

  • Inexperience and lack of skill of individual social workers.

  • Failure to follow established procedures.

  • Inadequate resources to meet demands.

In Khyra’s death, the factor which for me is most obvious of those four is “Failure to follow established procedures.” A key mistake – arguably the key mistake – was the social workers wrongly deciding not to complete Initial Assessments for the six children (even after saying that they would).

Lack of skill” is right up there too, though, since it influenced that mistaken decision: how did Miss G (social worker who took the case on 31 January) fail to grasp that the school’s referral was about child protection? And I suspect that a more experienced person would have known that the mother’s consent was not necessarily required to talk to the schools.

Failure of communication between different staff and agencies” clearly arises in various different ways. One might wonder in particular what Mr H (home ed person) might have said, if Miss G had actually asked him “So, are you happy to take on monitoring the children’s weight, food and health? seeing as you’re going to be round their house occasionally anyway?”

More fundamentally, I wonder what understanding Miss G and her manager had of

  • the nature and circumstances of Mr H’s day-to-day job
  • his duties and powers
  • the duties and powers of the Educational Social Workers in the case.

The influence of possible “inadequate resources” is not so clear to me, though I’d hesitate to conclude that it played no role. Was Miss G under time pressure due to a high caseload? Had she had enough time with her supervisor lately? What training had she been given on information-sharing and consent, or on inter-agency working? (And why was Miss G entrusted with the Initial Assessment at all, when it was due within seven days and she was shortly to go on leave?)

And when Miss C (social services referral officer) and her manager twice told (deputy head) Miss B that they wouldn’t take it further, did they have caseload & staff time on their minds at all?

Ofsted’s July 2010 report on Birmingham Social Services suggests that at present, nobody really knows what the Birmingham caseloads are:

30. … Pressures of work, capacity and capability pressures were cited as the root causes of the fundamental performance problems in the duty and assessment service. However, this could not be substantiated as no accurate data exist which show the nature and state of active caseloads. This major deficit prevents effective analysis and action by managers.

Human error and malfunctioning systems

Mrs Justice King rightly alludes to

the enormity of the task faced by these or any other social workers.

I too don’t want to rush to judgement of Miss G or her manager, or even whoever was responsible for training and supervising them. Social work is a difficult job to do well, with life-and-death responsibilities and (in practice) often not enough time to do them justice. There are probably lots of other social workers round the country who have made similar procedural mistakes, and got away with it in the sense that nobody died.

My point is that giving more and more people more and more legal powers and legal duties still can’t legislate away human error, or make malfunctioning systems28 suddenly function well.

Working Together to Safeguard Children has a section on what was learned from Victoria Climbié’s death in 2000. It includes this summary:

1.7 The examination of the legislative framework for safeguarding and promoting the welfare of children set out in the Children Act 1989 found it to be basically sound: the difficulties lay not in relation to the law but in its interpretation, resources and implementation.

Summary and conclusion

To sum up: Khyra and her siblings were still in school when the problems began, her school rightly reported to Social Services their concern about the children’s nutrition, and if Social Services had followed their own procedures, she’d probably still be alive. It’s quite true that the LA’s home education person had no right to insist on seeing the children, but Social Services did have that right – given the serious nature of the concerns – and failed to exercise it due to mistakes. A well-functioning Social Services team would almost certainly have saved Khyra’s life.

So, does Khyra Ishaq’s death mean – as both Maggie Atkinson and the Times imply – that education departments need the legal powers which social workers already have, to insist on coming into people’s homes and speaking to children alone?

No, it does not. What ought to happen is simply that when an education professional (or anyone else) has evidence-based concerns about a child’s safety, the social workers who are trained for it act upon those concerns.

The laws for that system already exist; the “gap” is in reliably doing it.

1. Report: Birmingham City Council v AG & others, 6 March 2009. England & Wales High Court. Available online at

2. Working Together to Safeguard Children: Available as PDF file from I’m linking to and quoting from the 2006 version, since that was current at the time of Khyra’s death, although there’s since been a 2010 version.

3. “Account of law 20 years ago is inaccurate”: It’s still very common for Local Authority personnel to be ill-informed about the laws and guidance on which they and their colleagues rely. The Judge discusses one such instance in the Court report, about parental consent for professionals to share information.

4. Summary of the children in Khyra’s family:

Birth year Age at May 2008 School Stopped going to school / nursery in Dec 2007 Notes
A 1996 12 H No At secondary school from autumn 2007.
L 1997 11 G P Yes Statement of SEN.*
Z 1998 G P Yes SEN, Independent Educational Plan.
M 2000 8 H S No Autism; “very significant” SEN; at “special school”.**
Khyra 2001 7 G P Yes Statement of SEN.
B 2004 4 G C nursery Yes

* SEN = Special Educational Needs.

** It seems likely to me that M too had a Statement of SEN; but that’s not explicitly documented in the Court report.

This table uses the dates of birth given in paragraph 1 of the Court report. From those, I’ve calculated the ages at the time of Khyra’s death.

If the dates of birth are correct, then the ages given in the report seem inconsistent: A’s is given as 12 years one month, true at the time of Khyra’s death, whereas L’s is given as 12 years, true at the time of the Court report in March 2009. Z’s is given as 10 years 3 months, true at the apparently arbitrary date of January 2009.

5. “Khyra & siblings stopped going to school in Dec 2007”: See paragraph 76 of the Court report, “K attended school for the last time on 6th December 2007. Z and L continued to attend until 17th December 2007”. Paragraph 89 notes that B had been withdrawn from nursery on 5 December 2007.

From the Court report, it’s not clear when the mother first claimed to be educating the children herself; apparently her first intention had been to get them into a different school:

201. On 21st December 2007 the mother had spoken to SENAS, Special Educational Needs Assessment Services. She spoke to a Lynn W. The mother told Miss W that she was taking the children out of school and wanted to move them to a school called G P School. [Not sure if that’s a misprint – G P School is the one they’d just been taken out of.]

There’s no mention of the mother ever writing a formal “de-registration letter” to the school (though she did write to SENAS on 3 January 2008; see paragraph 202).

Khyra, L and Z evidently remained on G P School’s register for some time despite their absence. Paragraph 222 reports that they were eventually removed from the register; it gives no exact date, but paragraph 221 suggests it would have been between February and April.

It’s therefore debatable when their legal status was “educated otherwise than at school” (home educated) versus, to use the phrasing of paragraph 222, “unauthorised absentees” (truants).

In my opinion, this is not a key point in understanding Khyra’s death, for the following reasons:

  1. Social Services ought to have acted on the safeguarding concerns regardless of the children’s educational status.
  2. Social Services were informed of the safeguarding concerns almost as soon as the three children at G P school stopped attending, about five months before Khyra’s death; the deputy head made a written referral on 19 December 2007. (See paragraph 192.)

It seems to me a side issue, therefore, to debate exactly when Mr H (the council’s one-person home education division) took over from truancy personnel the responsibility for interacting with this family about the children’s education.

However, in other cases, school registration status could be a significant issue, and it’s an area widely misunderstood and misrepresented. So I thought it was worth acknowledging here.

I’ll also note here that if the report is accurate, the Court was misinformed in professionals’ evidence about (a) the law on removing a child from a school’s register, and (b) the LA’s duties in respect of children in home-based education. I may return to the details of this in a future article.

6. An article from Community Care explains that the first trial, in June 2009, was “halted after three members of the jury were discharged“. The Daily Mail story dates from June 2009, which is why I suspect that’s the source. The retrial took place in 2010.

7. “Intervenor”: This term means something like “person involved in a legal case but not as one of the main parties”. See for instance definition 5 at the Free Dictionary.

8. Khyra Ishaq: Statement from Birmingham Safeguarding Children Board. Statement by Hilary Thompson, chair of the Birmingham Safeguarding Children Board, Thursday 25 February 2010. Available online at

9. Miss B visited on 29 December 2007, along with a Miss H. But they saw only the mother, not the children. (Miss H appears only in the two paragraphs relating to this visit; her role isn’t explained. Perhaps she was a school colleague of Miss B’s.)

197. Upon her return to school Miss B notified Miss C at social services of the outcome of the visit and her concern that she had not been able to see the children. Miss C said that her line manager would not make an assessment on the facts as they stood. She did, however, say that if there was a problem the school should contact the police to do a so called “safe and well check.” Miss C also told Miss B to ‘press hard’ to make sure that such a check took place.

198. Miss B in her oral evidence described being quite shocked when she was told to ask for a safe and well visit and the fact that Miss C had said that the police needed to be pressed hard to ensure it had happened. This, she said, had “left her with a feeling that if that was so why not go and carry out an initial assessment of the family?”

199. Miss B said that this was the first time she had ever asked the police to do a safe and well check. Miss B said that in any event such a check would not have allayed her concerns as given the history she felt that it was necessary to know what each child looked like on a day to day basis.

(As a side note, of course Miss B wouldn’t have seen the children every day during the school holidays even if the children had been in school during term time.)

200. Later that day, the 29 December 2007, the safe and well check was carried out. P.C. P gave evidence. She recorded that the mother was frustrated that the police had come to the house. She begrudgingly called K to the door. K appeared healthy and was dressed in clean clothing. That fleeting glimpse of K satisfied P.C. P who recorded that she had no concerns for her welfare. She did not see or ask to see any of the other children.

10. An example is this Guardian newspaper story:

Social worker Ranjit Mann visited the house in January 2008, following up a referral from the school. She peered through the letterbox and a window when there was no answer. Two days later she phoned Gordon, who accused her of breaching her privacy and became aggressive. Mann did not call again.

A less misleading final sentence would have read: “Mann referred the case to Social Services, who had the duty and legal power to investigate further”.

That article is doubly misleading in omitting to mention that Miss M had left the job shortly after that visit and phone call; in fact, her successor Miss S did accompany Miss G on the later visit.

11. “Children’s social care”: Working Together to Safeguard Children‘s glossary page gives a definition:

The work of LAs exercising their social services functions with
regard to children. This is not meant to imply a separate
‘children’s social services’ department[.]

12. Neglect as significant harm:

5.49 … Neglect, as well as abuse, can pose such a risk of significant harm to a child that urgent protective action is necessary. – WTtSC

In fact, before Khyra’s death there had been physical abuse as well, but it’s unclear from the Court report when that started, and there’s no indication that either school knew of it. I suspect that M’s teacher Mr Q may have had the possibility in mind when he instructed the staff “to look for marks on [M’s] body when he was undressing for swimming” (paragraph 61). But some of it would have left no marks: e.g. being made to stand in the cold.

13. Flow charts: I would speculate that the path that this referral ought to have taken, from Initial Assessment on, would have been something like:

(flowchart 2) Initial assessment completed within 7 working days from referral to LA children’s social care -> Child in need -> Actual or likely significant harm -> Strategy discussion, involving LA children’s social care, police and relevant agencies, to decide whether to initiate an s47 enquiry

(There’s an additional, optional path responding to “Concerns about child’s immediate safety” and leading to “Emergency action”. I suspect this would not have been taken; the physical abuse was not yet known, and back in January 2008, the children’s nutrition wasn’t yet an emergency, only a serious concern.)

-> (flowchart 4) Strategy discussion makes decisions about whether to initiate s47 enquiries and decisions are recorded -> Decision to initiate s47 enquiries -> Social worker leads core assessment under s47 of Children Act 1989, and other professionals contribute -> Concerns substantiated – child at continuing risk of harm -> Social work manager convenes child protection conference within 15 working days of last strategy discussion -> Decisions made and recorded at child protection conference -> Child at continuing risk of significant harm -> Child is subject of child protection plan; outline child protection plan prepared; core group established – see flowchart 5.

I won’t speculate beyond that point; the earlier the intervention, the more possible it may have been to support the mother in recognising and meeting her children’s needs, so I’m not assuming that Khyra and her siblings would necessarily all have been taken into care, although I’m not assuming they wouldn’t, either.

15. “Overriding the absence of consent”:

Working Together to Safeguard Children says, for instance,

5.21 In deciding whether there is a need to share information, professionals need to consider their legal obligations, including whether they have a duty of confidentiality to the child. Where there is such a duty, the professional may lawfully share information if the child consents or if there is a public interest of sufficient force. This must be judged by the professional on the facts of each case. Where there is a clear risk of significant harm to a child, or serious harm to adults, the public interest test will almost certainly be satisfied. However, there will be other cases where practitioners will be justified in sharing some confidential information in order to make decisions on sharing further information or taking action – the information shared should be proportionate.

Likewise, Information Sharing: Guidance for practitioners and managers says:

1.12 Significant harm to children and young people can arise from a number of circumstances – it is not restricted to cases of deliberate abuse or gross neglect. For example a baby who is severely failing to thrive for no known reason could be suffering significant harm but equally could have an undiagnosed medical condition. If the parents refuse consent for further medical investigation or an assessment, then you may still be justified in sharing information. …

16. Initial Assessment Record: This has the Department of Health logo and is labelled Initial Assessment Version 1 (2003), though also “© Crown Copyright 2002“.

As of July 2010, it’s available from the web site of the Department of Children, Schools and Families, as PDF Document Integrated Children’s System: Exemplars: Initial assessment record (207.5Kb).

The DCSF web site warns: A new UK Government took office on 11 May [2010]. As a result the content on this site may not reflect current Government policy. All statutory guidance and legislation published on this site continues to reflect the current legal position unless indicated otherwise.

I think this probably means the form is still in use at the time of writing; but at any rate it seems to have been current from 2003 till May 2010, including the time when Khyra died.

17. “Form SCS35”: I can’t find any such form on the web; it may be one local to Surrey County Council.

18. “Take a second person”:

120. … So concerned was she by the aggressive nature of her conversation with the mother that Miss M suggested to Mr H that in the event that he was to carry out a home visit he should take a second person with him.

19. “Ought not to be”: I put it this way because the fact is that professionals do sometimes become concerned for a child’s wellbeing purely because a parent takes a child out of school. But as far as I’m aware, there is no evidence base to back up such a concern; Graham Badman’s statistics seeming to suggest a heightened risk deserve an article of their own. At present, the rational course is to be concerned when there are other causes for concern, as there were in the case of Khyra and her siblings.

20. “Ten Pitfalls”: original source cited as Cleaver, H., Wattam, C. and Cawson, P. (1998), Assessing Risk in Child Protection.

21. Inspection of safeguarding and looked after children services: Birmingham, available from

22. Education Otherwise: Note 1 of the Court report clarifies,

This and all further references to “Educating Otherwise” or “Education Otherwise” contained within this judgment refer to “Birmingham City Council’s Elective Home Education Advice Service” and not the Registered Charity No 1055120 “Education Otherwise Ltd”

23. I am not, of course, suggesting that this is the only possible role for non-school education in a case of child abuse and/or neglect. This analysis relates to Khyra Ishaq’s death in particular. If I were given a similar level of detail about another case where home ed seemed to play some part, I’d analyse it from a similar practical/procedural perspective.

24. Guardians: For more details of this role, see paragraph 2.134 to 2.137 of Working Together to Safeguard Children.

25. “Education staff role”: There’s also this:

5.16 If somebody believes that a child may be suffering, or be at risk of suffering, significant harm, then they should always refer their concerns to LA children’s social care. … – WTtSC

26. “Anomalies in how the educational enquiries were treated”: As I’ve acknowledged in footnote 5.

27. The Victoria Climbié Inquiry report: sixth report of session 2002-03; report, and formal minutes together with oral evidence. This is not the report of Lord Laming’s actual Inquiry, but a subsequent shorter report produced after the Health Committee met to interview Lord Laming about the Inquiry. Available as PDF file from

28. According to Ofsted, in their report published 16 July 2010, Birmingham’s safeguarding of children is still inadequate as of June 2010.

17. The effectiveness of services in Birmingham to ensure that children and young people are safe is inadequate because of significant weaknesses in child protection arrangements. … there has been insufficient focus on the critical core business of protecting children and young people at the highest risk[.]


19. … managers are unable to establish if their
service is complying with statutory requirements and are largely unaware of the quality of the service. For example, social care services are unable to report upon the size of social workers caseloads, or whether children with child protection plans are visited in accordance with statutory requirements; the looked after children health team is unable to provide accurate data about the number and types of core health checks which are carried out.

20. … Five of the 42 cases selected and reviewed by inspectors demonstrated that the children and young people had not been seen by key professionals or that there were major deficits in practice which led to the children being or remaining at significant risk of harm.

Their discussion of Miss C’s department is also perhaps of interest:

26. Thresholds for access to services are clearly documented and generally understood across the partnership. They do not appear to be consistently applied, particularly at times of pressure but the absence of qualitative data prevents the service gaining a full understanding of this issue. All contacts and referrals received by the children’s social care service are initially screened by the unqualified referral and advice team. Decisions about whether they progress as referrals, are discontinued or signposted to other services, are taken by the qualified duty screening manager. This role is pressured and in the course of any day large numbers of decisions are taken, a significant proportion of which were observed to be on the basis of discussion without any reference to documentation which may have revealed significant facts about the child’s history.

Source: see footnote 21.

Here, have an index…
Systems, people and the death of Khyra Ishaq
Point-scoring with her name
Birmingham blame game
The Court report
Invitation for input
First signs
December 2007 and later
First approach to Social Services
The second referral
Miss M’s powers and duties
Social Services take it on
The nature of an Initial Assessment
Did Miss G need consent from the mother before talking to school staff?
Ambiguous information on obtaining consent
The 7-day limit
Mr H visits
Risk factor confusion
A brief glimpse of three of the six children
The social workers let it drop
Analysis from the Guardian and the Judge
The role of the schools
The Judge on responsibility
Parallels with the deaths of other children
Human error and malfunctioning systems
Summary and conclusion

Edited 16 Oct 2012 to add short summary at top (the bit shown in italics on most browsers) and the “Introduction and context” header, and change what was previously “Introduction” to “Sources”. This all to make the beginning of the article easier to read. No substantive changes.

Photo of Khyra Ishaq. A young Black girl is smiling at the camera. She has baby teeth and brown eyes. She is wearing a black headscarf. She looks happy.

9 thoughts on “Systems, people and the death of Khyra Ishaq”

  1. I’ve just skimmed through the serious case review J, and many of their conclusions are remarkably similar to yours in many respects.

    Well done for this carefully written and referenced piece


  2. Read in detail. Well done Jennifer (again!).

    Summary is spot on. Social Services were holding a hot potato and just didn’t want to deal with it.

    Had tears running down my cheeks reading about Khyra’s autistic brother stealing apple cores out of the bin, this is the kind of information that wasn’t reported before and it’s heart breaking that this was going on for so long.

    Thanks for doing this.

    Katya xx

  3. A thorough article. If only everyone could be so sensible! It is so infuriating home education is being used as a smokescreen to hide the deplorable state of social services in Birmingham. It is being reported there are 420 children home educated in Birmingham LA? add some more – my children have not been known to the LA in the 8 yrs we have been here.
    Thanks for this.

  4. Very very good, Jennifer. Painstaking, detailed, accurate, intelligent. Thank you.

  5. Thanks for such a thorough and useful article. I’ve spoken to the Secretary of State and strongly made the key point about poor Khyra: the failing was that of social services to do their duty and investigate the welfare concerns properly made by her school. Home education monitoring powers were not a factor and would not have saved her.

  6. Thanks everyone for the appreciation and for spreading the word.

    At some point I’d like to return to this subject and acknowledge some additional facts which became available via the Serious Case Review. I now know there are some minor ways in which this article was wrong. For instance, I called the December 2007 referral from the Deputy Head “the first referral”, but in fact there had been a previous one in February 2007, raising different concerns.

    But the key facts had already been elicited in the court case presided over by Mrs Justice King. So the short version, to be going on with, is: as far as I can see so far, there’s nothing in the SCR which would change the conclusions I reached in this analysis.

Appreciation, criticism & new ideas all welcome...

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