The appalling conditions a nine-year-old boy lived in before he tragically hanged himself have been laid bare in a shocking report.
An investigation was carried out after the youngster, named only as Gavin, was found unconscious in his bedroom eight days before his 10th birthday.
Gavin, a British junior wrestling champion, was found by his nine-year-old sibling on August 8, last year. He died nine months later on May 16.
The publication of a 76-page multi-agency Serious Case Review found 'nothing could have been done to prevent his death', the Gazette reports.
However the report revealed that Gavin, the eldest of three children, had been the subject of a child protection plan on three separate occasions due to neglect.
He and his family had been involved periodically with agencies in Stockton, including health, social care, education and police, going back to 2005 and prior to this, with Durham social services.
Gavin’s troubled family history included he and his siblings 'experiencing poor home conditions and witnessing chronic domestic violence and abuse', said the review.
At one point the children were made the subject of police protection, and they were briefly placed in foster care.
But at the time of the incident Gavin was not on a child protection plan - the last ended in May 2012 - and the family was not involved with children’s services.
But three months before he hanged himself, Gavin’s school had raised concerns over his appearance, describing him as ‘unkempt’, and reported the pupil as being withdrawn.
Paramedics who were called when Gavin was found unconscious said there were no lightbulbs in his room or anywhere upstairs in the house. To see to the youngster they had to get a bulb from downstairs.
The independent author of the report, Mike Harrison, who has more than 37 years’ experience in children’s social care services, said: “As an indicator of the care being given to Gavin and his siblings at the time this reported situation is of concern.”
The young boy was described as “lively” and “a beautiful singer” with “a good sense of humour” who was “popular with his classmates”.
But the head teacher of his school said “he was a child with a sad face even when he was happy”.
The schoolboy had been on medication for attention deficit hyperactivity disorder (ADHD) but the review said there was no history of self harm.
The investigation concluded: “Ultimately the ending of the child protection plan in May 2012 probably had little connection to the incident that led to the commission of this serious case review.
"However it may have had an unseen effect on the daily life experiences of Gavin which the agencies probably insufficiently took into account.”
Mr Harrison was concerned about the basis on which that decision was made.
“It is difficult to conclude other than the decision to end the child protection plan at the time it was ended was insufficiently supported by evidence and was probably unwise,” he said.
The author was also “struck by what appears to be the collective inaction of those professionals involved with Gavin and his family during the first half of 2013 to take supportive action to ensure his needs were being met and that he was being satisfactorily safeguarded.”
The review has highlighted a number of “missed opportunities” to safeguard Gavin over time and has revealed areas where professional practice across some of the agencies involved could be strengthened and improved.
But the review said it was clear that there “was no information or indication given to professionals or agencies throughout the period of this review, or before, that would give rise to concerns that Gavin would in any way harm himself deliberately”.
It added that it was “clear the events which occurred on August 8, 2013, could not have been anticipated by any of the professionals or agencies who were or had been involved with Gavin”.
The incident was investigated by the police who were clear that Gavin’s injuries were caused by his own actions and did not involve a third party.
Colin Morris, the Independent Chair of the Stockton-on-Tees Local Safeguarding Children Board, said: “This was a tragic incident and our thoughts are very much with ‘Gavin’s’ family at this difficult time.
“In the independent author’s view, the incident was not preventable. The purpose of a Serious Case Review is to ensure that lessons are learned and the independent author has made a number of recommendations to improve multi-agency working.
“Some of these recommendations have already been implemented while a number of others are well under way.”
'Missed opportunities' to keep Gavin safe
The Serious Case Review highlighted a number of “missed opportunities” to keep Gavin safe. This included:
- The child protection process could not locate information on Gavin’s father’s prior history - because he had had two surnames.
- Protection plans drawn up for Gavin and his siblings were “insufficiently robust and specific in describing what needed to change in the family”.
- There was a lack of understanding by the professionals working in the child protection system about the programmes available to help abusers like Gavin’s father.
- Programmes set up to tackle potential domestic violence and abuse within Gavin’s family provided too little information on how they were working with family members.