Serious Case Review : Hamzah Khan’s death was not “predictable”

The death of a four-year-old boy whose mummified body was found in a cot nearly two years after he was starved by his mother was not a “predictable event”, a serious case review has found.

A report investigating the death of Hamzah Khan, published this morning, claims there was not one opportunity for any individual to save the youngster’s life after he became “invisible” to a range of services, including health, early years and education.

Despite contact with at least 14 different agencies and organisations, there was no evidence of abuse and, therefore, no-one could have taken action to prevent his death.

The only person who could have prevented the tragedy, the report says, was his mother, Amanda Hutton.

The mum-of-eight , 43, was jailed for 15 years at Bradford Crown Court in October for starving her son to death and cruelly neglecting five of her children in conditions of “breathtaking squalor” at her Bradford home in September 2011.

During the trial, the jury was told that the family had been visited by police and health workers several times during the child’s short life.

But the serious case review, commissioned by Prof Nick Frost, independent chairman of Bradford Safeguarding Children’s Board, found there was no evidence of abuse and, therefore, no-one could have taken action to prevent his death.

None of the children in the family were on an at-risk register or child protection plan and no agency had raised serious concerns about the family to children’s social care until his body was discovered, it adds.

The report said: “The person who could have prevented this death was Amanda Hutton, who had the day-to-day responsibility for Hamzah and other siblings.

“She had become so overwhelmed with her own problems and needs that she was incapable of adequately caring for herself, let alone any dependent children.

“Nobody, save for the children that were living with her, will know when those conditions became so extreme and were in stark contrast to the conditions that were recorded by a succession of different services until some months before Hamzah’s body was discovered.”

The document describes Hamzah’s death as “profoundly disturbing” and that he had been starved and neglected for a number of months.

It outlines the involvement a number of agencies had with his family at various points in time, who each conducted management reviews of their agency’s actions after his body was found.

But it said the information known to those agencies at the time of the events did not suggest Hamzah’s death was a “predictable event”.

None of the organisations “had enough information to form a view about what life was really like” for any of the children in the household.

And the only multi-agency discussion to take place was in 2008, which focussed on the “risk to the mother” from domestic violence “and not the risk to the children.”

There were “no other inter-agency meetings or formal discussions, although there were discussions that took place over telephone or email or took place within single agencies”.

“The consequence was that individual people and services were always dealing with incomplete information.

“The children’s views, wishes and feelings were not given enough focus and priority when they came to the attention of support services or sought help in relation to the domestic violence their mother was suffering.”

However, it said there were opportunities to explore what it describes as “inconsistencies” – for example, how the children arrived at school well dressed, but at other times showed “symptoms of neglect”.

The document reveals the following overview of Hutton’s contact with agencies:

• From Hutton’s first pregnancy, there was a “pattern of avoiding contact with health services”. She also experienced low mood and depression with all of her pregnancies.
• She first reported domestic abuse in 1996, although declined to make a formal complaint to the police – something which is said to have become a “repeated pattern”. There were further episodes of abuse and violence and on at least one of those occasions, the report was made by one of her children.
• With all of the children, there were problems for the health visiting service and the GP in seeing the children or parents, which became more of a problem with her later pregnancies, including with Hamzah.
• In December 2006, one of the children went to the police to talk about the situation at home and his distress about the domestic violence. The police used their powers of protection to try and arrange accommodation with child social care, who were unable to find a placement. The child returned home.
• Shortly after this, there was a further incident where Hutton asked for police help. In February 2007, she was admitted to hospital with bruises and chest pains following an assault at home. She said she had separated from her children’s father. There were further attendances at A&E, one of which was via an ambulance called to the house by one of her children.
• At the end of 2007, one of her children appeared at magistrates’ court on charges of theft and deception and was remanded ‘as directed’ and placed with specialist foster carers for two nights before being returned home. The Youth Offending Team (YOT) was involved.
• In May 2007, the same child was injured after falling running away from their father and went to A&E. While there, they asked for help to live away from the family. This led to involvement from child social care as well as the police. The child was referred to the homeless service and given emergency accommodation, but returned home before the end of that month.
• By the summer of 2007, Hutton was asking for help to find alternative accommodation away from the father of her children. Several services became involved, including the YOT, the police and special services. Despite asking for help, she was unable to take up appointments that were made for her and further incidents of violence occurred later in the year.
•  Hutton’s mother died just before Christmas 2007, which coincided with the anniversary of the death of Hamzah’s paternal grandfather.
• She had further contact with the police in 2008 because, on more than one occasion, one of the children had gone missing from home. In April that year she asked to meet a specific officer who had previously provided support – but by the time the officer was able to contact her she didn’t want to meet any more.
•  In July and August 2008, there was a discussion at the Multi Agency Risk Assessment Conferences, designed to focus on addressing cases of highest risk of domestic abuse. In December 2008, there was another incident at home when the children’s father forced entry to the property and assaulted Hutton. He was prosecuted and given a community sentence.
• In March 2009, Hutton moved to a new property.
• In April 2009, three of her children were not collected from their primary school at the end of the school day. Police made a welfare visit that included checking all of the rooms in the house. One of the children did not have a bed and for another the arrangements were not clear. Hutton also appeared to be under the influence of some unknown substance. The police sent information to children’s social care to suggest a follow-up visit by a social worker might be needed.
• In June 2009, the children’s father was convicted of an offence of battery in relation to an assault on Hutton in 2008.
• In October 2009, Hutton and her children were moved from the register of their GP practice. This was after a protracted period when Hutton had been asked to bring the children for routine and developmental checks and immunisations.
• In late 2010, there was correspondence between health visitors, education and early childhood services and children’s social care which centred on difficulties in seeing the children. By the end of 2010 and the beginning of 2011, there were reports of the children living outside Bradford and a school was noticing at least one of the children was looking more neglected. The father told his offender manager at the probation service that the two eldest children were living with him.
• There was an anonymous referral in March 2011 about the children and in July, the school attendance service began making inquiries with the police about four of the children – this included Hamzah, who had never been enrolled for education. Hutton wanted services to believe the children were living with relatives outside Bradford and mentioned various places in the south of England. Contact was made with another local authority, which had no information. The report says the children were never living outside of Bradford.
• In September, another referral was made to children’s social care. Over a period of several days, a PCSO made persistent attempts to see Hutton and the children without success. The PCSO made a child protection referral to children’s social care who requested a uniformed officer visit the property after Hutton refused access to the PCSO. When police gained entry, Hamzah’s body was discovered.

However, the report says the overview panel received no information that suggested that there was one opportunity for a single individual to have done something to save Hamzah’s life.

It adds: “The information considered does not point to single acts or omissions but rather a constellation of factors that contributed to the circumstances.”

The document says a “significant theme” to the case was the extent to which Hamzah was unknown and invisible to services during his life, largely because his parents did not participate in the “routine processes”.

“The circumstances that caused a mother in particular to withdraw increasingly from any contact with services are complex,” it adds.

“A contributory factor appears to be the degree of domestic violence she suffered and the social isolation she felt.

“Associated with this was the reaction from some people in the community that involved partners from different cultures and religions.

“Hamzah was invisible to services largely because neither of his parents participated in the routine processes such as ensuring he saw health professionals on a regular basis or was enrolled for early years to educational provision.”

It continues: “Some people will ask why help was not provided. Help was provided on several occasions and sometimes with great sensitivity and persistence.

“However, as will become clear through the report, that help faced many and significant barriers.”

The serious case review was commissioned immediately after Hamzah’s body was discovered in 2011 and, although it could not be published until the criminal proceedings had finished, it was discussed by Bradford Safeguarding Children’s Board in 2012.

It warns that there is a danger that in a “highly charged and emotional case” like this, the crude application of hindsight could mean “any genuine and more honest learning will be lost”.

But the body said it looked at and revised services immediately and all questions raised by the review have been address and any necessary action taken.

It said information-sharing across agencies has since improved and there is now a multi-agency assessment team, where a police officer, education worker and health visitor all work together with children’s social workers.

There is more effective screening of domestic violence notifications, so that help can be targeted at families where children are affected by domestic violence.

And MARACs now have consistent representation from children’s social care.

“Each agency involved in the review has reviewed its own child safeguarding procedures,” it added.

Coun Ralph Berry, Bradford Council’s executive member for education, said it deeply regrets it did not have the sufficient information to take statutory action at the time.

“We wish we had known. Statutory action can only be taken if there is clear evidence of abuse.

“In the absence of serious concerns being reported, agencies have no general enforcement powers to insist children use early childhood or medical services.

“When children’s access to services is delieberately blocked by a parent, abuse and neglect invisible to any agency can be perpetrated.

“With hindsight, you can always look back and think we could have done that differently. Support and assistance was offered to the family, but this was not taken up by the family.

“We welcome the publication of the independent serious cases review report and its public examination of Hamzah’s death.”