Source · Prevention of Future Deaths

Archie Spriggs

Ref: 2019-0405 Date: 2 Dec 2019 Coroner: John Ellery Area: Shropshire, Telford & Wrekin Responses identified: 1 / 4 View PDF

The concerns are covered within the 8 recommendations of the SCR regarding referral pathways, understanding of private law proceedings, notification processes for Section 37 reports, and engagement with multi-agency frontline staff.

Date 2 Dec 2019
56-day deadline 27 Jan 2020
Responses identified 1 of 4
Child Death (from 2015)

Coroner's concerns

AI summary
The concerns are covered within the 8 recommendations of the SCR regarding referral pathways, understanding of private law proceedings, notification processes for Section 37 reports, and engagement with multi-agency frontline staff.
View full coroner's concerns
These concerns are based upon the SCR whose author was , Independent Safeguarding Consultant. Whilst the SCR is a public document feeding into it were 15 Individual Management Reviews (IMRs) which predated the SCR and are restricted documents.

The concerns are covered within the 8 recommendations of the SCR which, for consistency of approach, I adopt. The 8 recommendations are set out verbatim as follows: a) SSCB to clarify, and subsequently audit the application of the referral pathway and decision-making process for referrals to Early Help and Children’s Social Care. This should include the use and quality of written referral forms and feedback to referrers.

b) SSCB to seek regular assurance that:
i. Professionals understand how to refer urgent concerns in respect of cases open to Children’s Social Care;
ii. Children’s Social Care provide a timely and child centred response to this information.

c) SSCB to provide the multi-agency workforce with the knowledge and understanding of
i. the impact of protracted private law proceedings on children’s emotional wellbeing;
ii. the factors to be considered and assessed in circumstances whereby separated parents make allegations about the welfare of their children
iii. the features of filicide cases.

d) To test the impact of recommendation (c) SSCB to conduct a multi-agency audit of the services provided to children referred to Children’s Social Care whose parents are separated and where private law proceedings have taken place. The audit should consider the completion of whole family assessments and the response to safeguarding concerns and allegations of domestic abuse.

e) SSCB to work with Local Family Justice Board (LFJB) and CAFCASS to review the notification process for Section 37 reports to ensure timely and consistent arrangements.

f) CAFCASS to update their Child Protection Policy to include when and how safeguarding referrals (child in need) should be made.

g) SSCB to engage with multi-agency frontline staff as well as parents/carers to explore their experiences, and any barriers, to working with fathers. The findings of this work should be considered and acted on by SSCB.

h) SSCB to create learning opportunities for the multi-agency workforce to come together and reflect on their approach to providing a whole family focus; including how they consider the impact of parenting capacity on children.

This Regulation 28 report is directed to the SSCB so they with CAFCASS may provide a holistic approach with collective responses from those feeding in to the SCR as may be appropriate.

Responses

1 respondent
SSP Other
2 Dec 2019 PDF
Noted

The Shropshire Safeguarding Partnership (SSP) acknowledges the report and states they are responsible for owning and governing delivery against the action plan related to the Serious Case Review, which was commissioned by the previous Shropshire Safeguarding Children’s Board (SSCB). (AI summary)

View full response
Dear H.M. Coroner Mr. Ellery

I am writing in response to the Regulation 28 report regarding the late Archie Spriggs deceased, received on 2nd December 2019.

As you will be aware the serious case review was commissioned by the then Shropshire Safeguarding Children’s Board (SSCB) whose duty it was to receive the report, accept the recommendations and direct an action plan to support the delivery of them.

Following the publication of Working Together 2018 SSCB was de-constituted but it’s functions are now the responsibility of the Shropshire Safeguarding Partnership (SSP). The SSP is now responsible for owning and governing delivery against the action plan which I have included in full, together with related timescales.

Although CAFCASS are also required to respond to you, I have included their specific actions as the SSP also have a role in holding CAFCASS to account.

A small number of actions will not have been concluded by the due date for response to you, being 27th January 2020.

I would be obliged if you could give direction regarding your expectations on how you would like to be updated on progress. Please be assured that the SSP will be monitoring delivery of these outstanding actions as they become due.

Report sections

Investigation and inquest
On the 22nd September 2017 I commenced an investigation into the death of Archie David SPRIGGS, 7 years of age. I opened an inquest on the 26th September 2017 and adjourned it on the 23rd January 2018, having suspended my investigation pending criminal proceedings brought against Archie’s mother Leslie Speed for his murder. Following her conviction for his murder and completion of a Serious Case Review (SCR) by Shropshire Safeguarding Children’s Board (SSCB). I resumed the inquest on the 2nd April 2019 which was heard on the 11th, 12th, 14th, 19th, 20th & 21st November 2019.

The medical cause of death was Ia) Pressure to the neck with features raising the prospect of occlusion of the external airways.

The conclusion of the inquest followed the outcome of the criminal proceedings and was “Unlawful Killing”.
Circumstances of the death
Archie was murdered by his mother on the morning of the 21st September 2017. Archie was the subject of a bitter and acrimonious dispute between his parents. A child arrangements hearing was due to take place that day at Telford County Court. Archie and his parents were known to Social Services (and other agencies). Opportunities were lost to hear Archie’s voice in 2014 and 2017 but they cannot be said to have been causative of his death.
Copies sent to
Birnberg Peirce Solicitors, representingShropshire CouncilWest Mercia Policeand to the Local Safeguarding Board (including the Child Death Overview Panel)

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Report details

Reference
2019-0405
Date of report
2 December 2019
Coroner
John Ellery
Coroner area
Shropshire, Telford & Wrekin

Responses identified

Responses identified 1 of 4
3 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Jan 2020.

Sent to

CAFCASS
Shropshire Council
Shropshire Safeguarding Children's Board
Shropshire Safeguarding Partnership

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