Social services and medical professionals found no reasons why Laura and Scott Castle should not adopt – but just months later, a one-year-old boy was dead.
Because adopting a child is a multi-agency operation, it is inevitable that some information will fall through the cracks, but missed opportunities and conversations ended in tragedy.
A report into the events leading up to the murder of Leiland-James Corkhill has been published.
Laura Castle, 38, of Barrow, was jailed in May. She had admitted manslaughter but was found guilty of murder and child cruelty when she appeared at Preston Crown Court.
The report, from the Cumbria Child Safeguarding Practice Review, found red flags throughout the adoption process – none of which were picked up by the different agencies involved.
The review said there had been no known concerns about the Castles as the adoption process continued.
But omissions on health forms, including the family GP not bringing up Laura Castle’s rheumatoid arthritis diagnosis just weeks after Leiland-James’s placement with them, were among the failures highlighted in the report.
In November 2020, she told her GP she was struggling with basic tasks like opening jars due to pain in her hands.
The report said: “There is no indication that there was a discussion about how this could impact on her ability to care for the baby, or that the information was shared with other professionals by the adopter or by the GP.”
However, her GP also told the review that the surgery had not been informed that a child had been placed with the Castles, although this has been disputed.
CSC had a record of the notification on to Leiland-James’s electronic case file.
Drinking habits
Communication about the Castles’ drinking habits was also not shared among the several organisations involved in the adoption process.
A medical advisor commented that their drinking was above the healthy recommended limit and that this should be explored further by their social worker.
The female adopter had stated on her form that she drank two bottles of wine a week and the male adopter had stated that he drank around 10 cans of cider a week. Both wrote ‘on and off’ on the handwritten forms.
The assessing social worker undertook a further exploration of the couple’s drinking and evidence of the challenge and additional assessment.
This was acceptable to the adoption panel who approved the adopters and later the match. The social worker concluded that the couple had a ‘healthy and informed approach to alcohol’.
However, information which the prospective adopter had shared with NHS service First Step, which offered free counselling, at the time shows that she was drinking significantly more than this. This was not known by any other agency at the time.
A consultant Laura Castle saw during an appointment noted she was drinking 27 units of alcohol a week, which was thought to be having an impact on her health condition. The recommended amount is to drink no more than 14 units a week.
Mental health issues
She was also seeing First Step as she was struggling with her mental health – although no agency seemed to be aware and the issues were presented as being historic rather than current.
The report says: “The prospective adopters did not disclose this new health issue to their own social worker or Leiland-James’s.”
Credit card debts
The family also had ‘significant’ loans and credit card debts, which were not fully understood by the adoption agencies.
The report says: “It was apparent that the design of the form did not clearly ask for the total money owed, rather it asked for how much money was being spent each month on loans and credit cards.
“This does not give the full picture and enabled the family to disguise what they owed and that they were only paying the minimum amount each month, leading to the debt increasing. Changes were made to the form in 2019, but after this couple’s assessment.”
The Castles applied to become adoptive parents after a failed IVF attempt – which they said they did not want to go through again due to the financial, physical and mental health impact .
Her GP was involved in the assessment of the adopters and stated at the time that there was “no reason or medical conditions that may affect her ability to care for a child”.
The adoption process was regarded as unremarkable at the time, the review found and an assessment of the adopters included references, medical information, and police checks.
Castles rated as ‘united couple’
The independent adoption panel scrutinised the case and recommended that the couple were suitable adopters and their recommendation to match them with Leiland-James was agreed by the agency decision maker – another independent party.
Social workers’ analysis of the prospective adopters was that they presented as a “united couple” with a “strong and solid relationship.”
This was confirmed by those friends and family members who provided references.
References included questions about the parent’s relationship with their birth child and specifically asked if they are aware if the prospective adopters use smacking, physical chastisement, or inappropriate discipline. All were positive about the prospective adopters and shared nothing of concern.
Changing Leiliand-James’ name
The Castles did not like the name Leiland-James and wanted to call him James instead, but this was not agreed to by social workers as it is best practice for the child to use their birth name.
The report adds: “It was agreed that it was in Leiland-James’s best interests to change the spelling to make him less identifiable as he grew up. A lot of work was undertaken with the adopters about the need for him to retain his birth name, including being clear that if they didn’t like or accept the name they shouldn’t progress with the match.”
Social workers later found out he was being called James, despite the Castles denying it. However, the report says: “After Leiland-James went to live in his new home, small but potentially significant concerns began to emerge.
“The family appeared to be calling Leiland-James by his middle name despite them agreeing they would not do so. Then, against clear advice and unbeknown to the social workers, it was shared that Leiland-James was spending significant amounts of time, including overnight stays, alone with his soon to be adoptive grandparents and aunt and uncle.
“Those involved with Leiland-James recognised the signs and were concerned that the information emerging was an indication that the placement was at risk of breaking down, and they planned to increase support to the family.”
Social work visits
There were concerns that he was not developing mobility at the expected rate and there had been issues with feeding previously.
“As the months progressed, while there was communication between professionals and with the prospective adopters, direct social work home visits to Leiland-James were largely limited to statutory visiting frequency. The social workers spoke to each other regularly and there is evidence that the case was discussed in supervision.
“Leiland-James was only seen once in placement by his allocated social worker, once by another member of the child’s social work team, and on three occasions by the social worker for the prospective adopters.
“Considering the concerns about the possibility of placement breakdown, learning has been identified about the need to have more direct contact with a child in a vulnerable placement than the minimum expected, and a recommendation has been made.”
Impact of coronavirus
The report said COVID-19 could have potentially had an impact on the case, including the limited availability of community activities. like mother and baby groups and some limits to the support the family could request from family and friends.
The report adds: “There was a need at the time for questions to be asked of all families receiving support from agencies about the impact of COVID-19 on their family and on them as individuals.
“It is now known that the male prospective adopter had some time on furlough during the first lockdown. This had a significant financial impact which was not shared with the social workers at the time.”
Castles were ‘not honest’
The report concludes that despite the Castles being successfully assessed, supported by professionals and their own network, after Leiland-James moved in, it started to emerge that it may not be the right home for the baby.
But, it added: “There were no known indicators that Leiland-James was at risk of physical harm from his carers, however. What was not known at the time was that the prospective adopters had not been honest about their debt, their mental and physical health, their alcohol consumption and use of physical chastisement during the assessment, at the time of Leiland-James being matched with them or during his time living with the family.”
It said that learning had been identified that information in those areas should be ‘robustly sought, shared and considered’.
It added: “This is significant, as had the information held by First Step and the gastroenterologist been known, along with the understanding that the prospective
adopters were hiding these issues, the assessment could have better reflected the vulnerabilities and potential risks.”
Recommendations
The Child Safeguarding Practice Review Panel to ask the Department for Education to review adoption guidance considering its review, including seeking assurance that medical assessments do not rely on the self-report of the prospective adopters; the need for flags to be placed on the GP records for prospective adopters/adopters and the need for financial information, including the total of any debts, to be robustly assessed during any assessment of prospective adopters.
Its local recommendations are:
- Due to the likely delay in changes to national guidance, relevant partner agencies in Cumbria to be told to raise awareness of the importance of adoption health assessments, and to ensure that health information is requested, analysed20, and shared at the key adoption process stages to inform decision making, such as when agreeing a match.
. - The CSCP to ask partner agencies to determine how they will ensure that ‘systems’ identify a person as a prospective adopter, so that professionals are aware of this. Additionally, all GP records locally should have a flag placed on the record of prospective adopters, with the expectation that GP’s share any information that pertains to changes in health or lifestyle that may have implications for a child in their care.
- That the CSCP asks all relevant partner agencies to determine how they will ensure that all professionals are aware that children placed for adoption remain in the care of the local
authority until an adoption order is made, to ensure an improved awareness of their potential vulnerabilities and the need for professional oversight. - That Cumbria CSC, the CCG and the Adoption Panel Medical Advisor are asked to provide assurance regarding the need for all information to be sought, shared, and considered thoroughly in adoption assessments to enable a full understanding of a prospective adopter’s health and mental health.
- That Cumbria CSC are asked to provide information and assurance in the following areas:
- That all necessary information is sought and considered in assessments to enable a full understanding of a prospective adopter’s financial situation
- That the voice of other children in the household is sought at regular points in the assessment and placement
- That there has been a review of visits to children in adoption placements to ensure that those with allocated responsibility for the child visit the child in placement at least in line with statutory requirements, and more often when there are concerns about the viability of the placement
- That there is an appropriately timely and robust response in cases where there are concerns about bonding with a child placed for adoption.
