Archie David SPRIGGS · Prevention of Future Deaths report

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 1a) 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”.

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.

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.