Warning: This article contains descriptions of child abuse that some readers may find distressing
A safeguarding review into the murder of a five-year-old boy at the hands of his mother, stepfather and a teenage boy has revealed how multiple opportunities were missed for agencies to act on concerns around his safety and wellbeing.
A once "smiling, cheerful" boy, Logan Mwangi's body was found dumped in the River Ogmore in Sarn, Bridgend in July last year.
His mother, Angharad Williamson, his stepfather, John Cole, and a teenage boy, Craig Mulligan were convicted of his murder by a jury at Cardiff Crown Court in April this year.
The jury heard Logan was removed from the child protection register just weeks before his death, as social workers deemed him no longer at "significant risk of harm."
Today, a review commissioned by Cwm Taf Morgannwg Safeguarding Board examined the role of police, school workers, NHS staff, and social services in Logan's safeguarding, and whether more could have been done to save his life.
The review reveals that some organisations, particularly healthcare staff, failed to work with social services to effectively to pass on information, to escalate concerns, and to challenge decision-making that they disagreed with.
It also showed social care staff failed to overcome challenges presented by the pandemic to deliver their services effectively and in full.
So what more could have been done to protect Logan?
Limited contact with Logan due to the pandemic
The pandemic – and the government's Covid restrictions – led to key information around Logan's wellbeing being missed.
Agencies had "no knowledge of the reality of [Logan's] lived experience," according to the review.
Many of the safeguarding activities normally carried out face to face – which are said to be "vital" to accurate assessments and decision making – had to be carried out remotely.
The review says that there was example of Logan being spoken with alone on a face-to-face visit, but that there was an absence of one-to-one sessions undertaken with him outside of his family home.
Overall, the Covid-19 pandemic seemed to limit contact between the family and agencies involved, and put "pressures" upon child protection systems at that time, such as high levels of staff absences.
The review also said that those working with the family didn't feel able to challenge them when the family used Covid 19 anxieties and Covid 19 symptoms as reasons to avoid co-operating with agencies.
Failure to report injuries
On 16th August 2020, police went to a hospital that Logan had visited after "falling down the stairs", as well as making a visit to his family home.Although Logan had sustained several "significant" injuries, the police recorded that a paediatric consultant did not think Logan had sustained a "non-accidental injury," a view which was also passed on to children’s services. However, when children’s services requested that the consultant confirm their position via email, there is no record that this happened.
There is also no evidence that information about these injuries was shared with agencies outside of the health board that could have taken appropriate action to safeguard him.This is despite the fact that several of the injuries, even if they had been in isolation, should have been enough to trigger a referral, according to the review.
Failure to speak up
Some healthcare staff were "uncomfortable" about Logan's management during his assessment at the hospital, but they didn't feel able to express their concerns, either to the clinician or afterwards.
It comes as the review says the health board in question seems to have a "culture" in which some staff are "reluctant" to challenge the clinical assessments and decisions made by "more qualified" members of staff.
There was also no use of the health board’s whistleblowing or escalation policies to allow people to raise concerns without having to confront someone face to face.
In response, the health board said it has already taken a number of actions to improve safeguarding.What's more, although the criminal investigation following Logan's death revealed a number of adults who had contact with Logan had concerns for his welfare, the review stated that there were "no reported concerns raised by the wider public to professionals prior to his death."
Failure to share information
Agencies failed to share an understanding of "the risks and the appropriate action that was needed" in Logan's case, according to the review.
Much of this has been put down to a failure to effectively share information across the different agencies involved, as well as the technology and systems available.
As the review puts it, "the lack of a shared information sharing system critically affected the ability to respond to this case."
In one instance on 7th May 2021, Logan’s mother called his GP and told them that on the previous day, Logan had burnt the skin at the back of his neck by leaning back on a hot water tap.
The GP received an image of the injury via email, but health records do not say whether the GP confirmed if children’s services were aware of the injury, or whether a referral was made to child protection services.
In regards to Logan's "significant" injuries recorded on 16th August 2020, the review says there is no evidence that information about these injuries was shared with agencies outside of the Health Board.
Failure to inform Logan's biological father
One of the key failings identified in the review is that the children’s services did not notify Logan's biological father of their involvement with him, despite it being his "right" to be informed of his child's safeguarding concern.
The review claims that this was down to a "lack of understanding" from professionals of their "duty" to inform any person who holds parental responsibility for a child of child protection concerns.
On Thursday, the council apologised for their failure to notify Mr Mwangi of this.
Failure to examine the risks within Logan's household
There was "a lack of curiosity" concerning the presence and impact of Logan's stepfather, John Cole, within his two families and the risks he posed within them.
The review claims that it seemed Cole was able to "effectively manipulate his partners and some professionals he came into contact with."
A former member of the National Front, the review says Cole would "call Logan racially derogatory names in front of family associates."
However, the agencies involved "did not fully explore the context of Logan's race and ethnicity on his lived experience," and the review claims that there are no records that say agencies were aware of Cole's "racist and discriminatory views" during their involvement with Logan.
What's more, as the review identified, there were "gaps in risk assessments and specialist skills around interrogating and analysing evidence," as well as risk management plans with regards to John Cole being stepped down without explanation.