A dangerous place to be young: Why have 18 vulnerable children died in Nottinghamshire in 18 months? Beatrix Campbell reports

TWO WEEKS ago Colin Sleat was convicted in Nottingham Crown Court of murdering Leanne White, his three-year-old stepdaughter. She had suffered 107 injuries at his hands. During the trial the judge criticised the county's social services for having failed to protect Leanne, despite repeated calls from relatives and neighbours.

That something is badly wrong with Nottinghamshire's social services is confirmed in a recently leaked confidential document, dating from early 1992 and written by Judith Dawson, an independent child abuse consultant employed by the department. Her report demonstrated that an authority with a consistently good record of caring for children at risk during the Eighties has undergone a spectacular decline in standards. It is widely thought that this is a direct result of changes in managerial practice within the social services department.

The statistics are shocking: in the past 18 months in Nottinghamshire 18 children have died at the hands of those with a duty to care for them. This compares with a previous rate of one or two a year, matching the figures in neighbouring Derbyshire and similar locations.

Dawson was among the many specialists appointed throughout Britain following the death of Jasmine Beckford in 1985. The Beckford case revolutionised public expectations and professional practice towards endangered children. Dawson's report illustrated how the style of social work practice that typified the late Eighties conflicted with the

Nineties marriage of modern managerialism and traditional values enthusiastically employed by Nottingham's director, David White.

Dawson's report was concerned with the deaths of two daughters of a couple living in Newark, and their baby sister. It called for an urgent management inquiry and a police investigation by senior officers. That did not happen.

The family at the centre of Dawson's report was already the subject of years of professional scrutiny by the police, health and social services. The woman's father had been convicted of incest. Her daughters' lives were shadowed by their mother's rejection, injuries inflicted at home, drug overdoses and violence. This mother made several attempts to take her own life and, some specialists suspected, to take the lives of her children.

Following the death of the seven-year-old daughter early in 1992 Dawson urged the county directorate to institute a management review of multi-agency practice, in terms that echoed the criticism of Brent social workers in the Beckford case for their 'overweening optimism' about dangerous parents.

Dawson also reminded the directorate of its obligation to assimilate new knowledge about adults' dangerousness, in this case Munchausen's syndrome by proxy, later to become notorious in the Beverly Allitt case, which happened in the same area. She warned: 'I would need reassurance that the police, who were recently resistant to the inclusion of Munchausen's in the (child protection) procedures, are open to new research and new areas of abuse.'

The local directorate had made no assessment of the mother's potential to harm her children. Neither danger nor depression featured in the area manager's strategy. Nor had there been an assessment of the history of sexual abuse in the family. 'I am horrified by this,' she told her directorate.

In 1985, a consultant paediatrician raised the alarm about any future children in the family after one daughter suffered brain damage following an incident at home. In 1986, after the mother overdosed on anti-depression tablets, complaining that she could not cope with her child, the child herself went into decline and died. According to Dawson's memorandum, the police had concluded at that time that she was not 'a woman who would harm her child'.

Yet this girl's body showed traces of her mother's tablets, not for the first time. Her paediatric consultant contacted the police, the coroner and social services to voice his concern. But Newark social services refused to share their information with the hospital, or to follow up the paediatrician's concerns.

The girls' father was dismissed by the social services as 'pestering' after he had gone to the police on 9 May 1989 to warn them that the mother would harm their baby with tablets. The police found no tablets in the home. The child continued to attract the attention of the health services, though not that of police or social services, and a year later she was found to have ingested her mother's tablets. The father is suing the authority for its failure to act.

Dawson left Nottingham a month after dispatching her report to the directors in January 1992. But it took another year before the child was made safe and the police began murder inquiries about her sisters' deaths.

The Social Services Inspectorate at the Department of Health has refused to answer detailed questions about the child deaths in Nottingham, save to say that it was kept informed. If it was aware of Dawson's document, however, why did the SSI do nothing? What was the use of being 'informed' unless it intervened?

Why did no one with any power bother about this baby? Despite the requirements of Working Together, the Government's guidelines, there was no review by each agency and the Area Child Protection Committee, nor was public and press concern 'allayed in a positive manner'.

There are chilling twists to this chronicle. Judith Dawson wrote her report after being told by the directorate to stop reading and reviewing the child protection cases in the county. This was in stark contrast to the expansion of such work in other counties. In Cornwall, for example, the consultant's role has been increased from an independent person to an entire team.

Dawson's role was being purged. The official reason was restructuring. The unofficial reason, according to senior staff, was that she picked up on too much child abuse and that she and the specialist child protection team were being punished for criticising the director and the chief constable in the aftermath of the county's largest child abuse case, the Broxtowe case, which had earned Dawson and the team the congratulations of a High Court judge and the prime minister in 1989.

The connection between the Broxtowe controversy and the county's current crisis is John Gwatkin, Newark area director.

Gwatkin's work has surprised and alarmed colleagues for some time. He had been criticised by police in 1988 for refusing to put a two- year-old boy on the at-risk register after his mother had rolled around laughing when she sent him spinning in the tumble drier. She had also beaten and scalded him on his genitals. She was jailed for 18 months. Gwatkin was pilloried by the judge, and subsequently called to an internal inquiry.

Yet a year later he was appointed by the social services director, David White, to head an internal inquiry into the Broxtowe case. This inquiry was to examine the serious rift that had emerged between social workers and police about the reliability of children's evidence in abuse investigations.

Gwatkin's Joint Inquiry Team endorsed the police and promoted the notion that social workers had brainwashed children. Although David White accepted this thesis, he later retracted and Gwatkin's report was thrown out by the authority's social services committee in 1990. Furthermore, the children's evidence was subsequently affirmed in several court hearings.

Throughout this crisis Judith Dawson kept the SSI informed. Her team requested an inquiry into outstanding cases and, more generally, into the prevailing style of investigation.

The SSI did not investigate. Instead, it advised the local authority to conduct a purely 'paper review', by a joint team of police and social workers - this time, however, with expertise. This review, in April 1991, gave a devastating picture of the effect of the Broxtowe case, the Gwatkin team's report, and role of the director.

The department's failure to support its staff had led to 'paralysis' and energy being expended managing differences with the police rather than inquiring into what was actually happening to children, said the review. A senior team set up to implement the review's recommendations stressed the importance of the Broxtowe case for all childcare work in the county. It warned that the legacy of the Gwatkin report, despite being rejected a year earlier, still adversely affected child protection work and polarised positions. It urged the directorate to take positive responsibility for the crisis and confront what everyone knew, that the police had become the most powerful, though not the most expert, presence in child protection.

David White was believed to be furious. Amidst all this the SSI continued to paper over the cracks with its own inspection which complacently concluded that there was 'a high level of effective collaboration betwen social workers and police'.

As confidence in Nottingham's child protection ebbed, children's deaths dramatically increased. On 29 May this year, Neville Lees, the Nottingham District Health Authority manager, alerted the authority to the unfavourable comparison with other cities. He could not tolerate these deaths. 'We put a lot of effort into investigation - but it is all after the event,' he said. 'I'm not sure we put the same corporate effort into prevention. We are not putting a sustained effort into children who have been abused.'

Lees's initiative was followed by the Area Child Protection Committee last summer - it had so many deaths on its agenda that it had to convene a special meeting. It is believed that the police were absent from this meeting, an absence that again raised concern among senior health and social services officials, as well as the public, about their commitment and their interest in crimes against children. Neither Nottingham's social services department, nor the police, nor the SSI would make any comment on the Dawson report or the 18 young casualties of this disaster area.