Education Secretary Michael Gove today said a report into the torture of two young boys was "insufficient" and showed the current system of serious case reviews is "failing".
The Department for Education today published a redacted version of the full serious case review into the brutal attack on an 11-year-old and a nine-year-old by two brothers, aged 10 and 11, in Edlington, South Yorkshire, in 2009.
The executive summary of the report was published by Doncaster Council in January 2010 and prompted a political row over whether to publish the full version.
The coalition Government made a commitment in June 2010 to publish serious case reviews (SCR) in full. Since then, reports into the deaths of Baby P and Khyra Ishaq have been made public.
Mr Gove said: "The redacted serious case review overview report published today does not meet my expectations.
"It is an example of how the current model of SCRs is failing.
"It documents everything that happened but with insufficient analysis of why and what could have been done differently.
"In the future, we want SCRs to focus on why professionals acted the way they did, and what was getting in the way of them taking the right action at the right time."
In the savage attack, the two brothers lured their victims to a secluded spot and subjected them to 90 minutes of violence and sexual humiliation.
The victims, who are uncle and nephew, were strangled, hit with bricks, made to eat nettles, stripped and forced to sexually abuse each other.
The older boy was seriously injured when a piece of ceramic sink was dropped on his head.
The attackers were jailed in 2010 for a minimum of five years and will only be released at the end of their sentence if the Parole Board believes they are no longer a danger to the public.
The brothers had been placed with foster carers by Doncaster council shortly before the attacks. They had grown up in an extremely violent home in Doncaster, where they watched ultra-violent movies and pornography and were exposed to drink and drugs.
The case provoked widespread criticism of agencies involved with the brothers' family in Doncaster.
The previously published version of the serious case review found that the attack could have been prevented.
Doncaster Council said today that following an independent investigation, it is taking disciplinary action against five members of staff and has referred one former employee to the General Social Care Council, the social care regulator.
The council said in a statement that 279 members of staff were involved with the brothers' family over a 15-year period.
Commenting on today's publication, Roger Thompson, chair of the council's Safeguarding Children Board, said: "On behalf of the Board, I would like to reiterate our apology and our thoughts continue to remain with the victims and their families.
"The publication provides a real reflection of just how weak individual services and multi-agency working was at the time of this incident, and we made a commitment then to make sure lessons were learned and ensure as best as we can that something like this never happens again.
"The Board has ensured 18 recommendations for improving practice and procedures have been actively addressed by all agencies involved. All are now working much better together as part of a Government approved improvement programme to deliver high quality outcomes for vulnerable children and young people of Doncaster."
But Mr Gove, in his letter to the Department of Health, Home Office, Ministry of Justice and other MPs, said he was "not satisfied", and has commissioned a further independent review, to be carried out by Lord Carlile QC.
Mr Gove said: "Today's serious case review report puts a good deal more information into the public domain on the 'J' children case and it is right to publish it.
"However, I am not satisfied with the position we have reached. In particular, I want to be confident that all the necessary lessons and improvements have been identified."
The Education Secretary said he did not want serious case reviews to assign blame when "terrible" incidents took place. He said people working on cases such as this needed to be given "confidence that they will be backed by their managers when they take difficult decisions with good intent and sound judgment".
He continued: "We want an open, confident, self-regulating system where professionals are continually asking how they can improve, rather than a system clouded by secrecy and fear.
"Where there is clear evidence of failure or incompetence, individuals and organisations need to be held to account. Where there are successes, these should be celebrated and shared."
Doncaster council's director of children's services, Chris Pratt, said a recent Ofsted report found major improvements in child protection services.
He said the council had set up a new referral and assessment service, with the council, police and health services all working "under one roof".
Mr Pratt said: "This has helped us to strengthen working and good information sharing with our partners, and ultimately maximise protection for children and young people against abuse and harm."
Temporary Chief Superintendent Tim Innes, of South Yorkshire Police, said the force's own internal investigation has led to improvements in the policing and monitoring of domestic abuse and anti-social behaviour.
He said: "South Yorkshire Police will continue to work with all agencies in Doncaster to protect children.
"Now the Government has published the redacted report, today is about drawing a line under this case and concentrating on how agencies are providing better safeguarding services."
Mary Shepherd, NHS Doncaster's associate director of quality and safety, said health and social care workers were now working together under the same management structure and training for front-line staff has been improved.
She said: "We are confident that Doncaster's children are now much safer as a result of the lessons we have learned and action we have taken as a result."
In response to Mr Gove's letter, Mr Thompson said: "The serious case review was prepared under the Government guidance at the time, and all aspects were judged to be good by Ofsted.
"Comments made by the Secretary of State today are about the reporting of serious case reviews nationally, not just Doncaster."
In today's serious case review report, the victims are referred to as V1 and V2, while the convicted brothers are called J1 and J2 to protect their identities.
Large sections of the report are blacked out.
In one section the report states: "The panel are very mindful that examining events and decision making through hindsight can fundamentally distort how obvious the right or wrong judgments and action looked to practitioners at the time.
"Nonetheless, the following chapters provide compelling evidence about the extent to which XXXXXXXXXXXXXXXX children suffered neglect and that different decisions could and should have been taken at several points during the extensive involvement of agencies with this family from 1995 up to April 2009 and that better outcomes could and should have been achieved for the J children."
The report continues: "It is not possible to reasonably conclude on the basis of the evidence and information examined that any individual could have predicted the severity and extent of the assaults on V2 and V1 on April 4 2009.
"Neither an expert independent psychological assessment nor the local psychiatric services suggested a heightened risk of extreme violence from any of the children.
"It was, however, entirely predictable that the boys would continue to assault and cause injuries to other children (and adults).
"This is a pattern of escalating behaviour established over many months. For this reason, more assertive and effective action should have been taken and as late as a week before the assault on V1 and V2 and there were opportunities to do this. As such, the assault on V1 and V2 was a preventable incident.
One section covered the role of agencies in assessing the parenting skills of the parents of the convicted brothers.
The report stated: "There was no assessment of either parent's capacity to meet the needs of a XXXXXXXXXXXXXXXXXXXXXXXXXXXX at any time during the 14 years of agency involvement.
"Very little is known about the family history of either parent. Very little information over and above incidental and anecdotal conversation with mother or XXXXXXXX is gathered regarding their lifestyle."
The report concluded that "professionals were generally ineffectual in planning and executing more effective intervention".
It added: "Collectively they could have reduced both the risk and opportunity for such a serious crime to have been committed."
"The boys lack effective parenting over many years. This should have been a fundamental starting point for collective intervention," the authors said.
"The lack of engagement by children's social care services is an important factor."
"The single most influential factor in this case is the corporate and organisational inadequacies that contribute to the missed opportunities identified later in this report.
"It is no coincidence that during the latter months when there is a marked escalation in the boys' problems that children's social care had very high vacancies, and almost a quarter of children subject to a child protection plan did not have a qualified social worker responsible for leading on their safeguarding arrangements.
"If the most vulnerable children in need do not have access to suitably qualified and experienced staff, it will be unsurprising to find other children who have yet to be properly assessed in terms of risks to their physical safety and emotional and psychological wellbeing.
"The effect on children can be very damaging and enduring. This is such a case."
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