Case Review Into Boys Deaths
Professionals did not think fire safety was a "presenting or imminent problem'' at the family home of two brothers who died when a blaze swept through their makeshift den, a report said.
Lewis Jenkins, seven, and five-year-old Taylor were found huddled together in a camp they made using duvets, sheets and a clothes airer under the stairs at home.
Taylor in particular was "absolutely obsessed'' with fire and had been caught setting paper alight upstairs at home, a three-day inquest into their deaths heard in October.
However professionals who were working with the family following concerns over domestic abuse and the boys' behaviour knew nothing of their fascination with fire, the report said.
It added that their parents appeared to have known about the obsession but failed to ensure fire safety measures were in place before they died on October 4 2008.
The boys' bodies were discovered by emergency teams in their hideout where a disposable lighter, tealight candles and an aerosol can were also found.
Investigators said it was likely the boys started the fire themselves at their rented three-bedroom house in Milfoil Drive, Eastbourne, East Sussex, due to their access to lighting materials.
A serious case review published by the East Sussex Local Safeguarding Children Board said "opportunities were missed to develop a fuller picture of what was going on and what standards of parenting'' the boys received.
It added that their deaths would not have been prevented had communication between the teams working with the family been better.
The report's executive summary said: "Undoubtedly, a more consistent and coherent multi-agency response to the problems faced within this family would have resulted in closer attention to the needs of the children.
"At times, interagency communication was inadequate. It does not follow, however, that the deaths of the children would have been prevented had communication been better.''
The report added: "Fire safety within the family home was not considered by any professional working with this family to be a presenting and imminent problem because the fact of the fascination with fire from both children was not known to workers.
"Their parents, who appear to have known about this, did not act to ensure that adequate fire safety measures were in place. It is not clear if they were aware of the support available from East Sussex Fire and Rescue Service for children who demonstrate fire-setting behaviour.''
The inquest, at Eastbourne Magistrates' Court, into the boys' deaths heard depressing accounts of their lives living in an environment with no routine.
Despite their young age, they routinely stayed up until the early hours, slept where they wanted around the house and were rude and disruptive.
The report said their father, Stewart Jenkins, referred to in the document as "EF'', was seen as a "pernicious influence'' and had subjected their mother Denise Goldsmith to ``totally unacceptable'' violence which had impacted on the boys.
It went on: "Although physical standards of care were inconsistent at time, it was probably not poor enough or pervasive enough to warrant the label of physical neglect.
"However, the children were certainly living in an emotionally abusive and neglectful context, if not all the time then certainly for a large part of it, due to persistent domestic abuse, parental substance misuse, inability to set consistent boundaries to their behaviour and a father in particular that did not appear able to consider their needs above his own.
"There is nothing that would lead to the conclusion that fire safety for these two children was an issue that agencies were aware of.''
Ms Goldsmith escaped the burning building through a window wearing just her night-clothes before dialling 999 from a nearby phone box.
In her evidence at the inquest, she admitted she was not in a fit state to look after her sons on the day of the fire because she had binged on vodka into the early hours.
East Sussex Coroner Alan Craze recorded verdicts of misadventure and said he believed that the boys' school, social services and other agencies could have done no more for them.
Following publication of the report, Cathie Pattison, chair of the East Sussex Local Safeguarding Children Board, said she was satisfied that agencies involved in the boys' welfare had already acted on recommendations made.
She said: "The serious case review, which is normal procedure in cases like this, was held to look at the support that was provided to this family before the very sad deaths of these two young boys.
"Its purpose was to see whether any lessons could be learned. It found that a wide range of support was correctly provided by a number of agencies but that certain areas of inter-agency working could have been better.
"It is important to note that the key conclusion of the report is that, while certain areas of procedure could have, and should have, been better, it does not follow that the deaths could have been prevented.
"The recent coroner's inquiry concluded that death was caused by misadventure and the coroner commented that, in his opinion, agencies could not have done more to prevent this from happening.
"However, the case has highlighted a number of areas where some processes should have been followed more robustly, where some assessments should have been more full, and occasions where information-sharing between agencies should have been better.
"The LSCB is committed to continuously improving safeguarding and to this end has produced a set of recommendations for improvement and is satisfied that the agencies involved have taken appropriate action to address each of those.''