The deaths of three disabled New Malden children smothered by their mother "could not have been prevented" despite social workers' concerns about child protection needs being met, a serious case review has found.

But a decision to replace a friendly and experienced social worker was an 'important trigger' the independent report, published today, acknowledged.

Mum Tania Clarence, 44, smothered Olivia, four, and twin boys Ben and Max, three, at their Thetford Road home in April 2014 after becoming overwhelmed with caring for them.  

Father Gary Clarence said that he disagreed with the conclusions and that his wife’s desperation to provide good care for her children coupled with having to deal with “more than 80” health professionals led to “feelings of desperation and helplessness”.  

Your Local Guardian: A police officer places flowers in the driveway of the family home

A police officer lays down tributes to the children outside the home 

He said: "Tania’s depression was certainly not helped by some aspects of the medical profession who could not agree with our stance to provide quality of life for our children over [invasive treatments.]

“Today’s report highlights only some of the complexities we have faced over the years.

"[We tried] to provide [our children] with a loving and normal life as possible.

"We are hopeful that lessons can be learnt."

The children all suffered from a rare genetic muscle weakening condition called type 2 spinal muscular atrophy.

The condition which affected their body movements, breathing and swallowing, is said to be a life-limiting illness, although care improvements have meant many people with the condition can now live longer. 

Your Local Guardian:

Police stand on guard outside the house in Thetford Road after the deaths 

The report by Kingston’s local safeguarding children board stated that health and social care professionals from Merton, Wandsworth and Kingston offered “wide-ranging” support to the Clarence family.

It added “important lessons” would be learned from the case.

The report follows the family from July 2010 when they were living in Merton and the twins were born prematurely, through to their deaths in New Malden in 2014.

It said: “This is a case of children with complex health needs, parents who provided good and at times outstanding care, but where specific concerns of medical neglect which meant that there was suspicion that one or more of the children might be, or might become at risk of significant harm.”

Kingston social workers found the children, referred to in the report as P (Olivia), Q and R (Ben and Max) and N (the couple’s oldest child who does not have the same condition) to be “happy, intelligent and lively” and got along well together.


Olivia was shy but had "a mischievous twinkle in her eye, even when ill in the hospital's paediatric intensive care unit". She loved pink and fairies, was very intelligent, had a sunny personality, good sense of humour and strong will. Olivia used to be affectionate with her mother, receiving cuddles, exhanging baby high fives and being told 'bye my angel'.

Twins Ben and Max were close and described as 'cheeky' and part of a happy family.


But parents Tania Clarence and her husband Gary, an Investec executive, were criticised for “their lack of cooperation” with some professionals and cultural differences.

Father Gary Clarence, was on holiday with the eldest child in his native South Africa at the time of the deaths. 

The couple were criticised because of their comfort with medical agencies in their home country.

The parents were aware of “veiled criticisms” of their medical views, although this was never formally acknowledged.

The report noted that health and social workers often found Mrs Clarence “difficult”, adding that she was told to seek help for perceived depression from her GP, but refused.

Mrs Clarence is now out of hospital and has been seen outside the family house. 

Your Local Guardian:

Tributes left outside the home in Thetford Road 

The report also suggested that there had been “consideration that the family’s social status led to different safeguarding response.”

However the report noted no evidence could be found that social workers were less quick to act because Mr Clarence was an investment banker and the family were affluent.

The report’s authors were also refused access to Mrs Clarence’s medical history to complete review. She also did not cooperate with the authors.

Mr Clarence was, however, interviewed by the board.

During his wife's trial a forensic psychiatrist Philip Joseph told the Old Bailey Kingston Council's decision to switch Tania Clarence's social worker was "an important trigger" before the killings.

Your Local Guardian:

Forensic officers are allowed into the home following the deaths in April 2014 

The replacement, he said, was "a real novice".

The report's authors say that "the abrupt departure of a professional the family knew and with whom they had developed a reasonable working relationship was not managed well.

"The family were unable to say goodbye to the first social worker with whom they had managed to develop the beginnings of a trusting relationship."

Your Local Guardian:

Tributes left outside the home to Oliva, Max and Ben 

And they say that there was no constructive handover which had implications for the new social worker, who had less understanding of the complexities of the family.

The authors conclude: "In this case the new social worker, did everything that would normally be expected in her role.

"However, the lack of management understanding of the need for a careful hand-over and negotiation of any changes, meant that during April, with her husband away, the mother was engaged in conversations about medical intervention, and the children were directly engaged in professional communication.

"Moreover, the decision to allocate a case of such complexity to a newly qualified social worker is problematic, even if the team manager provided considerable support as occurred in this case."

Your Local Guardian:

Gary Clarence outside Wimbledon Magistrates' Court after the first hearing for his wife's case (Pic credit: Jon Sharman)

Deborah Lightfoot, the independent chair of the board, said: “The deaths of the three siblings is nothing short of a tragedy.

“They could have gone on to lead long fulfilling lives.

“While the review states that all of the deaths were not predicable nor preventable, it has found that there are learning points involved.”

To read the report for yourself click here Family A Serious Case Review Report November 2015.pdf

Criticisms in care – what went wrong?

There were welfare concerns for the Clarence family’s children and the report notes that a care worker had suspicions they were being neglected.

Instead of using child protection processes, the use of legal intervention was repeatedly debated. Legal interventions should be the final stage following other child protection processes.

It is unusual for Kingston’s local safeguarding children board to go straight to legal proceedings without going through the child protection process. There may have been a “misunderstanding” of child protection processes.

The Clarence parents wanted their children to have a good quality life, which was as pain free as possible, and they felt at odds with health professionals about this aim.

According to the report, this was also the professionals’ aims but they often disagreed with what was the best medical care for the children.

All local safeguarding children boards will now establish if

professionals can make specific child protection referrals when they have such concerns, so that their view does not get lost as part of the usual information sharing process.

The family was under considerable stress. Professionals had to balance working slowly to gain parental agreement to procedures or facing confrontation.

Kingston local safeguarding children board will now consider if there are adequate resources available for practitioners to seek more consultation on complex cases.

Impact of change in social worker

During Tania Clarence’s trial forensic psychiatrist Philip Joseph told the Old Bailey Kingston Council’s decision to switch Tania Clarence’s social worker was “an important trigger” before the killings.

The replacement, he said, was “a real novice”.

The report’s authors say that “the abrupt departure of a professional the family knew and with whom they had developed a reasonable working relationship was not managed well”.

The report said: “The family were unable to say goodbye to the first social worker with whom they had managed to develop the beginnings of a trusting relationship.”

It added there was no constructive handover which had implications for the new social worker, who had less understanding of the complexities of the family.

The authors conclude: “In this case the new social worker did everything that would normally be expected in her role.

”However, the lack of management understanding of the need for a careful hand-over and negotiation of any changes, meant that during April, with her husband away, the mother was engaged in conversations about medical intervention, and the children were directly engaged in professional communication.

”Moreover, the decision to allocate a case of such complexity to a newly qualified social worker is problematic, even if the team manager provided considerable support, as occurred in this case.”

The report recommends Kingston Local Safeguarding Children Board should ensure that the existing transfer protocol within achieving for children (AfC) is developed further to include transfer of cases between social workers within the same team.

Criticism of the family

Tania Clarence is described as “difficult” and it states social and medical professionals found her hard to deal with.

Her past as a designer is brought up and the report notes her desire not to turn the family home into a “mini-hospital” meant she was resistant to some medical equipment being in the house.

Care workers found Mr Clarence far easier to talk to at times.

The report states: “Professionals modified their usual working practices in order to accommodate the family. The family was not always easy to work with.

“The parents related in different ways with professionals and this meant that sometimes information was not shared with both parents at the same time.”

To combat this Kingston Local Safeguarding Children Board has commissioned training into working with families for multi-agency practitioners.

Timeline

July 2010: Twin boys Ben and Max are born prematurely while the family is on holiday in Portugal. This is the date the report starts from.

August 2011: The family moves from Merton to a rented house in Wandsworth.

September 2011: Merton social workers indicate no child protection concerns in their handover to Wandsworth Council. This is despite suggestions Mrs Clarence told a doctor she “wished her children were dead” at some time between August and December.

January 2012: There are concerns about Mrs Clarence’s mental health, but she turns down an offer to meet with a psychologist at St George’s Hospital when daughter Olivia is receiving treatment there.

October 2012: The family moves to New Malden.

November 2012: A Kingston social worker undertakes an initial assessment and notes Mrs Clarence is depressed, but refuses assessment or treatment.

February 2013: There are professional meetings regarding neglect and emotional abuse of Olivia. Care services are “on the brink of legal intervention”, but no definitive decision is made.

April 2013: Mrs Clarence is reported as shouting and crying in front of her daughter and says that her “life is hell” in front of nurses at St George’s.

June to July 2013: Concerns about Mrs Clarence tampering with her daughter’s oxygen equipment and turning off alarms are raised by St George’s staff caring for Olivia in hospital. Mrs Clarence admits turning off the alarm because it was waking her daughter.

August 2013: St George’s withdraws its statement of concern and the legal intervention is dropped.

September 2013: Olivia starts school.

February 2014: The Clarence’s experienced social worker is replaced.

March 2014: The twins start school.

Early April 2014: The new social worker visits Mrs Clarence for the first time and she is told that the social worker will undertake a “core assessment”. This was perceived as an “intent to go down the legal route again”.

Between April 20 and 23, 2014: Ben, Max and Olivia are smothered in their beds. 

What do you make of the case review? Call the newsdesk on 020 8722 6317 or email newsdesk@surreycomet.co.uk