An inquiry into the circumstances leading to the manslaughter of a 24-year-old man by a 14-year-old girl has found “a failure of the system as a whole” to protect her and her victim. The child safeguarding practice review by Birmingham and West Sussex authorities found that the systems put in place to help the child throughout her troubled life had had “no effect at all”. No one involved in the case can be named to protect the identity of the girl. The parents of the victim, described by investigators as “a young, innocent man” told the Guardian they believed the death of their son was “absolutely avoidable”. They said the review highlighted “multiple and sustained failings by a range of state agencies throughout the entire life of the girl”. The report said it was rare for children to kill and that it was “the rarest phenomenon of all” for a girl to kill an adult. The girl, referred to in the report as Child A, killed the man, who had been having a relationship with her mother for a few months, in October 2020. The man, described in the report as “kind and gentle” did not live with the mother and daughter. The girl said after she had killed him, that she saw him as a positive influence in her life. The girl spent most of her life in Birmingham and had only moved to West Sussex a few months before the killing in April 2020. She pleaded guilty to manslaughter due to diminished responsibility in July 2021. The report said: “Child A is more than a perpetrator of a terrible crime. She is also a vulnerable child who has been a victim of significant and horrific trauma and abuse on her short life.” The girl’s problems began even before she was born, when her young mother was a victim of domestic violence. Some of the incidents highlighted in the review include the girl trying to smother her three-year-old half-brother. She had a track record of repeatedly going missing, was found to be carrying a knife at the age of 12 and was a victim of serious sexual assault in 2019. She had been cautioned for common assault of a police officer and possession of a knife, and had been linked to addresses known for gang and gun activity as well as child exploitation and modern day slavery. The girl was remanded to a secure unit after stabbing her mother in the leg and setting fire to her bedroom but was released back to her mother’s care although she made further threats to stab her. The report states: “In 2019, after the significant assault, child A was known to be overwhelmed by the number of services and professionals involved.” The report found that there were “many missed opportunities to protect her and there was no evidence that the systems put in place to protect her had any effect at all”. “It is the opinion of the review that systems in place to protect such vulnerable children were ineffectual.” “There is little evidence that, despite significant input and undoubted time and effort, partnership intervention had any positive effect over Child A’s lifetime.” Child A was the subject of numerous types of multi-agency support plans, education health and care plans, child in need plans and child protection plans. The victim’s parents told the Guardian that it had compounded their grief that they are unable to name their son publicly and pay tribute to his too short life. His mother said: “We understand that the girl has the right to be protected but where are our rights and our son’s right to be remembered. Our son had a massive heart. He was happy, cheeky, smart and a very sensitive soul. When he was younger he wanted to change the world.” She added: “We were told there were 6,000 pages of documents about the girl in her file. That’s more than one page for every day of her life until she killed our son.” His father said: “The pain and grief we’ve suffered in the last few years is immense beyond belief. As time goes by I feel worse not better. I feel there has been a massive lack of care and compassion for us who have lost our son. “We understand that the girl will be released soon but we haven’t been told what protections will be put in place to ensure that nothing like what she did to our son can happen again. We want justice.” His mother added: “Children are our future but the mental health services for them are just appalling. We are worried that when the girl is released something might trigger her to do something terrible again. The system is completely broken and we have paid the highest price for that. It is not fit for purpose and it needs to be overhauled.” Community activist Stafford Scott, who is supporting the victim’s family, said: “This is an incredibly distressing and unusual case where a young, innocent man lost his life and his family lost him from their lives for ever. It is rare for a child to commit such a serious crime against an adult; even rarer when that child is a 14-year-old girl. This man was a good Samaritan who walked into a nightmare scenario and paid the price with his own life.” In a statement accompanying the report Penny Thompson,
independent chair
of the Birmingham safeguarding children partnership, and Chris Robson,
independent chair
of the West Sussex safeguarding children partnership, said: “This report will help us to learn and improve our practice; it does not seek to apportion blame or examine culpability. There were missed opportunities by services involved with the family, who didn’t fully understand her lived experience and the impact of childhood trauma.” They added: “The review acknowledges the extensive range of professionals who worked with this child and family; however, despite professionals’ efforts, the processes and plans in place did not result in a positive relationship with the family. This meant that professionals did not gain a sound understanding of safeguarding risks and effective mitigations or interventions, which would have resulted in an enduring positive impact for this child and her family.”