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Events leading to the death of an eight-year old child in Helsinki in May 2012

A child was born to a couple living in Helsinki in 2004. Soon after the birth, the child's parents moved to separate addresses, with the child staying with her mother. In 2010, the child's custody was transferred to her father because of the mother's mental health problems and substance abuse. The child moved to live with her father and the father's female companion. Evidence from this period suggests that the child was subjected to sustained physical and psychological violence. This violence eventually led to the death of the child in May 2012. The emergency medical services, the rescue services, or the police had no immediate opportunity to affect events on the night of the death.

The father's and his female companion's backgrounds were not sufficiently checked before custody was transferred. The father's prior history included alcohol abuse, a sex offence and disorderly behaviour during the child´s first months. Soon after he became sober. His female companion was living under a false identity, had a history of mental health problems and had lost the custody of her own children. Standard procedures for the clarification of circumstances in a home should be adopted, to ensure that certain checks are performed before the decision is made on where a child should live. At a minimum, such procedures should include background checks on the people living in the home and the compilation of information from various actors such as the police, the school and health care officials.

After the child was placed in her father's custody, concern for the child's well-being was expressed from several quarters. Neighbours, the school, the meeting

location for the child and her mother, and the child's mother signalled their concern and filed child welfare reports. The police were not notified, probably partly because information on the child had not been collected, leaving the gravity of the situation unrecognised.

Information on the measures taken by various parties with regard to the child was not shared by other involved parties, reflecting insufficient cooperation between authorities. Furthermore, at the various levels of the health care system, insufficient efforts were made to check whether or not the child was being subjected to violence. All of the above gives the impression that the various actors had no clear idea of their duties as support providers for child welfare. While child welfare authorities bear overall responsibility for a child placed under their care, the other actors must have a clear notion of their duties as support providers for the child welfare system and there must be a low threshold for triggering interaction within this system.

It appears that the idea of supporting the family, parental rights and the family's right to privacy, overrule the child's interests in a decision-making situation. In this particular case, the child's views were not heard in a proper and well-balanced manner. The child's own experience was mostly conveyed to the authorities indirectly, with adults acting as intermediaries. Several surveys have highlighted flaws in the ability of the social services and the health care system to recognise violence directed at children and to intervene. Family centre personnel, school health care staff and other health care professionals need clear guidelines for recognising and dealing with signs of child maltreatment. Teachers, kindergarten teachers and other people working with children should also make themselves familiar with such guidelines.

Standard procedures should be created for the child welfare system, enabling personnel to report on observed deviations and errors. Such reports should come under systematic scrutiny, for example, in the co-operative working group referred to in the Child Welfare Act. The procedure should be aimed at providing information for the further development of child welfare.

By Western standards, Finland shows high levels of domestic violence that ends in fatalities. However, insufficient lessons have been learned from violent incidents, because there is no obligatory systematic multi-professional inquiry, only criminal investigations. A system should be adopted for gathering information on all cases of serious domestic violence, including regular reporting on such cases and the presentation of any conclusions that can be drawn.

Events leading to the death of an eight-year old child in Helsinki in May 2012, in Finnish (pdf, 0.7 Mt)

Published 11.6.2013