This essay centres on the tragic killing of Antoine, aged 10, and Keneice, aged 3 by their mentally ill mother. The Gamor Serious Case Review (Hackney LSCB 2008) states that no further action on the part of the social workers could have prevented the killings and this essay will examine whether other social work interventions could have made a difference to the terrible outcome of this case. exists plenty of policy and multi-agency guidance which seek to provide direction to social workers in their duties and to what extent they can intervene in cases which they consider to be a real and significant risk to children. This essay will also consider what interventions should be allowed to respond to the needs of the adults of the family. When examining vulnerable individuals, it is easy to immediately think of children, but adults with learning and mental difficulties are pose a risk to others and themselves (Scrag, 2011: 6).

The Gamor Serious Case Review

The Gamor Serious Case Review (Hackney LSCB, 2008) centres on Vivian Gamor, who was the mother of both Antoine and Keneice. She had been looked after by social services since the age of 14 and suffered from paranoid schizophrenia. During an unsupervised visit in January 2007, she killed her children by use of a claw hammer and suffocation. In August 2007, she was convicted of manslaughter by way of diminished responsibility and was sent to prison for an indefinite period. The fact that Ms Gamor was suffering from paranoid schizophrenia ensured that she should have been the subject of a risk assessment by the social workers prior to any visits by her children according to policy guidance. This is only one power of intervention available to social workers, as it will be shown. There was an Inquest into the death of both children and a verdict of unlawful killing was delivered by the Coroner. The Coroner was heavily critical of the role that social services had played in this case and criticised Hackney LSCB for its, “serious and cumulative failures” in allowing the unsupervised visits (Taylor, 10 December 2012). Therefore it is somewhat surprising that the Gamor Serious Case Review (Hackney LSCB, 2008) declares that no single action could have prevented the deaths. The Coroner went on to say that the social services board had suffered from, “a catalogue of failures on the part of several incidents in mental health and social services” (Taylor, 10 December 2012). One of the main reasons for this criticism was that social workers had failed to carry out an adequate risk assessment on Ms Gamor before allowing her overnight visits with the children. Also, it was upsetting for the children’s father to hear that the social workers had made the decision to close the case days before the death. Social workers are under a statutory duty to undertake risk assessments, both for the safety of the children and the vulnerable adults. They are pivotal in ensuring the welfare of the children is put above any other considerations.

The Gamor Serious Case Review (Hackney LSCB, 2008) stated that following a thorough and efficient investigation of the case, it was decided that the father’s considerations should have been taken into consideration. For example, Ms Gamor had completed successful contact visits with the social workers and voiced her proposals to live with the children and the father should have been asked for his attitudes towards further contact. According to Judge Peter Rook QC, “This terrible tragedy could have been avoided if Gamor had not been allowed unsupervised access and the children’s father’s grave concerns had been given weight.” (BBC, ‘Failures allowed mother to kill). The main failure of the social workers was not adequately assessing the risk posed by Ms Gamor. The City and Hackney Local Safeguarding Children Board said that the underlying reason for the failure by the services was a “mismanagement issue” which allowed the overnight visit (Gamor Serious Case Review, Hackney LSCB 2008). Furthermore, interventions should have been made such as supervised visits and ensuring that Ms Gamor’s psychology treatment was kept under control.

The Children Act 1989

The Children Act 1989 is the main piece of legislation in this area. Section 47 of the Act imposes a statutory duty upon professionals who are working with children to take the necessary steps to preventing children from harm. This also encompasses the responsibility to ensuring their welfare. This was a requirement not fulfilled by those social workers looking after Ms Gamor, and often this section will be used as a basis for justifying any intervention by social services. In addition, section 17 of the Act provides that a similar statutory duty is placed upon every local authority in the country to safeguard and promote a child’s welfare. This is often known as the preventive action when a child is thought to have been at risk. What remains the most important factor in the Act is section 1, which outlines that the child’s welfare is paramount and this overrides any other consideration. Whenever social services are intervening to protect a child, this is the section that often all protective orders are based upon. A protective order should have been obtained in this case which would never have allowed Ms Gamor the opportunity to look after the children overnight in an unsupervised environment.

The Statutory Guidance outlines the threshold for intervention by social workers which is, “that everybody who works with or comes into contact with children should be able to recognise and know how to act on evidence that a child’s health or development is, or may be, being impaired and especially when they are suffering or likely to suffer significant harm.” (Working Together to Safeguard Children, 2006).

By reaching this threshold, social workers can then make referrals for a section 47 child protection investigation and also important for the Gamor case, section 47 encompasses an investigation on ‘Persons who pose a risk to children.’ This should ensure an adequate risk assessment is taken of the child and the parents, which was clearly not done in this case as Ms Gamor’s case was closed prior to the killings (Hackney LSCB, 2008). Upon completion of the investigation, if the risk to the child is deemed high enough, then with parental consent, a section 20 order can be applied for to accommodate the child. However, if the risk to the child is thought to be of immediate and high risk then police protection can be applied for, along with an application for a section 44 (Emergency Protection Order) or a section 38 (Interim Care Order). As the guidance says, “Assessment is a key role in social work” (Birmingham City Council, ‘Children’s Social Care: A Guide for Family Support Workers in Children’s Centres’) and this lies at the root cause of the Gamor case. It can be argued that the children’s father would have consented to intervention by the social workers, and this should have prompted the social workers into action by ordering a section 47 or 44 order. However, evidence is required in order to apply for a protective order described above and the Serious Case Review argues that the Hackney Children and Young People’s Service did not have any such evidence for an intervention. Instead, the Review pointed to positive contact meetings and that it is why the decision to close the case was made. Instead, the report emphasises the responsibility the East London & the City Mental Health Trust should bear in this case (Gamor Serious Case Review, Hackney LSCB 2008). This highlights how important it is to undertake risk assessment on adults, especially those with mental illnesses. The Report argues that the signs were there that Ms Gamor suffered from a mental illness by saying that her children had been still born and these children were not hers. Such behaviour is arguably concerning at the least, and these delusions should have ensured the social workers assessed her psychological state. This is part of the risk assessment that the social workers can do to protect children and ensure they are in safe hands.


This essay has examined in detail the Gamor Serious Case Review (Hackney LSCB, 2008) and looked at the main piece of legislation in this area, namely the Children Act 1989 to discuss what social work interventions might have been in place to protect the children and Ms Gamor herself. As it was shown, risk assessments did take place for the family but a combination of mismanagement and disorganisation ensured that this was not adequate. Furthermore, the decision to close the case days before the killings shows that more action was required and that the interventions open to the social workers were not taken. In this tragic case, it is hoped that the Hackney Children’s and Young People’s Service can listen to the recommendations of the Report and take immediate action to ensure a similar devastation does not happen again (Ofsted, 2010 ‘The voice of the child: Learning the lessons from serious case review’).


BBC, (17 July 2008) ‘Failures allowed mother to kill’ Available at: Children Act 1989 Birmingham City Council, ‘Children’s Social Care: A Guide for Family Support Workers in Children’s Centres’ (March 2011) Available at: Department for Education, (2006) ‘Working Together to Safeguard Children’ Gamor Serious Case Review (Hackney LSCB 2008) Ofsted (2010) ‘The voice of the child: Learning the lessons from serious case review’ Scrag, T. (2011) Safeguarding Adults in Social Work (Transforming Social Work Practice) Exeter: Learning Matters Taylor, D. (10 December 2012) ‘Hackney social services condemned over failures after mother kills children’ (The Guardian) Available at: