The death of foster carer Dawn McKenzie, who was stabbed by her 13 year old foster child four years ago could have been avoided, because the company which placed the boy should have recognised that she and her husband were too inexperienced, a Sheriff has ruled.

The boy, known as Child D, had previously been regarded as a nice boy who was settling extremely well despite a very troubled background. But he became violent without warning after contact with his family led to him being grounded and having his Xbox console and mobile phone confiscated.

In findings from the Fatal Accident inquiry into the death of 34 year old Mrs McKenzie, of Hamilton, Sheriff David Bicket said of the agency, Foster Care Associates Scotland (FCAS) “They were the body who had knowledge of the potential foster carers.”

They knew the McKenzie’s background, that they were a childless couple with experience of looking after their nephew, temporarily, who was slightly older than Child D and without his troubled background. They knew that Mrs McKenzie’s experience – she had been a nursery nurse - was with children up to the age of five, and that it was the couple’s first foster placement.

He concluded: “The death of Mrs McKenzie, might have been avoided if Foster Care Associates Scotland, when considering if they had a suitable placement for child D ... had taken proper account of Mr and Mrs McKenzie’s status as new carers , and lack of suitable prior experience of adolescent aged children such as child D and accordingly had not recommended them as suitable prospective carers for [him].”

In his formal findings, Sheriff Bicket ruled that Mrs McKenzie’s death had been as a result of a stab wound to the abdomen, inflicted by the boy, who was detained for seven years in August 2012 after admitting culpable homicide at the High Court in Edinburgh.

He had stabbed Dawn ten times, including two blows to the head, one of which left part of the knife blade stuck in her skull.

Sheriff Bicket refrained from criticising the practices and policies of the agency Foster Care Associates Scotland (FCAS), which recruited the McKenzies and those of Glasgow City Council, which placed the boy with them.

However he backed the findings of child protection expert Kirstie McLean who told the FAI that the placement should not have been made. He said this was correct, highlighting a host of.

While they were seen as potentially excellent new foster carers the McKenzies agreed to take Child D partly because they feared ‘slipping down the list’ if they rejected the placement.

The FAI heard that Dawn McKenzie and her husband Bryan had just become foster carers when the 13 year old from Glasgow was placed with them in January 2011. The placement was rushed and badly handled due to the collapse of a previous placement and staff shortages and bad weather meant they received less support from social workers than they should have done.

They were also given limited information about Child D, who had had a very traumatic childhood and was a bedwetter who still had difficulty using cutlery.

Although he had apparently settled well, the teenager stabbed his foster parent with a kitchen knife after a series of events which included unplanned contact with his real mother using social media, and news that his father was not the same man he had previously been told, as well as the confiscation of computer equipment.

Describing Mrs McKenzie’s death as ‘tragic’, Sheriff Bicket said all foster carers should receive training in crisis prevention and intervention when they first started to look after children. “Whereas it cannot be said that such training would have made any difference in Dawn McKenzie’s case, in my view such training should be given to foster carers at the outset of their career, and repeated later.” he said

He recommended that new carers receive much better, accessible, written information about a child’s background.

He concluded that there was no reason why Glasgow City council should not have accepted, when FCAS offered the placement with the McKenzies. “Looking at matters from the perspective of the best interest of the child, not the carers, GCC acted appropriately in accepting the offer made,” he said.

Estella Abraham, chief executive of Foster Care Associates Scotland (FCAS) said: “Dawn McKenzie was highly regarded as a child care worker before becoming a foster carer with FCA Scotland.

“Sheriff Bickett has recognised that in a short space of time she made a positive contribution to a young person’s life. Today our thoughts are with Dawn’s family and Brian in particular and we wish to express our sincere condolences to them.”

She did not comment on the report’s finding that Mrs McKenzie’s death might have been prevented, but said: “The conclusion of the inquiry was that Dawn’s death was the result of an entirely unpredictable event.

“We will now reflect on the full findings and the recommendations made in the judgement.”

A spokesman for Glasgow City Council added "This has been an incredibly distressing case and our thoughts remain with Mrs McKenzie’s family.

“While Sheriff Bicket is clear that nothing could have predicted this tragedy, we believe it is appropriate to take time to give his findings the consideration they deserve, before commenting in any detail.

“A report that will consider the implications of the sheriff’s findings for the council and what action we require to take will be submitted to our children and families committee as soon as is reasonably possible.”

Dawn's death has already led to changes

Seven weeks after starting taking evidence, and after three months of deliberations, it is perhaps surprising that Sheriff Bicket’s recommendations after the Dawn McKenzie FAI are so limited.

He calls for more training, to make sure that all first time foster carers approved to take adolescents, or children in ‘middle childhood’ receive crisis prevention and intervention training, before they start.

He recommends improvements to the way foster carers are assessed and an end to the use of broad age ranges when matching children with suitable families.

And he says prospective foster carers should be given as much written information as possible in a digestible format, about the child who is being placed. This is a response to confusion over what the McKenzies were told about Child D: with a lot of information conveyed verbally, in a single informal meeting at which no notes were taken.

However the sheriff also pointed out that many of the recommendations he might have made have already been made by the serious case review commissioned by Glasgow City Council and FCAS.

This was carried out by experienced social work chief Colin Anderson and its findings included a need for Glasgow City Council to plan better to cope with organisational change, staff sickness and turnover, so they does not impact on services for vulnerable children.

Following that review, agencies have been urged to review the way they deal with unusually well-behaved foster children, especially where that good behaviour is not in line with what would be expected, based on their previous upbringing.

Social workers and Children’s Hearings Scotland have been asked to look at how contact with parents can be realistically restricted in an age when children have access to social media and networking sites.

FCAS was also advised to look at staff turnover issues, the way it assesses the age-appropriateness of placements and training needs.

Although FCAS has disputed the need for training in crisis prevention before children are placed with foster carers, Sheriff Bicket backs this finding from Mr Anderson’s report and reiterates the demand.

Meanwhile a Scottish Goverment foster care training review is currently being carried out by the Scottish Social Services Council.

This will now take on extra significance, particularly in the light of recommendations by sheriff Bicket about training and the problems caused by social media.