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The coroner particularly pointed to issues in recording risk assessments and failures in finding adequate placements for children, after Marcia Grant was run down by a child in her care.
Transcript
00:01These past two years have been deeply distressing for us as a family.
00:05We have been on an agonising journey to uncover the truth behind the events and systemic failings
00:11that led to the death of our beloved mum, Marcie Grant.
00:16What has become evident over the last few weeks leaves us with no doubt that our mum
00:21was failed, our family was failed, and so too the foster child that was in our long-term
00:27care.
00:29It remains a source of deep sorrow and frustration that senior leadership within the council
00:34has consistently refused to acknowledge their own accountability despite being fully aware
00:40of the risk history of Child X and our mum's own needs as a foster carer.
00:46They chose to look away, take no responsibility and to make no meaningful change for carers
00:52after her, our mum's death.
00:57We wholly welcome the coroner's findings that our mum was failed on numerous fronts,
01:02and that these failures directly contributed to her death.
01:07however, whilst this leaves us with a sense of vindication, it also serves to reinforce to
01:14us how badly she was failed.
01:18If not for these failures, our mum would still be here with us today.
01:23Our mum was dedicated to protecting vulnerable people, she did so with strength, compassion,
01:29and an unwavering sense of duty.
01:33Yet when it mattered the most, the same system she gave so much for did not protect her in
01:38return.
01:39She deserved better.
01:40She deserved better.
01:41We all did.
01:43I'm going to check the spelling of your name, Sean, is it S-E-A-N?
01:47S-H-A-U-N.
01:48S-H-A-U-N.
01:49S-H-A-U-N.
01:50Your mum sounds like she would do anything to help anyone.
01:55She couldn't refuse a child in need because she seems to be that kind of person.
01:59All she wanted to do was help, but she didn't know what she was being brought into.
02:04It was not disclosed to her what she was being brought into.
02:08And had she would have known, based on what previous breakdowns that she'd had in other
02:13children that she had in her care, she wouldn't have known.

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