Recently published case reviews

Case reviews published in 2024

A list of the full overview reports and executive summaries added to the National Case Review Collection. To find all published case reviews search the national collection.

Case reviews describe babies', children's and young people's experiences of abuse and neglect. If you have any concerns about children or need support, please contact the NSPCC Helpline on 0808 800 5000 or emailing help@nspcc.org.uk.

2024 – Anonymous - Child J1 and J2

Admission to hospital of a 4-week-old infant in December 2021, presenting as blue and floppy. Concerns were raised with regards to parental drug use, attachment and a delay in parents accessing medical support for poorly children.
Learning themes include: information sharing across the health economy; neglect of child health care; registering children with GPs; discussing cannabis use with families; and the impact of cannabis on children/parenting.
Recommendations include: the partnership request assurance from maternity services around the notification processes to GPs and health visitors; the partnership seek assurance from paediatric services that information sharing robustly takes place between GPs and health visitors; the primary care team work with practices to develop a standard response to children missing immunisations; the partnership seek assurance that meetings are happening between GP’s, health visitors and midwives to support information sharing where concerns are identified for children; the primary care team make enquiries to see if the data on unregistered patients is shared and if this has been considered as a possible safeguarding risk previously; and Turning Point review their resources and develop them into a response to this review to consider the impact of cannabis use on parenting and how to discuss the use of cannabis with parents.
Keywords: premature infants, medical care neglect, non-attendance, drug misuse, neglecting parents
> Read the overview report

2024 - Anonymous - DHR

Murder of a female adult victim by her former partner. A child born to the victim and perpetrator was placed with the perpetrator and his then partner under a Child Arrangement Order (CAO). Concerns were shared that the perpetrator exploited the placement of the child with him to manipulate and control the victim.
Learning includes: the need for enhanced professional awareness of the potential for CAOs to be exploited or subverted to coerce or control individuals who are a party to the CAO; the impact of loss of custody or restrictions on contact with children on the mental health of females who have experienced domestic abuse; the need for professionals to consider both the victim and the perpetrator’s prior domestic abuse history when assessing risk and making referrals; raising awareness of the Domestic Violence Disclosure Scheme (DVDS); where there are concurrent safeguarding children and domestic abuse concerns, the importance of not overlooking the needs of parents who are suffering domestic violence and abuse.
Recommendations include: the relevant children’s services to review arrangements for the grant of CAOs in which children’s social care are involved, to consider the response to indications that the CAO may be breaking down, and the notification of the CAOs to partners, particularly primary care; and for children’s services to ensure appropriate emotional support is offered to parents whose children are removed from their care.
Keywords: residence orders, child protection, children in violent families, separation [mother-child], partner violence, children’s services
> Read the overview report

2024 – Barking and Dagenham – Child F

Death of a 9-month-old baby in Autumn 2018. Child F had a head injury consistent with shaking. The child’s mother was 18-years-old, separated from the father and had a history of adverse childhood experiences.
Learning themes include: responding to risk to babies both before and after their birth; assessing parenting capacity of a vulnerable young parent; unseen men; and coordination of effort between services and information sharing.
Recommendations to the partnership include: all training should include clear guidance about the importance of gathering social history information from parents, checking agency records and making an assessment of all adults involved in the care of young babies, especially new partners; review and revise the existing multi-agency guidance about supporting and assessing the parenting capacity of young vulnerable parents to clarify what factors would heighten risks and which would serve as protective factors for their child; and undertake a multiagency review of the effectiveness of partnership working with parents with high needs, particularly those families of vulnerable children under two years to ensure that there are more effective joint responses, information sharing and systems to support parents and to safeguard children.
Keywords: adolescent mothers, adverse childhood experiences, infant deaths, non-accidental head injuries, parenting capacity, shaking
> Read the overview report

2024 - Bath and North East Somerset - Skye

Suicide of a 17-year-old girl in March 2023. Skye had a range of physical and psychological needs. She had been subject to a full care order since she was 15-years-old, and was living in a residential home in Scotland at the time of her death.
Learning themes include: understanding a child’s world; support and protection for children in care; and transitional arrangements.
Recommendations to the partnership include: ensure records of practitioners’ visits to children evidence the views, wishes and feelings of the child; highlight to the National Panel the impact of placement sufficiency issues in individual local areas upon children with complex needs, and upon children placed in areas under different legislative jurisdictions; seek an action plan which addresses how, when children with complex needs are placed out of area, information sharing translates into a coordinated single agency and multiagency risk assessment and plan, and outlines the therapeutic approach to young adult mental health services for those reaching 18-years-old who require specialist interventions to support them in the transition to adult services; use the new virtual school tracking system to ensure educational outcomes are progressed for children with complex needs who have been placed out of county; ensure effective use of escalation procedures by all partner agencies; ensure all procedures focus on ensuring impact for children; and develop a transitional planning group which pays particular attention to children with complex needs and recognises the need for preparing for adulthood work to start at 15-years-old or earlier.
Keywords: children with a mental health problem, children with multiple disabilities, placement, participation, suicide, transition to adulthood
> Read the executive summary

2024 - Berkshire West - Alex

Serious accidental injuries to a 7-year-old boy whilst in the care of his mother in February 2021. Alex’s mother failed to seek medical treatment and the consequences could have been life threatening. She has since been prosecuted for neglect.
Learning themes include: how agencies work together; making and responding to referrals; response to neglect and substance misuse; consideration of the role of the stepfather; risks and protective factors; consideration of child’s identity; and the impact of Covid and other organisational issues.
Recommendations to the partnership include: arrange a multi-agency audit that considers the effectiveness of the service provided to children who are referred to Children Single Point of Contact (CSPoA) late in the day where there are potential concerns about significant harm; arrange a multi-agency audit regarding whether fathers’ names and dates of birth are being recorded by practitioners, including mother’s presenting for antenatal care and all referrals to CSPoA; seek evidence from social housing providers that they will contact CSPoA if they become aware that any utilities for a household containing children may or have been disconnected; address any challenges that frontline practitioners experience in identifying whether a child protection medical is required and then offering and/or securing one; seek assurance from the police that they will ensure increased oversight of the use of police powers of protection, and that they will continue their ongoing partnership intelligence sharing pilot, and arrange for a multi-agency appraisal of the pilot at the conclusion, whose findings will be shared with the MASH board partnership.
Keywords: addicted parents, child neglect, drug misuse, injuries, interagency cooperation, step-parents
> Read the overview report

2024 – Bexley – Baby Y

Serious non-accidental injuries to a 9-month-old baby in July 2022. Adult A, the partner of Baby Y’s mother, was arrested on suspicion of causing the injuries.
Learning considers: assessment of neglect; physical and mental ill health in the family; parents’/carers’ background and history; issues of domestic abuse; ethnicity and issues arising from intersectionality and diversity; working with uncertainty and gut feeling; working with fathers and other significant males; and assessing risk to children from men who join vulnerable families.
Recommendations include: to oversee the completion of an evaluation of the use of the multi-agency neglect toolkit; to develop a seven minute briefing and tips for practitioners about how to act on gut feelings and professional curiosity; to seek assurances from all member agencies that their training strategy includes awareness raising about the importance of including fathers and other male family members in assessments and ongoing work; and to ensure that professionals have the knowledge and understanding of intersectionality to identify and consider issues around families who experience multiple oppressions and disadvantage, when assessing and managing the risk to children.
Keywords: neglect identification, injuries, infants, family violence, unknown men, professional curiosity
> Read the overview report

2024 – Birmingham - Breaking the cycle: BSCP 2022-23/02

Death of a 16-year-old male in the summer of 2022, by a stab wound to his chest. The police commenced a murder investigation. One of the individuals was a 16-year-old male who following trial received nine years imprisonment for manslaughter.
Learning themes include: governance of serious youth violence; assessments -  traditional safeguarding, child criminal exploitation (CCE) and serious youth violence (SYV); place; trusted adult mentoring reachable moments; and unregulated premises.
Recommendations include: that all relevant statutory and voluntary sector organisations at both strategic and operational levels are committed and actively involved in the long-term implementing of the reducing serious violence strategy; all strategic leaders, managers and practitioners understand their role in preventing SYV; there is a need for individual children that may be at risk of SYV (either as a victim or perpetrator, or both) to be identified at the earliest opportunity; review the current screening tool so that they ensure that they pick out SYV where it is a separate risk to CCE; develop a model that looks at alternative but complementary pathways for SYV and CCE to those that are currently used in child protection cases if they are deemed not suitable for an individual child; a lead professional in place to coordinate multi-agency activity for children who are at risk of SYV; support education efforts to raise awareness of the dangers of knife crime in secondary, primary schools and in those settings providing alternative school provision; and awareness of the range of community-based support within neighbourhoods and availability of mentoring services across the city and their effectiveness in supporting children at risk of SYV and CCE.
Keywords: gangs, child criminal exploitation, drugs, mentoring, risk assessment
> Read the overview report

2024 – Birmingham - BSCB 2018-19/01

Life changing injuries to a 3-year-old child in November 2017 whilst in the care of their parents. Evidence was found of old fractures and bleeding on the brain. After two years in hospital the child was discharged to parents. Mother was found guilty of child neglect in July 2020.
Learning points include: assessments of parenting capacity to fully consider the impact of the experiences of asylum seekers in their countries of origin and the potential for post-traumatic stress disorder and potential isolation in the UK; the need for professionals to understand national and local asylum seeking systems and processes, the role of the Home Office and contracted services, and local arrangements for support; the importance of early help to support first-time parents facing complex challenges and the need for comprehensive and holistic assessments; health professionals should consistently follow the ‘was not brought’ policy and inform social workers involved with the child concerned; the need for robust discharge planning for premature babies and children with complex needs; when children present with unexplained or suspicious injuries, professionals to exercise professional curiosity, healthy scepticism, respectful uncertainty, and work to avoid assumptions and the rule of optimism; following child protection procedures when a child is in hospital with a non-accidental injury; timely progress of plans to initiate care proceedings; and the importance of effective multi-agency communication between children’s social care and hospital providers, including the appropriate level of supervised contact for parents with their child in hospital.
Recommendations are embedded in the learning points.
Keywords: child neglect, injuries, non-attendance, asylum seekers, parenting capacity
> Read the overview report

2024 – Birmingham - BSCP 2019-20/01

Death of a 3-month-old baby in May 2019. The baby was found deceased, and it was apparent that death had occurred significantly earlier. Both parents were arrested on suspicion of neglect.
Key learning points include: practitioners, including those working with adults, should be familiar with expectations and requirements in respect of information sharing in line with ‘Right help, right time’ guidance; there should be arrangements in place for effective communication between HMP offender managers, sex offender managers, and all other relevant agencies on the release of a prisoner who may pose a risk to children; all agencies working with men need to consider whether those men have children in their lives, or a pregnant partner, and the strengths and risks the individual may present to those children to inform what action should follow; probation are a key partner within MASH to help facilitate effective information sharing and coordination of support; the exchange of information within MASH should receive prompt responses from all agencies to enable professionals to make timely and proportionate decisions; the early help and support arrangements should highlight the importance of the lead professional role in coordinating the work of agencies involved with the child and the family; the quality of referrals should be consistent with sufficient understanding of the ‘Resolution and Escalation Protocol’; all professionals working with children and their families need to have some understanding of substance misuse and the barriers for parents/carers being honest about their drug use; and children and their families must be a priority for housing providers.
Recommendations: N/A
Keywords: addicted parents, child neglect, disguised compliance, heroin, infant deaths, probation service
> Read the overview report

2024 – Birmingham - BSCP 2020-21/01

Serious head injuries and bruising to the body of a 1-month-old infant in June 2020. These were believed to be non-accidental, and possibly because of a shaking incident. Agencies were involved soon after the baby’s birth when there was a witnessed episode of domestic abuse at the hospital. Following a criminal trial both parents were found guilty of causing or allowing serious physical harm to a child.
Learning themes include: assessment in the pre-birth period and planning support for after birth; the initial response to domestic abuse and strategy planning; attempts at escalation and professional challenge; and early help assessment and response to domestic abuse following discharge.
Actions taken to improve the following areas of practice: MASH Health practitioners are able to access both parents’ GP health information when screening referrals; strengthening the engagement, referral and assessment of fathers during pregnancy and infancy; improved response to parental conflict, coercive control and domestic abuse in pregnancy and infancy to ensure consistent agency responses to domestic abuse; increased support for parents where parental neurodiversity, learning disability and emotional dysregulation may impact on parental capacity using a ‘Think Family’ approach, through appropriate policies, procedures and training provision; practitioner understanding of the effect of adverse childhood experiences on parenting ability and use of trauma informed approaches in interventions; practitioners’ understanding of confirmation bias as well as their application of professional curiosity; and ensuring the timeliness of information sharing, accuracy of information in referrals and understanding of parental history is embedded in practice.
Keywords: adolescent mothers, adults with a learning disability, domestic abuse, newborn babies, non-accidental head injuries, shaking
> Read the overview report

2024 - Birmingham - BSCP 2021-22/01 (the child)

Disclosure of physical abuse at home by a 14-year-old girl in June 2021.
Learning themes include: barriers and enablers to enhancing cultural competency and confidence; effective engagement and support for children in elective home education; responding to allegations of physical abuse; how understanding historic and contextual information enhances decision making and assessment of risk; and maximising protective factors by engaging communities in safeguarding children.
Recommendations include: ensure that all frontline safeguarding professionals have the necessary skills, experience and confidence to work with and support children and families of all cultures, faiths, backgrounds and communities; provide training, resources, support and supervision to enhance professionals’ cultural knowledge and confidence; make it mandatory for tuition centres to register with Ofsted and strengthen the formal engagement and information sharing between local authorities and tuition centres; ensure that the child protection medical assessment pathway is always adhered to and monitor its effectiveness; ensure that all relevant agencies are consulted on whether sustainable change has been demonstrated before closing a child protection case; and promote a cohesive community and agency response to physical abuse by increasing engagement with minoritised communities through relationships with religious leaders, faith organisations and community groups.
Keywords: abusive parents, assessment [social work], culture, physical punishment, physically abused children, religion
> Read the overview report

2024 – Bradford - Children B and C

Removal of a 10-year-old boy (Child B) and his 9-year-old sister (Child C) from their home in July 2022. Officers were so concerned about the presentation of Child B and poor home conditions that they exercised their powers of protection and took the children to hospital. Child B was found to be severely dehydrated and malnourished. It was subsequently discovered that he had an extremely rare and undiagnosed chronic health condition.
Learning themes include: parental consent; stepping cases up and down between early help and children’s services; the recognition of neglect; working with parents and carers who are resistant to accepting services and working with professionals; educational neglect; issues around monitoring the health of young children and distinguishing when medical concerns become safeguarding concerns.
Recommendations to the partnership include: undertake further work to overcome the barriers in sharing information about parents and carers as well as children in the ‘Integrated front door’ screening process; consider how to further promote the use of genograms and chronologies by all agencies; review how much detail about referrals is shared by social workers with other agencies in the screening process and when assessments are completed to ensure that professionals working with a child are fully aware of the risks and needs reported; assure itself of the take up and implementation of the neglect toolkit in practice and to include educational neglect in more detail when it updates the neglect strategy; and implement a strategy to improve take up of training (particularly by social workers).
Keywords: assessment [social work], bodyweight, child growth, child health, child neglect, education
> Read the overview report

2024 – Bristol - Quality of child protection investigations

Death of a 4-month-old child in December 2022 which was determined not to be the result of abuse or neglect. The family had previous periods of agency contact including early help, child in need and child protection involvement with the older siblings. Explores key barriers and system pressures that impact on achieving consistently good quality child protection investigations.
Learning includes: professionals involved in the initial stages of child protection investigations want to work together more efficiently and more effectively; chairing of strategy discussions is seen as critical to the initial stages of achieving consistently good quality child protection investigations; a call for greater knowledge and skills about how to conduct multi-agency child protection investigations; a need for mapping and explaining the different agency roles and responsibilities; and the development of quality standards, or descriptors relating to the child protection process could be helpful to the multi-agency network.
Recommendations include: seek assurance that there is information and data available which supports the regular review of the quality and standard of child protection investigations; the development of a three to five year workforce strategy specifically for those professionals involved in child protection work; compile a selection of analysis tools to support practitioners and managers achieve stronger analysis for use from the point of strategy discussions onwards; and develop a resource, which easily explains the different agency roles, responsibilities and expectations.
Keywords: infant deaths, interagency cooperation, staff development, information sharing, organisational behaviour, training
> Read the overview report

2024 - Calderdale - Child P

Significant injuries to a 3-month-old infant boy in April 2018 whilst in the care of his parents. Child P’s mother had longstanding mental health problems, with the family receiving support from a range of agencies since her first pregnancy.
Learning considers: the impact of parental mental health; the effectiveness of early intervention co-ordination and planning; child-focussed practice; and the role of the father and other adults in the home.
Recommendations include: remind partner agencies of the need to consider the potential impact of the birth of a subsequent child to a family about which there are prior concerns and to ensure that support needs are acted upon promptly; emphasise the importance of fully assessing the risks that parental mental health could present to children in the household, ensuring that single and multi-agency policy, systems and training supports the assessment of such risks, and obtain assurance that adult mental health services always give priority to the child’s needs when considering risk; obtain assurance that the provision of early help is timely, addresses all needs and is managed robustly to avoid drift; examine the issue of how the lead agency/practitioner for early help is decided upon and, where necessary, reviewed; remind agencies of ‘hidden male’ research findings with a particular focus on raising awareness in adult services; seek assurance that the perinatal mental health pathway includes sufficient focus on parenting capacity and that knowledge of the pathway is promoted by the local NHS foundation trust; and the local NHS foundation trust to update guidance to practitioners on the safety of breastfeeding whilst the mother is taking medication.
Keywords: infants, injuries, maternal depression, psychoses, early intervention, postnatal care
> Read the overview report

2024 – Cardiff - CPR 03/2019

Infant girl was admitted to hospital in April 2019 with bruising to her neck and jaw area with an initial medical assessment of acute, severe hypoxic ischaemic brain injury, with CT imaging showing features of physical abuse. The child survived the injuries but is likely to live with the effects of lifelong brain damage as a result.
Learnings is embedded in the recommendations.
Recommendations include: assurance that practitioners and relevant partners, understand their duty to report children at risk, by confirmation that the referral documentation is fit for purpose by ensuring that all known relevant information regarding the child and the family is provided with sufficient detail to enable the receiving team to consider the impact on the child; practitioners reviewing a referral into children services should consider the current referral within the wider family context, including previous referrals/assessments and case notes as well as actuarial risk factors; practitioners are aware of their duty to request specialist medical examination of all injuries of a non-mobile child and that clear referral pathways are maintained to avoid delay; practitioners understand the association between domestic abuse and child abuse and are aware of their organisation's policies and procedures in relation to domestic abuse; understand the association between parental non-engagement and unwarranted lack of consent and child abuse and review their organisation's policies and procedures in relation to working with families with such risk factors; understand the association between the parent's vulnerabilities and child abuse and review their organisation's policies to ensure such vulnerabilities are considered as part of the assessment process; and develop guidance for practitioners on describing and recording home conditions that pose a potential threat of harm to children.
Keywords: brain damage, cleft lip and palate, health visitors, non-attendance, physical abuse
> Read the overview report

2024 – Cheshire East – Child L

Disclosure of sexual abuse of a 13-year-old girl in 2022 by a known sexual offender. At the time of the incident, Child L was subject to an interim supervision order and a child protection plan and had previously made three allegations of rape and sexual assault outside of the home.
Learning themes include: appreciating the child's lived experience and the cumulative impact of adversity, harm, and trauma; listening to children and young people who make disclosures of abuse with intent to take action; ensuring systems and practice are domestic abuse aware and trauma-informed; recognising the safety that school can provide for children experiencing intra and extra-familial harm; increased awareness of the signs of child sexual exploitation and processes to access specialist guidance and support; and developing a whole family response to support understanding of risk where there are complex adult issues.
Recommendations to the partnership include: consider how it can strengthen practitioner skills that enable the child’s voice and experiences to be listened to and responded to verbally or non-verbally, including child observations and understanding of behaviours that may reflect harm and distress; work undertaken with regard to the role of education in providing a key protective factor should include learning about the importance of relational practice, trusted adults, and advocacy; clear leadership and challenge should be provided about victim-blaming language; and seek assurance that when services are commissioned/decommissioned, a relational approach is taken with regard to children and families to be mindful of the importance of continuity of relationships from the child’s perspective.
Keywords: extrafamilial child sexual abuse, rape, children in violent families, substance misuse, trauma informed practice, voice of the child
> Read the overview report

2024 - Cheshire East - Jez and siblings

Death of a 17-year-old boy in December 2022 from a drug overdose. Jez was autistic and known to services due to experiences of domestic abuse, mental health issues, substance misuse and self-harm. There were allegations against Jez’s stepfather of domestic abuse and sexual abuse.
Learning includes: response to concerns about child sexual abuse and the impact a lack of a robust response can have on children’s lives; support for children and families when they experience domestic abuse; responding to allegations of physical abuse; support to mothers with care and support needs; and professional response to deteriorating mental health, self-harm, and substance misuse in the context of a trauma informed approach.
Recommendations to the partnership include: set up a task and finish group to improve the multi-agency response to child sexual abuse; consider how to strengthen practitioner skills that enable the child’s voice and experiences to be listened to whether there is a verbal or non-verbal disclosure; ensure that all partner agencies have awareness of self-harm NICE guidance and the key principles of safety planning, managing risk and suicide prevention; and implement a domestic abuse-informed response within child safeguarding responses.
Keywords: suicide, substance misuse, domestic abuse, children with a mental health problem, autism spectrum disorder
> Read the overview report

2024 - Cheshire West and Chester - Child suicide or death through undetermined intent

The children considered as part of this review all died as a result of a deliberate act of self-harm. Some deaths have been concluded as suicide or undetermined intent.
Learning themes include: recognition of bullying; think family in blended families; child’s voice: how could a child present so differently between school and home; child to parent violence: adult issues versus the focus on the child; and multi-agency communication and consent as a barrier.
Recommendations include: undertake scrutiny of how consent for information sharing is addressed by agencies to ensure that the best interests of children are maintained; when there are concerns about violence or behaviour that is challenging to the parents, professionals must be able to explore why the child is behaving in a particular way and develop an action plan based on this knowledge; policy must be able to make a difference to children across all localities to reduce inequalities of access to therapeutic support; ensure that local policy and procedures emphasise the need for assessments, including school admission, to incorporate any parent or carer, especially biological fathers, male carers, and male partners, this should include the requirement to record the status of the adult in the child’s life, parental responsibility, and how they are involved in the care of the child; and undertake an audit of cases which are at the level of early help or team around the family, and explore the views of children and young people in relation to sharing information.
Keywords: suicide, child behaviour problems, voice of the child, self harm, bullying
> Read the overview report

2024 - City and Hackney - Case A

Conviction of an adult male in 2023 for over 30 sexual offences involving both children and adults. He had previously been found guilty of possessing indecent images of children and given a suspended sentence.
Learning includes: the sufficiency of the arrangements in place to risk assess and manage Mr A as a 'registered sex offender'; effectiveness of multi-agency practice at the point it was established that Mr A had children; the sufficiency of the arrangements in place to engage relevant agencies and share information about known child sex offenders; and the extent that practitioners across all agencies understand the potential risks posed by viewers of child sex abuse material.
Recommendations include: in all cases where known child sex offenders are having contact with children, the Metropolitan Police service (MPS) should ensure that referrals are always made to children's social care. Both the MPS and the safeguarding children partnership should review their guidance on the risk management of known offenders and as required, strengthen the clarity on triggering a Section 47 enquiry when known child sex offenders are believed to be in contact with children; the MPS should consider the sufficiency of its arrangements covering the disclosure of an offender's details to third parties; the child safeguarding practice review panel should look at the potential for the secure and routine information sharing of Level 1 MAPPA offenders with other key agencies, particularly GPs; and the partnership should commission context specific training on child sex offenders and include this as part of its annual programme open to all practitioners.
Keywords: child sexual abuse, child abuse images, sex offenders, sex offender orders, information sharing
> Read the overview report

2024 - City of London and Hackney - Child V

Death of a 7-year-old girl unexpectedly in January 2023. Child V had complex health needs and disabilities and, in the years, preceding Child V’s death, there had been significant contact with both health and social care practitioners.
Learning includes: insufficient focus on the cumulative harm that Child V was being exposed to meant that risk was never fully understood or agreed across the multi-agency network; insufficient management grip, knowledge deficits and the significant number of services involved with Child V meant there was an ambiguity about risk, case ownership, roles, responsibilities and communication; the main inhibitor to effective engagement in this case was Child V’s father; the priority afforded to Child V’s needs was diluted by repeated attempts to influence a change in parental behaviours; and care proceedings were neither timely nor effective in bringing about a material change for Child V.
Recommendations include: safeguarding partners should seek to strengthen their arrangements for how neglect is understood, identified, assessed and planned for across the partnership; the local authority and NHS should review the effectiveness of its arrangements governing multi-agency practice with children with disabilities and complex health needs; and the partnership should issue practice guidance and review its offer on delivering local multi-agency training aimed at working with parents/carers where their engagement is reluctant or sporadic.
Keywords: children with multiple disabilities, child health, child neglect, parental behaviour, interagency cooperation, treatment
> Read the overview report

2024 – Croydon - Eva

Non-accidental injuries to a 4-month-old girl in June 2023. Baby Eva was taken to hospital by both parents, with a pain in her right arm. Examination revealed a spiral fracture and further examination revealed multiple fractures, including rib fractures of varying ages. Both parents were subsequently arrested and remain under investigation, with Baby Eva's mother later alleging domestic abuse by the father.
Learning themes include: assessment of the impact of previous learning; the impact of systems on the quality and response to information sharing; and responding to information about fathers and other children.
Recommendations include: ensure partner agencies review and enhance their systems and practices to facilitate effective information sharing, particularly concerning fathers or male partners; share the findings of this review with the out of area hospital where Eva’s mother attended antenatally and gave birth, to enable them to consider what action they need to take in response to the identified factors that impacted upon safeguarding; seek assurance that the ‘normalisation’ of parental/carer aggression is not happening routinely and there are appropriate systems in place to support professionals who may be at risk of vicarious trauma; and consider whether there is a need for the Integrated Care Board to undertake an assessment to gain assurance across the borough that GP practices are applying a system of coding that facilitates the immediate identification and sharing of safeguarding concerns for different health practitioners working within the practice, staff who may work in multiple practices, and for when patients transfer surgeries.
Keywords: adverse childhood experiences, abusive men, aggressive behaviour, family violence, fathers, physically abused infants
> Read the overview report

2024 – Cumbria - Leo

Death of a 4-month-old boy in October 2021. Leo was found by paramedics in cardiac arrest. He was taken to hospital and died a few days later. Medical examinations showed serious injuries including rib fractures that occurred roughly two weeks earlier. Leo’s father was subsequently convicted of murder.
Learning themes include: involving and assessing fathers and identifying strengths or risks they bring to parenting; the importance of the effective provision of early help services; recognising parental misuse of prescription and non-prescription drugs; feeding difficulties as a trigger to harm; the importance of following ‘was not brought’ procedures; and the need to identify and meet the needs of care experienced parents.
Recommendations to the partnership include: ensure that where information is requested by health and midwifery services, this is completed in line with protocols, and information held on expectant mothers and fathers is disclosed; relevant integrated care boards (ICB) to provide assurance that children who are not brought to appointments are responded to in a timely manner; health visitors and GP training pathways to raise awareness of the impact of feeding difficulties on child safety, and provide assurances that feeding difficulties and unsettled infants are recognised as potential triggers to harm; ensure all agencies are clear on their responsibilities in relation to assessment of early help needs and provision of services; create a pathways plan for care experienced parents with the local care experienced parent group; and ensure that training for professionals enables them to understand the prevalence of the misuse of prescription drugs.
Keywords: abused parents, adults in care as children, infanticide, physically abusive parents, prescription drugs, non-attendance
> Read the overview report

2024 - Cwm Taf Morgannwg - Child F

Suicide of a 13-year-old girl in September 2021. Child F was a child looked after (CLA) who had been in foster placement out of area since March 2021.
Learning themes include: domestic abuse; substance misuse; mental health support and assessment; communication and information sharing; and how agencies maintain family relationships and support.
Recommendations include: information from specialists (such as forensic psychology) should be shared with foster carers, health and education colleagues to ensure a holistic approach for the child; pathways for CAMHS referrals should be clear and communicated to all relevant professionals with risk assessments and safety plans in place before discharge, particularly with a CLA or if previous history; interventions around care-experienced children’s needs should be prioritised for further consideration and escalation; where staff changes occur there should be a detailed handover including chronologies and there should be a robust supervision process to support complex cases; all foster carers should ‘check in’ with children prior to sleep each night to provide an opportunity for emotional support.
Recommendations specific to CLA placed out of area include: the health care needs notification form should be completed and include a risk assessment undertaken by the CLA nurse; appropriate education provision should be identified and school placement arranged as soon as possible; police should be notified of any identified risks or concerns; there should be robust arrangements for maintaining contact with family and friends and advocacy for the CLA must be offered by the allocated social worker; and the child death review group should explore work around child suicide in this group.
Keywords: child deaths, children in care, domestic abuse, foster care, placement, suicide
> Read the overview report

2024 - Cwm Taf Morgannwg - Child Q

Suspected non-accidental injuries sustained by a 5-month-old boy in early 2020.
Learning themes include: the significance of missed healthcare appointments; the need for comprehensive case recording; compliance with assessment/care and support planning processes; risk assessment procedures; professional curiosity and disguised compliance; family structures and relationships; and information sharing between and within agencies.
Recommendations include: undertake regular audits to ensure all case recordings are comprehensive and case management is compliant with relevant legislation; outline appropriate and robust responses to past, present and future risks, and to incidents which suggest changes in a risk determination; include the views of the family and other professionals in risk assessments; highlight the need for professional curiosity and the risks of disguised compliance; provide training to help professionals work with families where care-giving structures are complex; promote joint visits between professionals working with the same or different family members; share all children’s missed hospital appointments with the health visitor; ensure all medical practitioners understand the significance of and procedure following repeated missed healthcare appointments; promote information sharing about healthcare issues between and within agencies; ensure all supervision and recordkeeping complies with the relevant quality assurance framework; and develop a single shared strategy discussion record to promote clarity and shared understanding about child protection decisions.
Keywords: assessment [social work], family dynamics, infants, injuries, professional curiosity, non-attendance
> Read the overview report

2024 – Cwm Taf Morgannwg - Child Y

Concerns for a child’s safety and wellbeing in 2021. Does not give details of the circumstances.
Learning themes include: information sharing and the quality of assessments; and processes in place for convening strategy meetings out of hours.
Recommends that multi agency training on assessment is needed to address the following areas: identifying gaps in knowledge and information, and recording the implications of this for the assessment; determining the credibility of information and balancing competing and conflicting information through processes of testing assumptions and beliefs, and documenting rationale for conclusions and decisions; taking an exploratory approach that applies curiosity about the motivation underpinning what children say, whilst maintaining a rights-based approach that recognises and upholds the importance of children’s wishes and feelings informing all decisions that affect them; and the impact of control and coercion by others on what people say and do. Also recommends that the partnership develops multi-agency practice guidance on the convening of strategy discussions outside of usual weekday working hours where there is a significant incident such as a child death. This should include the actions to be taken when a child is or has been known to local authority social services because of concerns about their protection or welfare and ensure key relevant partner agencies are invited to out of hours strategy meetings and have access to the information that will inform robust decision making.
Keywords: assessment [social work], domestic abuse, family courts, foster care, parents with a mental health problem, placement
> Read the overview report

2024 - Derby and Derbyshire - Theo

Death of a 10-month-old boy while in his parents’ care. On examination, Theo was found to have multiple injuries. Evidence suggests his death was likely to have been the result of abuse.
Learning themes include: the quality of ‘parenting assessments’ and ’social work assessments’; recognising the difference between ‘family arrangements’ and being looked after; the effective use of pre-proceedings; concealed pregnancy; parental cannabis misuse; increasing the level of multi-agency work in care proceedings; reunifying children with their parents during care proceedings; working with families who appear to be avoiding contact with professionals; responding to issues of domestic violence and abuse; and workforce issues.
Recommendations include: undertake a multi-agency audit of recent parenting assessments to evaluate the quality of analysis and conclusions and the effectiveness of information-sharing and professional challenge; ask the local authority to provide evidence of its improved practice in distinguishing between ‘family arrangements’ and ‘placements’; ask the local authority to provide evidence of the improved effectiveness of pre-proceedings work with children and parents; revise its procedures and guidance in respect of concealed pregnancy; encourage local public health commissioners of substance misuse services and the local authority to develop a working joint protocol in line with guidance; work with the local authority’s legal service to develop and implement a practice model that will enable effective multi-agency work while children are subjects of care proceedings; complete a multi-agency audit of cases where children were reunified with parents in pre-proceedings or during care proceedings; seek a report from its domestic abuse strategy lead to verify that child safeguarding partners have arrangements in place to deliver an effective local response to domestic abuse.
Keywords: assessment [social work], CAFCASS, care proceedings, child abuse, child deaths, family reunification
> Read the overview report

2024 – Derby and Derbyshire - Zac

Death of an 11-year-old boy in June 2022 following a fatal injury (severe liver trauma) which was initially thought to be because of an unwitnessed accidental fall from a tree. The fatal injury was later found to be the result of a physical attack by the child’s father which took place at the family home.
Learning themes include: coercive control; recognising and safeguarding vulnerable children; impact of Covid 19; elective home education; transient families and cross border issues; and child death review processes.
Recommendations include: audit early help arrangements with a focus on the quality and content of assessment and analysis; seek evidence from partner agencies about the measures they have in place for safeguarding cases to assure themselves of the quality of management oversight and supervision including evidence that training on domestic abuse and coercive control is promoted and monitored; the LA to provide a scrutiny report to the partnership which focuses on the impact and effectiveness of communication and information sharing arrangements between schools, the elective home education service, 0-19 children's service, and the children missing from education service (including cross border arrangements); and child death leads should facilitate a specific meeting to include integrated care boards, local authority and police members, to consider how the joint agency response guidance can be strengthened to promote cross border working in relevant situations when a child dies suddenly and unexpectedly, as well as include the specifics of when children die following unwitnessed injury.
Keywords: child deaths, domestic abuse, filicide, home education, physical abuse, transient families, unknown men
> Read the overview report

2024 – Devon Lancashire – Child Sydney

Serious incident involving a 13-year-old-girl in April 2023. Sydney and a friend went missing from their placement and were located by police five days later. They disclosed that during this time they had been drinking, taking drugs and were sexually assaulted by several older males. Sydney has a history of trauma, mental health difficulties and repeated missing episodes.
Learning explores: autism spectrum disorder (ASD) assessment delays; missed opportunities for risk assessments; and responding to contextual safeguarding risks for vulnerable children.
Recommendations include: raise awareness of the ‘out of area placements policy’ to ensure that all relevant information is shared with the host local authority (LA) at the earliest opportunity; ensure that health records and notifications can be shared with the receiving integrated care board; ensure that risk assessments are regularly reviewed and updated; equip all children in care with a safety plan in the event of a missing episode; ensure that the new version of the ‘safer me assessment’ is embedded within the electronic recording system as a matter of priority; provide further guidance to practitioners regarding timely applications to court to protect vulnerable children; develop practice guidance in relation to the matching of children within placements and matching to their allocated social worker; when challenging health or additional needs are identified, discussions should include CAMHS/health services; ensure that a manager has oversight of any missing episode that reflects safeguarding concerns and there is a direct conversation between both LAs to agree responsibility; and the partnership should work with health providers to resolve drift and delay in completing ASD or ADHD assessments.
Keywords: adolescents who go missing, autism spectrum disorder, child behaviour problems, child sexual exploitation, contextual safeguarding, residential child care
> Read the overview report

2024 – Dorset - Daniel and Sarah

Death of a 7-week-old boy in May 2021. At the time of publication, the cause of Daniel’s death remains unascertained, but the post-mortem identified multiple rib fractures of varying ages. Daniel’s family had been known to children’s social care since August 2020 following a head injury sustained by Sarah, Daniel’s older sibling, who was 4-months-old at the time.
Learning themes include: the impact of the pandemic on service provision; the effect of seemingly small details adding up to a major incident; injuries to non-mobile babies; parent education around safe sleeping, coping with crying and preventing non-accidental head injuries in babies; decision-making and influence; information sharing, assessment and analysis; professional curiosity; neglect; assessment of parents; and the voice of the child.
Recommendations to the partnership include: review the protocols and training around injuries in non-mobile babies; conduct a multi-agency audit covering agency response, risk assessment, and follow-up, of babies up to 6-months-old attending the emergency department with any injuries; review and update the parenting programme ICON, which helps parents and carers to understand the normal crying pattern of young infants and to develop successful coping mechanisms; conduct an audit of strategy meetings, initial child protection conferences (ICPC), and child in need cases where there has been disagreement between professionals; promote the attendance of paediatricians at ICPC; establish shared assessment tools and a multi-agency approach to identifying neglect; and agree a protocol to prioritise risk assessments for siblings when a child has died and there are safeguarding concerns.
Keywords: assessment of children, child neglect, child patients, infant deaths, injuries, siblings
> Read the executive summary

2024 – Dorset – Edie

Death of a 15-year-old girl who was electrocuted when walking home via a train track late at night in March 2023. Prior to her death, Edie was repeatedly missing from home and briefly from care, and was considered on four occasions at strategy discussions due to thresholds of significant harm, including child criminal exploitation. Edie was considered to have mental health and neurodiversity needs.
Learning themes include: understanding adolescent contexts; relational practice to understand a child’s world; working with parental barriers; holistic approaches to intra- and extra-familial harm; trauma informed services and interventions; education provisions for children with a complexity of needs; responding to critical incidents involving children; keeping children safe in their local communities; and working with marginalised young people.
Recommendations include: the National Child Safeguarding Practice Review Panel and Department for Education should consider arm’s length-bodies such as Network Rail being included within the statutory Working together guidance; ensure all children’s social care staff are trained in motivational interviewing techniques and this continues to be embedded to support practitioners when there is resistance from parents; continue to support statutory agencies in developing trauma informed approaches; ensure specific work is undertaken by relevant statutory partners on the safety of railway tracks, with a targeted approach towards marginalised or vulnerable children and young people; and children’s services lead on further targeted outreach work with groups of marginalised young people to hear their views and ensure their participation to address extra-familial harms, and consider how to address drug and alcohol issues and non-school engagement.
Keywords: adolescents who go missing, child criminal exploitation, children missing education, neurodevelopmental conditions, parental attitudes, substance misuse
> Read the overview report

2024 – Dudley - Child F

Assault to a teenage boy in 2022 by a group of males. This was believed to be a targeted assault, possibly linked to criminal exploitation. Child F was a looked after child and had police and youth justice involvement. Child F’s mother had involvement from services for mental health and substance misuse.
Learning includes: information sharing and communication, specifically how complex decision making and rationale is explained to families; relationship building and professional curiosity around potential safeguarding concerns; recognising exploitation risks; the potential relevance of ‘adultification’ in safeguarding teenagers; Think Family approach in relation to safeguarding, contextual risk and lived experience of a child; and identifying young carers.
Recommendations include: agencies working with adults and/or children to provide assurance to the partnership that they have effective joint working practices when working with members of the same family, recognise how the needs of each person in the family affect each other, and respond appropriately; the partnership to revisit the multi-agency training content to incorporate ‘adultification’ into appropriate courses to raise awareness of this concept so practitioners can understand how this can relate to practice and professional curiosity; and the partnership should strengthen communications to ensure that professionals are aware of their responsibilities in identifying and ensuring that there is assessment of young carers.
Keywords: child criminal exploitation, contextual safeguarding, adolescent boys, professional curiosity, violence
> Read the overview report

2024 – Ealing - Combined safeguarding adult review and child safeguarding practice review

The prevalence of abuse and exposure to violence was seen as significant in the children’s lives and learning was derived from this combined safeguarding adult review and child safeguarding practice review.
Learning includes: ability of professionals to work in a multi-agency capacity to consider all the information they hold (current and historical) about vulnerable children, in particular the information held by schools; provision of timely feedback to referrers on referral outcomes and the use of the local escalation process where professionals disagree on the right course of action; multi-agency oversight of children experiencing multiple reported incidents of abuse and the maintenance of that oversight where support services are declined; multi-agency assessment of and response to neglect to ensure that theoretical frameworks guide assessments and that children’s lived experience and full life histories are considered; ability of professionals working with children to identify adult safeguarding concerns and follow adult safeguarding procedures; ability of adult services, children’s services, and community safety services to work together to respond to safeguarding concerns; multi-agency approach to welfare checks; engagement of fathers and wider family members, as well as mothers, in the assessment of vulnerable children’s lives and safety planning to reduce the risk of significant harm; and understanding across all professionals working with families, adults, or children of what constitutes a private fostering arrangement.
Recommendations are embedded in the learning.
Keywords: assessments, information sharing, professional curiosity, school attendance, voice of the child
> Read the overview report

2024 - Enfield - Emily

Report of the rape and drugging of a 16-year-old girl in December 2022 by a perpetrator encountered whilst online gaming. Emily was in care from 4-years-old due to neglect, and experienced placement instability. She has a diagnosis of autism, global developmental delay and ADHD.
Learning themes include: planning to prevent the escalation of risk; effectiveness of multi-agency practice in risk assessing a child’s changing needs and risks alongside balancing the prevention of harm against Deprivation of Liberties Safeguards (DoLS); online safety and use of social media by children with additional needs; how a child’s capacity to make decisions and give informed consent is understood and influences care planning and decisions; and assessment and planning for transition to adulthood.
Recommendations include: partner agencies to develop a tool that supports more consistent and effective risk assessment and planning for children with complex needs; where there are children who are discussed at the dynamic risk register meeting, it should be considered to share relevant risks with the police; the partnership to flag the lack of suitable placements for children with complex needs to the national panel; and provide further guidance on transition planning to all children’s practitioners so they are clear what the pathways are for children approaching adulthood.
Keywords: rape, online grooming, children with a learning disability, children in care, risk assessment
> Read the overview report

2024 – Epsom - Emma, Lettie and George

Murder-suicide in a family home in February 2023. Emma (45-years-old), Lettie
(7-years-old) and George (39-years-old) had all died as a result of gunshot. Police investigations confirmed that George was a licensed shotgun holder, and that he had killed his partner, Emma, and their 7-year-old child, Lettie. No specific motive about why George acted in this way has been uncovered.
Learning themes include: n/a
Recommendations include: several specific to strengthening gun licensing guidance; The Home Office and the Domestic Abuse Commissioner’s Office should promote the Public Health England and Business in The Community Domestic Abuse Employer Toolkit which helps employers of all sizes and sectors make a commitment to respond to the risk of domestic abuse and build an approach that ensures all employees feel supported and empowered by their workplace to deal with domestic abuse; the partnership should raise the profile of this toolkit and the employers initiative on domestic abuse across all partner agencies, to raise awareness that supports all employees, regardless of role, status and position held, to seek help if they are a victim of domestic abuse; and The Epsom and Ewell Community Safety Partnership should work with relevant agencies and other strategic partnerships to examine methods for reaching into local communities that encourage adults (particularly adult males) to seek support about emotional or mental health worries or any mental distress they may be troubled by.
Keywords: domestic abuse, filicide, homicide, marital problems, suicide, weapons
> Read the overview report

2024 – Essex – Child F

Hospitalisation of an 8-year-old girl. Child F was found to be severely malnourished. Both her parents were later imprisoned for child neglect. Child F and her family had been known to services for a number of years due to concerns about child neglect. They recently moved from another local authority after being evicted from their home.
Learning themes include: identifying and responding to child neglect; the impact of Covid-19 restrictions; responding to parental needs, including mental ill-health; the impact and involvement of the wider family network; professional disagreement and escalation; the safeguarding role of education settings; child in need transfers between local authorities; hearing the voice of the child; children not brought to appointments; and housing and homelessness.
Recommendations include: review single and multi-agency neglect policies and practice guidance; explore how multi-agency child in need review assessments and processes are managed; encourage the inclusion of specific reasons for closing cases involving children; explore how to gather information about and encourage involvement from wider family networks; and support agencies in evaluating the needs and capabilities of parents and identifying appropriate interventions which promote children’s wellbeing.
Keywords: assessment of children, child neglect, housing, non-attendance, professional collaboration, transient families
> Read the executive summary

2024 – Gloucestershire – Child X

Sexual abuse of a 15-year-old girl in care with complex emotional and behavioural needs. Child X was the subject of a Deprivation of Liberty order and was cared for in an unregistered placement. Child X became pregnant in this setting, which was thought to be the result of grooming and sexual abuse by a male carer.
Learning themes include: crisis placements; the child’s voice, culture and identity; commissioning of placements and care packages for children with complex needs; quality assurance arrangements for placements and care packages including the quality and competence of professionals commissioned to look after children with complex needs; and managing allegations against staff working with children.
Recommendations include: the Safeguarding Children Partnership Executive should have oversight of all children placed in unregistered settings and ensure that there is good quality governance and accountability; the children in care nursing service must be involved when a child is placed out of authority to support careful and consistent health and care planning; all agencies must develop a robust and informed approach to assessing and meeting children’s cultural, race and identity needs; all agencies must ensure that there is an understanding of racism and bias that can lead to the adultification of some children where their vulnerability and support needs are not understood; and awareness should be raised of the local authority designated officer (LADO) role and ensure that partners understand their responsibility in contacting the LADO when there are concerns that an adult may cause a child harm through abuse or professional neglect.
Keywords: secure accommodation, racism, sexually abusive people, special educational needs, additional needs and disabilities, adverse childhood experiences, institutional child abuse
> Read the overview report

2024 – Gloucestershire - Operation ACORNE

Operation ACORNE was a large scale and complex multi-agency investigation into child sexual abuse. It was initiated in June 2017 in response to concerns about the behaviour of multiple children. The case in question developed over several years and encompassed multiple children and adults from four families within a tightly controlled family network, including close family friends.
Learning is embedded in the recommendations.
Recommendations include: highlight the findings of this and other relevant reviews with regard to sexual abuse; highlight to the Department for Education (DfE) the lack of guidance for staff managing sexually harmful behaviour in primary schools, ‘peer on peer abuse’ is not appropriate for children of this age group; develop local guidance for practitioners in all agencies in managing sexually harmful behaviour; identify appropriate assessment tools for children demonstrating sexualised behaviour; ensure that working with sexual abuse and harmful sexualised behaviour are part of the inter-agency safeguarding training programme; local guidance regarding complex abuse inquiries to be clarified to explicitly state that all relevant agencies should be represented at a senior level from the outset; the constabulary and children’s services should review the numbers of achieving best evidence trained staff and commission new training programmes to train new staff and refresh those who may have undertaken the training some time ago; review how both strategy meetings and child protection medicals are carried out more rigorously and holistically; undertake a thematic review of cases where there has been concerns about sexual abuse; review how cases are managed when there are concerns about both children and vulnerable adults; and undertake a review of how cases where children are subject to child protection plans are ‘stepped down’ and reassert the rigour with which children in need plans need to be managed.
Keywords: child sexual abuse, foster parents, harmful sexual behaviour, voice of the child, risk assessment
> Read the overview report

2024 – Greenwich - Child G

Death of a 1-year-old infant in October 2022. Child G had a cardiac arrest after being left unattended in bath water. There were concerns around Child G’s mother’s mental health and lack of engagement with services.
Learning considers: when to refer or signpost parents to agencies or services; vulnerable babies hidden from or missed by services; the impact of COVID-19 on new parents; and encouraging parental engagement in universal services.
Recommendations include: the partnership to ensure that commissioned services are represented in its work to increase an understanding of safeguarding across the system and assure itself that health visitor providers and commissioners work closely together to ensure that case information is actioned during transition periods; the partnership to continue to promote information about home safety and water safety; and health visiting services to ensure home safety information is circulated when one-year checks are cancelled or delayed.
Keywords: infant deaths, drowning, parents with a mental health problem, non-attendance, child safety
> Read the overview report

2024 – Greenwich - Child I

Death of a 16-year-old boy in October 2023. Child I had been subject to a full care order since February 2023, and had previously been subject to a child protection plan. He had multiple missing episodes from home and from care and was known to have gang affiliations.
Learning themes include: the impact of placement insufficiency; strategic responses to child criminal exploitation and child sexual exploitation; the role and relevance of the national referral mechanism (NRM); the family as a system; and managing risk that escalates rapidly.
Recommendations to the partnership include: develop a strategic approach to adultification in the context of intra- and extra-familial risk; ensure approaches to adultification consider the intersection of ethnicity and gender, with a particular focus on how these factors influence the way risk is understood and responded to; increase understanding of the risk of criminal and sexual exploitation in the context of family and community systems; consider how services can work together to hold the ‘system’ around a child in mind when responding to individual incidents; update, share and promote local practice guidance on the NRM; ensure practice guidance reflects the limitations of the NRM and gives suitable weight to risk assessments and safety planning outside of the NRM; review opportunities for regional commissioning of placements to establish a range of local placement options for children experiencing exploitation; and explore local arrangements to allow for child mental health services to hold responsibility for children experiencing exploitation across neighbouring boroughs.
Keywords: adolescent health, adultification, Black children, child deaths, gangs, placement breakdown
> Read the overview report

2024 – Gwent - Case Stanley

Death of a 4-year-old boy in December 2021. Stanley became unwell at his father’s home and was not taken straight to hospital because his father believed he didn’t have parental responsibility. Stanley was on the child protection register due to concerns about his mothers’ relationship with a registered sex offender, domestic abuse and sexual abuse allegations against Stanley’s father. Stanley’s parents had previously had another child who died at 6-months-old in 2018.
Learning themes include: quality of safeguarding assessments; missed opportunities to submit safeguarding referrals; domestic abuse concerns and missed opportunities to refer to independent domestic violence advisers (IDVA) services.
Recommendations include: the local safeguarding board to develop a quality assurance framework to ensure the correct process is being followed when closing cases and to ensure compliance with ‘Wales safeguarding procedures’; local authorities should increase the availability and effectiveness of training to help frontline practitioners engage meaningfully with fathers and explain father’s rights, such as parental responsibility; the local safeguarding board to disseminate duty to report threshold guidance to agencies and monitor the implementation within each organisation; the local multi-agency public protection arrangements (MAPPA) unit to provide training for local IDVA services; the MAPPA unit to provide briefings to MAPPA chairs regarding disclosure discussions and decisions and accurate recording of agreed disclosures; and a seven minute briefing on IDVA services to be formulated and shared with organisations, including what the service can provide and the referral process.
Keywords: child deaths, parental responsibility, domestic abuse, referral procedures, disclosure
> Read the overview report

2024 - Haringey - Child Jay

Removal of a child from his mother’s care after an NSPCC referral in December 2021. A paediatric medical was undertaken and concluded Jay’s injuries were non-accidental.
Learning themes include: cross borough practice; antenatal care and support from mental health services; risk assessment, intervention and multi-agency decision making; and agency responses to parents who struggle to engage.
Recommendations include: write to NHS England to emphasise that written communication provided for patients on GP registration should be more explicit about whole family registration; when family members are registered at different GP practices safeguarding agencies need to ensure that they have the correct details for each family member; review the multi-agency training on parental mental ill health and ensure that staff working with parents have an appropriate level of skill and expertise to assess and intervene; promote awareness for safeguarding professionals on mental health assessment and interventions for parents of young babies; a mechanism should be established between the health visitor and GP, so that following multidisciplinary discussions, there is a shared understanding of actions, by when and by whom; decisions to close children’s casefiles in safeguarding agencies should be communicated to all involved and if there is professional disagreement about that decision, agencies should use the existing escalation processes; review the use of their existing Escalation and Resolution Protocol and make sure all professionals are aware of its use; and ensure that all multi-agency safeguarding training explicitly reminds professionals of the crucial roles of birth fathers and carers in a child’s life.
Keywords: abuse allegations, NSPCC, parents with a mental health problem, physically abused children, family violence
> Read the overview report

2024 - Hartlepool and Stockton-on-Tees - Child Roo

Death of a 7-month-old infant boy in August 2023 whilst sleeping in his cot at home. At 5-months-old, bleeds on Roo’s brain were identified. Roo and his siblings were subjects of interim care orders and remained in the care of their mother with supervision by a family friend.
Learning themes include: recording and evidencing the cumulative impact of neglect; recognising behaviour as evidence of domestic abuse without disclosure; recognition of signs of abuse and neglect in young children, particularly in those with violent behaviour or ‘adultification’; professional’s understanding of the impact of a parent’s learning disability or difficulty; clarity of explanation between medics and non-medics; adhering to procedure in the management of bruising in non-mobile babies; the impact of race, culture and ethnicity on professionals’ decision-making; abusive fathers, their parenting choices and the impact on family functioning; and the child’s lived experience.
Recommendations include: children’s social care assessment of family members or friends proposed to supervise a parent’s care of their child(ren) must include thorough local authority checks and clear expectations of the level of supervision required; the partnership to collaborate with education to reduce the risk of a child being excluded as a result of childhood trauma; designated professionals to ensure child protection medical reports use laymen terms and deliver multi agency training on understanding child protection medical reports; and evaluate the child's lived experience in multi-agency assessment using the child's language, reflecting their developmental stage, and recognising all children equally.
Keywords: infant deaths, interim care orders, adults with learning difficulties, culture, child neglect, domestic abuse
> Read the overview report

2024 – Herefordshire - Child HN

Suspected diabetes mismanagement of an adolescent boy after he presented at hospital in a critical state in March 2023.
Learning themes include: management of type 1 diabetes; cross-border working together; understanding an adolescent’s world; working effectively with families; and assessing medical neglect to inform levels of need and intervention when working with adolescents with chronic conditions.
Recommendations include: ask the National Panel to consider the benefits of producing national multi-agency guidance on the management of chronic health conditions in children; ensure that the roll-out of child neglect tools and training is updated and includes guidance on understanding and identifying what constitutes medical neglect; run a series of multi-agency practice learning briefings on direct work and voice of the child; address the quality of CIN plans and communication with partner agencies, including ensuring minutes are circulated to all partner agencies and the family in a timely manner; in line with NICE guidelines a task and finish group should find a solution to ensuring that children and young people with type 1 or type 2 diabetes are able to see a mental health professional who is skilled to understand their issues, including psychological barriers that children with diabetes can have; review the guidance for both regions around protecting children and families who move across local authority borders, ensuring that they are aligned and include guidance on information sharing when a family move into a refuge and are subject to a statutory plan, as well as information about cross-border transfer of children with chronic health conditions.
Keywords: children with a chronic health condition, medical care neglect, refuges, school attendance, temporary accommodation, transient families
> Read the overview report

2024 - Islington - Child W

Life-changing injuries to a 17-year-old boy in March 2022. Child W is a young man of Black Caribbean heritage who had been known to multiple services including the police throughout his teenage years. He also had an education, health and care plan (EHCP) following a diagnosis of obsessive-compulsive disorder (OCD) and anxiety. He later received a diagnosis of severe PTSD.
Learning themes include: safeguarding children with additional needs; intersectionality of Black boys and adultification; transitional safeguarding and EHCPs; contextual safeguarding and the carrying of knives; and the impact of bereavement on adolescent boys.
Recommendations include: develop a shared agreement of how Black boys will be safeguarded from extra-familial harm, including how partners will challenge each other when the agreement is not enacted; the police should ensure that all police officers are prioritising the safeguarding of all children, including Black adolescent boys; police should demonstrate to the partnership how it is working with the local Black community to address the perceived discrimination of Black boys; police should ensure that all officers are trained in trauma-informed practice, especially in relation to serious youth violence; and information should be provided for agencies on how bereavement support can be accessible for adolescents who experience the death of peers due to serious youth violence.
Keywords: Black children, adultification, racism, contextual safeguarding, children with a mental health problem, trauma-informed practice
> Read the overview report

2024 – Jersey - Ross

Examines the involvement of agencies and professionals with a child. From birth, Ross experienced considerable adversity which continued throughout his childhood. His experiences included specialist health care needs – which were often not met, persistent parental alcohol use, drug use and drug dealing, witnessing disorderly and violent behaviour, witnessing domestic abuse, parental mental health issues, and likely exposure to sexual grooming.
Learning points include: the importance of early assessment and early help; behaviours exhibited by children and young people which may be viewed as inappropriate, are often symptomatic of deeper underlying problems; assessing parental capacity plus parental capacity to change are two key activities for those cases where risk factors are in plain sight; balancing the need to support and protect young people that are disadvantaged by either their life history and circumstances and who then become offenders, with punishing their deeds when lines are crossed, can often require fine judgements; helping all professionals gain the confidence to disagree or challenge should form part of each agency’s responsibility to their staff development and management support; the use of assessment and intervention methodologies - such as restorative or trauma informed models - can often support busy professionals think about how they approach and work with a child or family; and where health and medical needs are identified which require the input of a number of professionals from different health disciplines it is important to ensure there is a multi-disciplinary plan in place that is regularly reviewed, alongside effective coordination and communication.
Recommendations are embedded in the learning.
Keywords: adverse childhood experiences, alcohol misuse, domestic abuse, medical care neglect, parents with a mental health problem, parenting capacity
> Read the overview report

2024 – Jersey - Susan

Examines the involvement of agencies and professionals with a child. In 2020 Susan had suicidal thoughts and was noticed to have previously self-harmed. This acute episode was responded to by professionals, but Susan reported not wanting to go home, having a poor relationship with her mother and that her mother’s emotional/mental health was unstable. Susan’s behaviours persisted into the following year, culminating in a serious incident. Eventually Susan was permanently excluded from her school and the combined impact of Covid-19 restrictions complicated her situation, school stability and family life.
Learning points include: the need to be proportionate and considerate of the views of the child as well as the views of the responsible parent; adopting a relationship-based approach when working with young people but also their parents is important, not only for dealing with the immediate and presenting issue, but also longer term working and support; providing young people with a key worker, at times of acute need or distress can be hugely influential and impactful going forward; it is important that suspension and exclusion processes are clear to all Island schools in order that there is clarity for children, parents and the wider school community; and where multiple professionals are involved with a child following an incident, consideration should be given to reducing the burden on the child or family, and not overwhelming them with multiple requests for the same issues.
Recommendations are embedded in the learning.
Keywords: anti-social behaviour, contextual safeguarding, exclusion from school, peer groups, self-harm, mother-child relationships
> Read the overview report

2024 – Kent - David

Death of a child in 2022 following an asthma attack. David was home educated and at the time of the incident, it was unclear what medication he was taking regularly and how his asthma was being monitored. David’s mother was arrested for neglect but later refused charge.
Learning themes include: medical neglect; ‘was not brought’ policies; secondary, primary and community interface and plans in place for children with asthma or allergies; engagement of wider professionals, including pharmacies, schools and public health; and engagement with families to ensure they understand asthma or allergy plans and medication.
Recommendations include: the partnership’s neglect strategy and associated training should emphasise the impact of medical neglect relating to chronic, potentially life threatening conditions on children with the wider children’s workforce; the adoption of standard templates for asthma and allergy plans; encouraging health and education professionals to discuss with parents the expectation that asthma/allergy plans are shared with other key professionals and the impact of any subsequent refusal of consent on the child is considered; public health to consider expanding the remit of the school nursing service so it is available for children with chronic medical conditions who become electively home educated; and the integrated care board to support all health providers to routinely review and audit their ‘was not brought’ policies to measure compliance and effectiveness.
Keywords: medical care neglect, children with a chronic illness, non-attendance, home education, child deaths
> Read the overview report

2024 – Kent - Iman

Suspected non-accidental injuries to an 8-month-old boy. Iman was admitted to hospital with seizures at the age of 8-months following rolling off the bed. The criminal proceedings process concluded in February 2024 with no charge as it was decided non accidental injury could not be proved beyond reasonable doubt.
Learning themes include: risk assessment and decision making; accommodation for care leavers; cultural competence; and cross boundary communication.
Recommendations include: consider the availability of support/advocacy services for all parents following removal of their children and during care proceedings; review the effectiveness of the current processes for sharing background information on families with universal services when the decision is to close the case to children’s social care following a children and families assessment; ensure practitioner’s understanding of trauma informed practice and the risk of specialist services not being taken up by a parent, as well as the impact of chronic pain on a parent are factored into risk assessments; ensure that practitioners are supported/challenged and have sufficient skill and understanding of trauma informed practice, sexual abuse, physical ill health and cultural competence factored into their direct work and assessments; raise with the National Child Safeguarding Practice Review Panel the national issue of the fragility of legislative support and local housing practice to support care leavers as they move into independence; ensure that universal service practitioners are confident in their understanding of cultural competence; and ensure that practitioners are encouraged and supported to escalate concerns where children are placed in another local authority area.
Keywords: adolescent fathers, adolescent mothers, family courts, housing, pain, unaccompanied asylum seeking children
> Read the overview report

2024 – Kent - James

Death of a 1-day-old infant in March 2023. James was born at home and died from an infection. James’ mother has a moderate learning disability.
Learning themes include: working with parents with a learning disability; antenatal care; and making and responding to referrals.
Recommendations include: the partnership should develop a multi-agency action plan to provide better support for parents who have a learning disability; practitioners should be able to understand the difference between learning difficulties and learning disabilities, the different degrees and aspects of learning disability, including the concept of ‘executive functioning’, and how to find out if a person has a learning disability diagnosis, and get appropriate support; the local integrated care board (ICB) should lead a multi-agency evaluation of the maternity hubs; and the ICB should promote GPs offering proactive support to pregnant women who have a learning disability, to facilitate prompt booking in for antenatal care and sharing information about their learning disability with midwifery services, and entering information on the patient record.
Keywords: infant deaths, adults with a learning disability, antenatal care, pregnancy
> Read the overview report

2024 – Kent - Jasper Red

Death of a 17-year-old boy by suicide in 2023. There were two known occasions where Jasper Red had taken overdoses prior to his death, and at other times he shared suicidal ideation with professionals. Jasper Red experienced neglect and abuse as a young child and spent time on a care order and in the care of West Sussex local authority from 3-years-old.
Learning explores: information sharing and communication when a child moves between areas; consideration of a parent’s history, on-going issues, and ability to meet a child’s emotional needs; assessment and support when a child is struggling with their mental health and has suicidal ideation; impact of a child’s learning needs and sexuality on their vulnerability and mental health; and the need for those working with adults to consider the wider family context.
Recommendations include: the NHS foundation trust to provide an update to the partnership on the work being undertaken to ensure improvements in safety planning for children who are known to be a suicide risk; the partnership considers how they can ensure optimum learning across agencies about cumulative harm; and relevant health agencies consider how they can improve practice in respect of appropriate access to information and information sharing about mental health.
Keywords: suicide, child mental health, LGBTQ, family conflict, foster care, adverse childhood experiences
> Read the overview report

2024 – Kingston and Richmond – Young Person W

Disclosure of abuse and neglect within the foster home by a young person in July 2022. Young Person W developed a functional illness while in this placement, from which they recovered shortly after moving to alternative foster carers.
Learning themes include: the difficulty for children of trusting professionals involved in their removal from their birth family; foster carers acting as the voice of the child; the need to share and act on concerns about foster carers’ behaviours; functional illness as a response to anxiety or trauma; the need for communication and a coordinated approach across education, health, mental health and social care services; the relationship between foster carers and local authority children’s services providers; and agencies’ actions following a disclosure.
Recommendations to the partnership and local children’s services provider include: develop guidance and training on hearing the voice of child; examine barriers preventing the escalation of concerns regarding foster carer behaviour; work with the Metropolitan Police to ensure that officers attending domestic abuse incidents take a proactive approach to establishing the occupation of people in the home, and to explore adding an alert to police records where adults are registered foster carers; when a child in care is diagnosed with a functional illness, review their care plan with practitioners with specialist understanding of possible underlying causes and effective treatments; include professionals from both local authorities in education and health care planning for a child placed out of borough; support professionals in knowing how to respond to allegations against a trusted person; and encourage collaborative partnership working.
Keywords: adolescent abuse, child health, child neglect, disclosure, foster parents, voice of the child
> Read the executive summary

2024 - Lancashire - Baby Lily

Death of a baby in February 2021. Lily died after her mother fell asleep in bed with her at her mother and baby foster placement. Lily was a looked after child, having been made the subject of a care order shortly after her birth and placed into the care of the local authority.
Learning: N/a
Recommendations to the partnership include: recommendations are embedded in the learning and include: placement planning from assessment units where end dates are known should be commenced early enough to allow for smooth, trauma-informed transition; where the placement proposed is for a child to be placed with a parent in a new setting, such as a mother and baby placement, care planning must run concurrently to the placement planning; risk assessments should be completed before placement, or as soon as practicable after placement and should always be undertaken by the designated local authority; professionals should ensure that assessments are read and understood by others working with the family and that plans and risk assessments which do not reflect the underpinning assessments are challenged; the local authority should review the use of language following assessments to ensure that simplistic language such as the use of ‘pass, fail, positive’ does not impact on practice and decision making; where the local authority has accommodated a baby within a mother and baby foster placement and there have been concerns in relation to co-sleeping, these should be addressed in writing within an agreed placement plan and include specific requirements for the foster carer to check that the baby is in its cot.
Keywords: domestic abuse, care orders, child deaths, parenting capacity, placement, sleeping behaviour
> Read the overview report

2024 – Lancashire – Child Cameron

Admittance to hospital of a 16-year-old-boy in December 2022, due to poor management of severe obesity. Cameron was suffering from Diabetic Ketoacidosis (DKA)1, septic shock and was in peri-cardiac arrest, and was also Covid-19 positive.
Learning themes include: cross border working of partner agencies; professional understanding of the long-term health impact of obesity; response to self-harming; engaging young people with social anxiety disorder; transgender support services; and the role of the mother in supporting the young person to access services.
Recommendations to the partnership include: with partners, GP practices should develop a system which enables them to maintain an appropriate level of contact with child and young person patients living with severe obesity; review guidance available to professionals when a child living with obesity could represent a safeguarding concern and consider developing a safeguarding pathway; relevant agencies to review their ‘was not brought’ policies to ensure they consider the impact of social anxiety on the ability of a young person to be supported to attend appointments and set out reasonable adjustments if a young person continues not to be brought, including a multi-agency risk assessment; professionals working with young people are made aware of self-neglect policy and practice and are provided with the necessary training including in relation to the Mental Capacity Act; and introduce a requirement to conduct a multiagency risk assessment when closing the case of a child being supported at level 2 or level 3 as result of lack of parental engagement.
Keywords: obesity, home education, LGBTQ, self-harm, medical care neglect, non-attendance
> Read the overview report

2022 - Lancaster - Child AF

This review concerns Child AF and her mother Sophie. Child AF was born at approximately 24 weeks gestation following her mother going into early labour. Child AF died at one day old, her prematurity being such that her survival prospects were poor from birth. This was Sophie’s sixth pregnancy, her other children and Child AF’s siblings did not reside in her care due to concerns that they would be at risk of significant harm.
Learning is embedded in the recommendations.
Recommendations include: all practitioners across children’s social care and mental health need to have a good working understanding of termination of pregnancy procedures within their local area; safeguarding information should be shared effectively between health professionals and children’s social care especially where there are safeguarding concerns and where the expectant mother has chosen to terminate the pregnancy; communication between partner agencies should be explicitly clear to reduce any misinterpretation around the confirmation (or not) of termination of pregnancy; develop and utilise a mechanism by which their case management system can show information regarding a parent’s learning disability on the child’s digital file; review relevant files when cases are allocated to them to ensure that they are they are working with parents in line with their identified learning needs; develop a robust definition to identify which expectant mothers should be treated as ‘vulnerable’; and information regarding the termination of pregnancies should be conveyed to women’s GPs with consent and as part of a patient’s health record unless there are expressed reasons for not doing so.
Keywords: infant deaths, adverse childhood experiences, domestic abuse, premature infants, autism spectrum disorder
> Read the overview report

2024 – Lancashire - Child Aidan

Suicide of a 17-year-old boy in May 2020. Aiden was not in education at the time of his death and had a history of suffering with mental illness. He had been diagnosed with treatment resistant unidentified schizophrenia, psychosis, and depression. He was twice detained under the Mental Health Act and had been an inpatient at a specialist mental health inpatient unit for young people.
Learning themes include: consideration of a parent’s ability to care for a child with severe mental health problems; capacity and parental consent; specialist mental health inpatient care; home leave planning; and discharge planning.
Keywords: adolescent boys, child mental health services, parenting capacity, psychiatric hospitals, schizophrenia, suicide
> Read the overview report

2024 – Lancaster - Olivia

Olivia died in July 2019 when she was 5-months old. Her cause of death was unable to be established.
Learning includes: the failure to identify the full picture of the families’ domestic circumstances must represent a missed opportunity for the agencies involved; there are several references in this case to professionals conducting routine enquiries, there is a risk that this procedure is carried out during appointments purely to satisfy the rules; failure to identify the complete domestic picture and share this information fully between appropriate agencies must be seen as a missed opportunity; and whilst staff consistency can never be mandated because of inevitable issues such as sickness or staff changing roles, managers must be aware of the risks.
Recommendations include: assure itself that health providers’ policies reflect the need for routine enquiries to be conducted in a detailed manner; incidents of domestic abuse are subject to appropriate supervision and scrutiny, this should ensure that in all cases, risk assessments are submitted following oversight from a supervisor, they should also assure themselves that training is available and mandatory for initial responders to such incidents; MASH policies and processes should be reviewed by all appropriate agencies to ensure that whenever possible a full picture of risk is identified and shared between relevant agencies in a timely manner; lack of consent should not be a barrier to information sharing if it would ensure safeguarding is fully considered; and all agencies are conscious of the risks associated with frequent changes of professionals.
Keywords: infant deaths, domestic abuse, risk assessment, sleeping behaviour, medical assessment
> Read the overview report

2024 – Leicester - Child C and D

Sexual abuse of two girls by one of their foster carers. Child C was a teenager at the time of the allegations and Child D was of junior school age.
Learning themes explore: children’s voice and disclosing abuse; recognising and addressing children’s vulnerability to sexual abuse; assessment of foster carers, support, monitoring and matching; management of incidents, concerns, complaints and allegations about foster carers; and support for the children.
Recommendations include: that the partnership involves looked after children in a wide-ranging ‘help me tell you anything’ initiative to support children recognising and expressing concerns to practitioners; that the partnership updates its sexual abuse procedure to ‘think the unthinkable’ and remind staff that abusers can include foster carers; that the partnership seeks reassurance from fostering services that arrangements are in place so that essential activities to minimise risk of abuse are monitored and any deficits addressed; and that the partnership seeks reassurance from fostering services that any professionals’ meetings convened to discuss emerging concerns are multi-agency.
Keywords: child sexual abuse, foster parents, siblings, voice of the child, disclosure, risk assessment
> Read the overview report

2024 – Leicester – Child E

Details improvements made following a Local Child Safeguarding Practice Review (LCSPR) commissioned in response to a disclosure of sexual assault by a male foster carer made by a 17-year-old girl in 2021. At the request of Child E, the full LCSPR will not be published. Actions by the partnership include: developing and delivering guidance and mandatory training on foster carer supervisions; implementing a practice model which promotes opportunities to hear the child’s voice; making it standard practice to check for referrals about foster carers’ behaviour annually and when placements are being sought; implementing risk analysis and including local authority designated officers (LADOs) in annual foster home reviews and post allegation reviews; improving clarity regarding the relevant LADO when carers live in another local authority; delivering mandatory training on the role and responsibility of social workers in supporting and supervising foster carers; delivering reflection and learning sessions with teams and individual practitioners involved in Child E’s case; sharing lessons from this and other LCSPRs with the local authority fostering service; ensuring that, when an allegation is made against a foster carer, it is identified whether there are any other children in the household and whether communication is needed with other agencies; and including children’s GP status in foster carer supervision reports.
Learning themes of the LCSPR include: children’s voice and disclosing abuse; recognising and addressing children’s vulnerability to sexual abuse; working with foster carers; management of concerns and allegations about foster carers; support for the child; working across multiple local authorities and partnership working; and escalating differences of opinion.
Recommendations: N/A
Keywords: abusive men, adolescent girls, child sexual abuse, disclosure, foster parents, referrral procedures
> Read the executive summary

2024 – Leicester - Patricia

Sexual assault of a 13-year-old girl by an adult in the community in April 2020. Patricia was living in a children’s home at the time, having experienced a number of placement moves since entering care and over the course of the review period. The local authority initiated legal proceedings in respect of Patricia when she was aged 10-years-old.
Learning explores: trauma-informed approaches; personalising moves from one place to another for children; addressing factors that create placement instability; paperwork; and partnership working.
Recommendations explore: supporting training and development around the use of trauma informed language; developing personalised, child and behavioural specific care plans to support children, and carers in meeting their needs; a process enabling better consideration of a child or young person’s experiences and histories, and how this can be taken forwards to inform any planning around future placements; developing a child friendly looked after child care plan; and consideration of the network around the child.
Keywords: child sexual abuse, foster care, placement breakdown, children in care, trauma-informed practice, adverse childhood experiences
> Read the overview report

2024 – Leicester - William

Death of a 4-week-old boy in September 2017 from suspected physical abuse.
Learning includes: the need to take early opportunities to refer and to assess; the need for professional curiosity about parent history and circumstances; the need for clarity between professionals about responsibilities to coordinate and ensure that timely information gathering, and effective intervention occurs to keep practice child-centred; and the importance of treating all contacts and referrals with sufficient care, thoroughness and gravity.
Recommendations include: the safeguarding board to seek assurance from partner agencies that concerns for unborn babies are being referred at the earliest stage within the pregnancy with a shared clarity about the criteria for such referrals; consideration about the actions that are required to improve the provision of detailed information and chronologies between local authorities and in providing information to, and from, partner agencies in a timely way even when cases are no longer open in a particular area; and the safeguarding board needs to be assured that, in terms of partnership working, children’s social care is retrieving relevant historical information and sharing and jointly evaluating that information.
Keywords: infant deaths, injuries, assessment, information sharing, physical abuse, professional curiosity
> Read the overview report 

2024 – Lincolnshire - Bethany and Darren

Murder of a 26-year-old woman and her 9-year-old son by her former partner in May 2021, following a period of physical and psychological abuse. The perpetrator had a history of violence, including a conviction for domestic assault on a former partner.
Learning considers: a child’s lived experience of domestic abuse; recognising key indicators of domestic abuse escalation to inform risk assessments and safety planning; how domestic abuse perpetrator history is transferred between areas, made accessible to those working to safeguard children, and used to inform current assessments of risk; policies and procedures for domestic abuse and safeguarding; and professional curiosity.
Recommendations include: partnership use and knowledge of the domestic violence disclosure scheme, domestic violence protection notices and domestic violence protection orders processes; partnership understanding of stalking, harassment and coercive controlling behaviour; partnership understanding that domestic abuse is always harmful to children; engagement by agencies to ensure they have strategies to interact effectively with reluctant and vulnerable victims; understanding and reducing the risks of perpetrators to victims and their children of domestic abuse, including a greater understanding of the homicide timeline; improvements to local child in need processes and inclusion of multi-agency partners, in particular those delivering adult services; and improvements to multi-agency information sharing to also include the voluntary sector information.
Keywords: homicide, domestic violence, professional curiosity, risk assessment, children in need
> Read the overview report

2024 - Manchester - Child S1

Suicide of a 17-year-old girl in 2021. Child S1 was sexually exploited as a young teenager and was made subject to a care order in 2018. Child S1 spent two years in a therapeutic residence, before returning home to live with her mother.
Learning considers: the visible and hidden complexities of childhood trauma; awareness of foetal alcohol spectrum disorder (FASD); trauma-informed practice; appropriate professionals in attendance at multi-agency meetings; individual and collective interventions; risk assessment and risk of death through self-harming behaviours; children’s plans; safety plans; chronology of significant impact events; and management of adolescent risk when threats to life have been identified.
Recommendations include: the partnership to request an early review of the local authority’s 2020-24 suicide prevention strategy to specifically address risk in respect of adolescent children, including response to alcohol and substance misuse and emotional and mental health difficulties, and guidance around the timing and completion of risk assessments across health and social care; CAMHS to provide expert advice and guidance to multi-disciplinary teams when plans are being formulated to respond to adolescent suicide and self-harm; the partnership to seek assurance from children's health and social care services that they have systems in place to support robust managerial oversight of children's plans; and the partnership to ensure that practitioners working with a child who has a neurodevelopmental condition, have access to information describing the impact of neurodevelopmental disorders and how this may shape their approach and intervention, making sure this is reflected in their assessments and care-planning.
Keywords: suicide, adolescent girls, self harm, family reunification, risk assessment
> Read the overview report

2024 – Medway - Julia

Explores the death of a 5-year-old girl who was found to have drowned in the bath after being left unsupervised. Julia was in the care of her local authority and had been living with her four siblings in a foster home provided by an independent fostering agency.
Learning is embedded in the recommendations.
Recommendations include: audit their records to ensure that the most recent information is provided in foster carer profiles to ensure the matching process for looked after children is fully informed; consider the learning around delay in the provision of key basic safety equipment for the children and audit to ensure that these issues are addressed in a timely manner and recorded in placement planning meetings; ensure that the terminology of ‘short term’ in relation to the placement of looked after children is fully understood by practitioners or foster carers/other practitioners within the children's workforce; consider using existing mechanisms such as professional network meetings to reflect on situations where emergency placements and/or large sibling groups are placed; address the delays to the initial health assessment process identified in this review; review their procedures to ensure that there are no additional delays caused by the request for ongoing delegated consent forms or the attendance of the social worker which are not statutory requirements; and assure that the current process involving the transfer of health information between the local authority/ICB/health trusts in relation to looked after children is effective and the procedure updated.
Keywords: child neglect, children in care, supervision, information sharing, risk assessment
> Read the overview report

2024 – Merton - Vamp

Death of a 13-year-old girl in July 2022. Vamp had been subject to a child protection plan since March 2022 under the category of neglect.
Learning themes include: understanding the lived experience of adolescents, for example around risk-taking behaviour, going missing, risk of exploitation, and being a young carer; ensuring services, including mental health support, are accessible and adaptative to adolescents; and working effectively across boroughs.
Recommendations to the partnership include: strengthen working together approaches across agencies; consider strategies to ensure children who go missing are protected within the community, such as by empowering community members to share information with agencies; utilise a trauma-informed approach to identify and support children and young people (CYP) at risk of exploitation; support professionals in engaging CYP in relationships of trust, enabling CYP to explore and address risky behaviours, situations, and relationships; stop referring to CYP's 'non-engagement' with agencies and prioritise reaching the child; ensure all agencies have a plan for how they will adapt their services to meet the needs of CYP; work with neighbouring partnerships to influence stronger commissioning arrangements across boroughs;; strengthen information sharing and working relationships between services, including between boroughs; liaise with other southwest London partnerships to develop a consistent approach to detached youth work services; develop partnership understanding of the experience of young carers and how they are identified and supported by agencies, including education and mental health services providers; and when there are allegations of sexual assault, all efforts should be made by the police to confirm the age of the victim and perpetrator.
Keywords: abuse allegations; adolescents who go missing; adultification; child carers; drugs; risk taking
> Read the executive summary

2024 – Mid and West Wales – Child A

Death of a 16-year-old girl in October 2020. The condition of Child A’s body was indicative of chronic neglect, and there were significant concerns about the unhygienic condition of her immediate living environment. Child A was found to be grossly obese and immobile and consequently had extensive inflammation and infection leading to her suffering and ultimate death.
Learning themes include: the importance of coordinated 'care and support' to help a child with a lifelong and potentially life-limiting chronic disability live a ‘normal’ life; the importance of monitoring weight and physical activity for children with spina bifida; the importance of monitoring skin conditions for children with limited mobility; transitioning from childhood to adulthood with spina bifida; and the context of the COVID-19 pandemic.
Recommendations to agencies include: undertake a review of existing training programmes and policy guidance to ensure all practitioners speak to and communicate directly with children and their responsibility to accurately record any communications is explicitly clear; clarify or create a protocol regarding regular monitoring of the skin condition of children with complex health needs and mobility limitations, including spina bifida; and review processes and pathways in place for children with chronic disabilities to ensure that: children’s complex care needs and the services they receive are overseen and coordinated by a single agency or practitioner; there are sufficient checks and balances in place to support opportunities for reassessment of a child’s changing needs; and relevant practice guidance is available to ensure children and their families receive the right information, advice and assistance at the right time.
Keywords: children with multiple disabilities, chronic illness, medical care neglect, body weight, poverty, children missing education
> Read the overview report

2024 - Mid and West Wales - CYSUR1/2019

Sustained unexplained and potentially life-threatening injuries to a 5-week-old baby in 2018 whilst in the care of, and living with, his biological parents and maternal grandmother. Following respective criminal proceedings, the biological mother and father pleaded guilty to assault and received prison sentences. The maternal grandmother was charged with assault; however, no evidence was offered by the Crown Prosecution Service, and the case did not progress to criminal trial.
Learning themes: n/a
Recommendations include: ensure that professional curiosity is consistently and effectively applied by all practitioners across adults and children’s services in their practice when working with families; and ensure that safeguarding referrals, assessments, and interventions include, reference and reflect the complete familial picture, always including the father.
Keywords: adolescent fathers, adverse childhood experiences, fractures, grandparents, physically abused infants, post-natal depression
> Read the overview report

2024 - Mid and West Wales - CYSUR 1/2021

Death of a 2-year-old girl in July 2020 following a violent attack by her mother’s partner. The family were known to services after Child A’s older sibling was born due to referrals regarding domestic abuse.
Learning considers: adult needs assessments; child assessment and sickness absence of assessors; health visitors responding to failure by parents/carers to engage; professional curiosity; information sharing; use of specific language in documentation; and record keeping.
Recommendations include: training for practitioners and managers in children’s services on the assessment/sign off process, including a robust process for the auditing of assessments; ensure a policy is in place regarding how staff are supported when sickness issues arise and how cases are managed when staff are on sick leave; multi-agency training on completing a multi-agency referral form (MARF); agencies consider mechanisms, such as multi-agency safeguarding hubs, to facilitate decision making and collaborative practice for cases that fall below the threshold of significant harm; information sharing on siblings between compulsory education and early years settings; training/managerial support for professionals when faced with parents who do not engage; regional police implement a flagging mechanism for addresses where there is a wider history of safeguarding concerns linked to the address; and supervision sessions with practitioners to address the importance of using specific terminology when completing records/reports, and for records to be sufficiently detailed.
Keywords: child deaths, assessment of children, parental involvement, record keeping, unknown men, domestic violence
> Read the overview report

2024 - Mid and West Wales - CYSUR 4 2020

Sexual abuse of a child by a young adult during a short stay with respite foster carers in February 2020. The respite care dates required for Child A and his sibling overlapped with the young adult's respite placement.
Learning themes explore: the importance of compliance with regulatory policies and procedures in the context of a lack of appropriate fostering resources; communication and accountability; and the importance of escalating professional concerns.
Recommendations include: reinforce the importance of escalating concerns and the whistleblowing process when there are concerns about decisions being made around risk and safeguarding; clarify the decision-making process for deciding respite care when there are conflicting needs of children and foster carers; ensure social work staff in the foster care service fully understand risk management and safeguarding of vulnerable children to ensure matching decisions are made with full knowledge of children's history; new foster care placements should be furnished with information about children's health background; and local authority to give assurances that childcare teams are fully consulted and central in decision making for respite provision and matching – and policies are being followed.
Keywords: child sexual abuse, foster care, foster parents, respite care, placement, decision-making
> Read the overview report

2024 – Newham - Child H

Death of an 11-year-old girl. The postmortem linked H’s death to her life-long health condition and poor control of this. This finding has been challenged by the team treating H. On the day of H’s death, her home environment was found to be very poor and unclean. The other children in the house were removed and the adults arrested on suspicion of child neglect, but no charges have been brought.
Learning themes include: illness and death of a parent; managing a child’s health needs; kinship care and parental responsibility; home environment; physical and mental health needs of adult family members; and intersectionality.
Recommendations to the partnership include: offer support to families of children with serious health conditions in a way that mitigates barriers to accessing help and understanding information; develop public health messaging which encourages families to seek support when a child is diagnosed with a serious health condition; provide appropriate training to all family members involved in delivering a child’s health care plan; review the cultural competence of bereavement support services; support professionals in helping families to access bereavement support services and in responding when this support is refused; ensure information about informal kinship care arrangements is shared with families in an accessible way that they fully understand; review the circumstances and thresholds for home visits from relevant agencies; ensure training and guidance for housing staff includes responding to home conditions that could be harmful to children; and ensure intersectionality and anti-discrimination are embedded in training and practice.
Keywords: child deaths, childhood illness, home environment, intersectionality, neglect identification, parental illness
> Read the executive summary

2024 – Norfolk - Delta

Fatal stabbing of an 18-year-old. Delta first came to the attention of multi-agency early help services when he was 13.
Learning includes: consider the implications for relationship-based practice, the meaning of the relationship/attachment between the child/family and practitioner and managing endings; pay attention to transitions at all stages of life, such as childhood to adolescence, and primary to secondary school; evolve the cultural response to how young people are supported into adulthood from 18-years-old and withdrawing services; strengthen trauma informed leadership and compassionate endings with families by supporting staff and their response to families after a child has died; strengthen an understanding across agencies of adolescent development and the importance of promoting a positive sense of identity and belonging; understand the difference between normal adolescent behaviour and help-seeking behaviour and address the root causes of ‘challenging behaviour’; develop an approach to working with families whose children are vulnerable to/are experiencing contextual risks based on a child first approach that places families at the centre; consider developing a contextual harm practice framework to encompass the learning from this review and the principles outlined by Delta’s family about the support they needed; consider how data, performance intelligence and local knowledge can be harnessed effectively to understand emerging trends, young people’s understanding of gang culture and what can be done to develop early help and prevention strategies.
Recommends that the partnership’s vulnerable adolescent group consider the questions arising and the thematic learning from this review and develop an action plan for the statutory partners to endorse.
Keywords: adolescent boys, child criminal exploitation, contextual safeguarding, gangs, young offenders, violence
> Read the overview report

2024 – Northamptonshire - Child Bk

Disclosure of sexual abuse from an 11-year-old girl in January 2023. The perpetrator had been investigated for downloading and distributing child sexual abuse (CSA) images in 2019 and was later found to have been sexually abusing Child Bk over a period of 12 months.
Learning themes include: the multi-agency response to adults who view CSA images; the identification of CSA; and responding to concerns from members of the public.
Recommendations include: explore barriers to professionals applying the correct thresholds to risk and subsequent convening of strategy meetings; review the need to create a separate pathway for children that live with those who have viewed CSA images; ensure that the police are informed immediately of any suspicion that indecent images of children are being viewed and any connected child(ren) are being protected; develop guidance for multi-safeguarding agency responsibilities regarding bail conditions including police communication and what action is required from all agencies; develop a workstream to consider issues around the identification of CSA; complete work around the issue of the sharing of single assessment outcomes with partners who have a continued role with the child and make expectations explicit in procedures; review the current practice of relying on a mother/family member to supervise children’s contact with adults who pose a risk, and develop guidance and an approach to safety planning; develop a risk assessment process to consider the risks adults pose to children of sexual abuse; and where concerns are raised by the public it is essential they are not considered malicious but explored thoroughly.
Keywords: child sexual abuse, child abuse images, child neglect, disclosure, rape, sexually abused girls
> Read the overview report

2024 – Northamptonshire - Child Bm

Case of child sexual exploitation. No details included.
Learning includes: how professionals understood, recognised and responded to signs of child sexual exploitation (CSE); the quality of strategy discussion and the child and family assessment; how professionals understood Child Bm’s lived experience and heard their voice; how agencies worked together to safeguard Child Bm from harm; how professionals identified and assessed protective factors; how personal student information was transferred when Child Bm changed school; and whether there were any missed opportunities.
Recommends that the partnership develops an action plan for improvements to systems and practice including: seek assurance that professionals from all agencies understand the referral processes into the new multi-agency child exploitation team and the benefits of seeking guidance and advice from the team when a referral cannot be made; ensure that strategy minutes and actions are being communicated to, and received by, all agencies (including GPs) involved with the child and family; be assured by partner agencies that section 47 checks are identifying wider professional and familial sources who can support risk assessment and intervention; the healthcare foundation trust (on behalf of the multi-agency safeguarding hub) and the integrated care board should work together with GPs in their area to gain an understanding of GP’s knowledge and experience of safeguarding practice, and how this can influence their support with multi-agency safeguarding hub process; and develop training for schools around the importance of recording conversations within records so that pupils’ records include robust documentation of safeguarding discussions and plans.
Keywords: child sexual exploitation, general practitioners, online abuse, referral procedures, school records, voice of the child
> Read the overview report

2024 - Northumberland - Sophia

Hospitalisation of a 13-year-old girl in March 2023. Sophia was unresponsive, had very low blood sugar, bone marrow failure and malnutrition. She weighed 13.8kg.
Learning themes include: the need to see a child and think about situations from their perspective in all interactions; the need to work together when a child has more than one developmental need or when a situation significantly impacts on how a child functions and develops; the need to share information and be curious; the need to have a co-ordinated multi-agency plan when there is one or more agency working with a child and their family; the need to have a discharge planning meeting following lengthy, complex or safeguarding hospital stays; and the need for everybody to use clear and simple communication.
Recommendations to the partnership include: consider how it can introduce shame sensitivity and shame sensitive practice into learning and development opportunities; encourage workers to gather a detailed history with parents and carers to identify roles and responsibilities; encourage agencies to record information in a child’s record as if they are writing to children and their family; review its information sharing procedures; develop a framework that supports people to feel confident in the role as a lead professional for any type of plan; provide guidance about child developmental milestones and growth charts; support designated safeguarding leads (DSLs) to have access to regular and accessible safeguarding supervision from an experienced worker; support ongoing multi-agency opportunities to reflect as a group on a specific circumstance for a child.
Keywords: child neglect, sexually abused children, eating disorders, children missing education, child development, special education needs, additional needs and disabilities
> Read the overview report

2024 - North Wales - NWSCB 01-2022 (Child A)

Death of a 13-year-old girl in September 2021 after contracting Covid-19. Child A had mitochondrial disease and experienced multiple health conditions. There were concerns about the impact of quarantine on Child A’s health following a family stay in Pakistan.
Learning themes include: the importance of a multi-agency approach to working with a child with a life-limiting condition and their global family; a holistic view of the child’s needs; and the impact of the Covid-19 pandemic, including the impact of UK Government imposed hotel-based quarantine.
Recommendations include: all professionals working with children and families to receive cultural diversity and intersectionality training with a specific focus on working with global families whose children have life-limiting conditions; information about a child's significant health condition and prognosis should be provided to parents in both their first language and English; the Welsh Government to consider how future quarantine facilities will be suitable for children with life-limiting complex health needs; consideration to be given to alternative provision of school-based health services when children are absent from school for a period that would impinge on their health and wellbeing; and the promotion of counselling and wellbeing support to be provided and promoted for practitioners who are working with children with life-limiting conditions.
Keywords: children with a chronic illness, intersectionality, culture, coronavirus, extended families, child health
> Read the overview report

2024 – North Yorkshire - Child N, Child R and Child S

Concerns three similar cases of non-accidental injury to non-mobile infants from different families. Child R presented with a swelling to the thigh aged 4-weeks-old, Child S with breathing difficulties aged 7-weeks-old, and Child N with unexplained seizures aged 3-months-old.
Learning themes include: developing professional skills to work collaboratively with families and colleagues and to formulate a holistic assessment; management of the ‘unsettled infant’, including perceived feeding difficulties and crying behaviour; and pathways to support parents with mental health difficulties.
Recommendations for the partnership include: reinvigoration of the ICON work on coping with crying behaviour to encourage practitioners to tailor this to individual need; development of guidelines for the management of the 'unsettled infant' to reflect both potential feeding problems, as well as normal infant crying patterns, and sources of help and support for practitioners and families; development of a resource which describes how to assess the impact of parental mental health on parenting; and resources available to support parents who are experiencing emotional or mental health problems, with particular consideration given to available sources of support for men.
Keywords: infants, injuries, crying, parents with a mental health problem, postnatal care, feeding behaviour
> Read the overview report

2024 – Renfrewshire - Child 3

Death of a 4-year-old boy and his father in May 2023. Due to the father’s history of mental ill health, Child 3 and his father were both in receipt of a multi-agency package of support from child protection and adult support services.
Learning themes include: parenting assessments; the voice and rights of the child; parental mental ill health; the role of the extended family; liaison between child and adult services; and the identification of risk patterns.
Recommendations include: consider how histories of domestic abuse and parental mental ill health may impact parenting over time; include adult mental health services in parenting assessments; outline contingency plans for potential risks identified in parenting assessments; ensure the voice of the child is highly visible in records after agency contact; ensure chronological data is kept up-to-date and is thoroughly analysed to identify and act upon emerging patterns of risk; develop workforce understanding about mental health diagnoses and how symptoms may present in a parent at risk of repeated illness or a relapse in wellbeing; promote knowledge of the formal process of information sharing, assessment, analysis and decision-making when a child may be at increased risk of harm; take a whole family wellbeing approach to child protection, considering family in its widest context and, where possible, including extended family in supporting the parent and child; and ensure ongoing collaboration and information sharing between child protection and adult mental health services.
Keywords: assessment [social work], child deaths, fathers, interagency cooperation, parenting capacity, parents with a mental health problem
> Read the executive summary

2024 – Rochdale - Child E1

Death of a 3-week-old baby in January 2021. Child E1 was taken to hospital by ambulance after their mother reported that the baby was unresponsive after having difficulty breathing. Child E1 later died from a head injury typical of being violently shaken.
Learning themes consider: professional understanding of maternal mental health needs, their impact upon parenting capacity and parental ability to manage the challenges of a newborn baby with a disability; professional consideration of an early help assessment when it was revealed that Child E1 had cleft lip and palate; and consistent and co-ordinated postnatal support and safe sleeping advice to help parents cope with crying and reduce the risk of abusive head trauma.
Recommendations include: ensure that all relevant professionals are aware of circumstances which indicate an increased risk to an unborn child and may require a pre-birth assessment, and the requirement to make a referral to children’s social care if there is increased risk; that the safeguarding policy on pre-birth assessments is amended to identify a diagnosis of a disability in an unborn baby as a factor which may be an indicator of increased risk; when referrals are made to the cleft lip and palate team, any information held in respect of parental mental health is shared with that team; advise the National Safeguarding Children Panel of the lack of abusive head trauma prevention advice and propose that appropriate abusive head trauma advice is provided to parents across other cleft lip and palate networks.
Keywords: infant deaths, cleft lip and palate, maternal depression, non-accidental head injuries, postnatal care, early intervention
> Read the overview report

2024 – Rochdale - Child l1

Child l1 has been supported from birth by the HMR health visiting team under universal partnership plus services due to him being on a child protection plan for two and a half years under the category of neglect. Child I1 was presented a significant number of times to hospital with health issues and injuries and was at risk of sexual abuse.
Learning is embedded in the recommendations.
Recommendations include: all agencies need to consider how to ensure all professionals are supported to recognise that if they have concerns about a person who presents as someone of ‘good standing’ and/or holds ‘professional status’ to be explicit about this to their supervisors and managers; all agencies need to assure the safeguarding partnership that they are ensuring professionals’ have a high level of awareness of the behaviours of predatory individuals, relating to child sexual abuse grooming and exploitation; the safeguarding partnership should review current training on trauma informed practice and adverse childhood experiences; the safeguarding partnership should consider how to increase understanding of and responses to disguised compliance ensuring professionals have heightened awareness of the behaviours; the safeguarding partnership should evaluate key agencies’ efforts to determine awareness of staff of coercive control within their current training programme for domestic abuse; and the safeguarding partnership to consider how effective key agencies are in raising awareness of bruising on immobile babies policy and guidance, and ensure those non-verbal children who are mobile receive the same level of attention.
Keywords: risk assessment, injuries, child sexual abuse, parent-professional relationships, professional curiosity, domestic abuse
> Read the overview report

2024 – Sandwell - SD

Serious injury to a 17-year-old male in 2022 whilst in the community with friends, leading to a permanent disability. The family was known to services for complex needs relating to criminality/exploitation.
Learning themes include: real-time information sharing and analysis, including use of mapping to inform assessments, plans and decision-making; co-ordination of support when multiple agencies are involved with a child or young person; the complexity and challenge of engaging with a family involved in criminal activity and exploitation; transitions between services when young people approach 18-years-old; and the role of ‘education’ in early prevention through identification of reduced school attendance/presenting behaviour change.
Recommendations include: within the parameters of GDPR, the early help system should consider how to ensure all agencies can see who has been involved with a family/individual, which interventions have been offered, and to what effect; the partnership should consider providing briefings to clarify the role of the lead professional in co-ordinating support across multiple agencies, and the role of the team around the family process; the partnership should provide learning to increase awareness and understanding of ‘adultification’ and its impact on children, young people and families; and education practitioners should be trained in the use of the Graded Care Profile 2 tool to help identify neglect.
Keywords: injuries, adolescent boys, child criminal exploitation, adultification, school attendance
> Read the overview report

2024 – Sandwell - SF

Details the partnership’s strategic commitment to tackling neglect as a response to the death of a newborn baby in summer 2023. The cause of death was unascertained. Describes the implementation of a 2023-25 neglect strategy and action plan and the responsibilities of the tackling neglect subgroup, including: appointing a named strategic lead from all partner agencies; implementing a neglect strategy which includes supplementary toolkit and action plan, and outlines expectations; updating and continuing to maintain the neglect toolkit with up-to-date research, interventions, tools, and good practice case studies; ensuring strategic leads brief all staff within their agencies about updated processes and expectations; delivering multi-agency training to support professionals in identifying neglect and understanding threshold criteria and intervention options; ensuring clear communication pathways between agencies; implementing robust and varied monitoring and scrutiny of the quality of practice and performance regarding child neglect; and ensuring assessments and work with families is timely, effective, family-focused, strengths-based, relational, and trauma-informed.
Learning: N/a
Recommendations: N/a
Keywords: child abuse identification, child neglect, infant deaths, interagency cooperation, referral procedures, threshold criteria
> Read the executive summary

2024 – Sandwell - Thematic Child Safeguarding Practice Review

Outlines the findings of a Child Safeguarding Practice Review (CSPR) that examined the effectiveness of the partnership’s response to child neglect. The thematic CSPR was commissioned following the death of a 5-year-old and two further separate serious child safeguarding incidents where neglect was a feature.
Learning themes include: knowledge, understanding and implementation of the partnership’s neglect strategy; the use of child-centred assessment tools, practice models and frameworks; the need for a shared, multi-agency understanding of neglect and thresholds for intervention; professional confidence; cultural competence; and intersectionality, including the effects of poverty, deprivation and additional needs or disabilities.
Recommendations to the partnership include: develop and disseminate a suite of accessible briefings, targeting specific sectors, which support frontline practitioners in operationalising the neglect strategy into day-to-day work; incorporate the partnership’s strategic aims into all safeguarding and child protection training courses; develop a single suite of tiered multi-agency assessment tools; monitor the use and impact of these assessment tools, alongside staff confidence in using them; develop simplified threshold guidance; expand the guidance, resources and examples available to practitioners; conduct a multi-agency audit of safeguards for children already known to agencies due to concerns about neglect, that are electively home educated, classed as missing education, or have disabilities or special educational needs; raise awareness about parental consent for information sharing and what action to take if concerns remain when consent is withdrawn or not given; and seek out and consider the views of families with previous agency involvement due to concerns about child neglect.
Keywords: assessment [social work], child deaths, child neglect, information sharing, poverty, referral procedures
> Read the executive summary

2024 – Sefton - Charlotte

Rape of a 17-year-old girl in January 2023. Charlotte had been known to agencies since 2007 due to concerns including domestic violence, alcohol abuse by Charlotte’s mother, Charlotte’s mental health, drug use by Charlotte, and previous reports of rape. Charlotte experienced 11 periods of support as a child in need, most recent to the incident between August 2022 and January 2023.
Learning themes include: the assessment and management of changing risk; a child’s legal status under the Children’s Act 1989; the management of continuing vulnerability, including episodes of missing from home, homelessness and self-harm; trauma-informed approaches; multi-agency safeguarding arrangements responsibilities; the management of rape allegations; support for children who are at risk of or suffering sexual exploitation; agencies’ delivery of corporate parenting responsibilities; and enablers of timely agency responses to harm.
Recommendations to the partnership include: ensure multi-agency engagement in cases of children in need; ensure comprehensive assessments of children in need which use child and family assessment tools and result in a timely multi-agency action plans; ensure professionals are aware of and use the practice tools available to them; deliver training to all agencies on the impact of early trauma on children; support all staff in understanding the significance of a child’s legal status with respect to the management of missing from home episodes; and when reports of rape or sexual assault cannot be followed up through the criminal process, the police should consider what other support services might be helpful.
Keywords: adolescents who go missing, children with a mental health problem, homeless adolescents, police, rape, self harm
> Read the executive summary

2024 – Solihull – Arthur

Provides evidence-based opinion on the actions of practitioners involved in the case of 6-year-old Arthur Labinjo-Hughes, who was murdered in June 2020 by his father and his then partner. Focuses on the specific period from 15 April 2020, when Arthur's paternal grandmother contacted the local emergency duty team (EDT) regarding bruising to Arthur, to when the case was closed by children's social care on 27 April 2020.
Examines the actions and decisions of the local emergency duty team (EDT) following contact from Arthur's grandmother; the police in response to EDT's request for a welfare check and on receipt of photographs of bruising; MASH in response to EDT's referral and on receipt of the photographs; and the local authority social worker and family support worker during and after a home visit.
Identifies three missed opportunities for sharper practice, largely centred around the photographs of the bruising to Arthur's back.
Learning: N/a
Recommendations: N/a
Keywords: murder, child deaths, professional curiosity, bruises, physical abuse identification
> Read the overview report

2024 – Solihull – Serious Youth Violence

Two separate incidents of serious youth violence in 2022. The first occurred in January, where a young person under the care of the local authority inflicted serious harm on another. In August, a fight between rival groups involving knives and machetes left three individuals with stab wounds.
Learning themes include: intersectionality and adultification; exploitation strategy and the understanding of gangs; disruption activity; threshold criteria; early help and community organisations; and education.
Recommendations include: consider agreeing a strategic approach to practice with the safeguarding adults board that includes ACEs and a trauma informed approach; review the existing language matters guide and disseminate across the partnership, aiming it at frontline practitioners and managers with a focus on upskilling the workforce around use of language and approaches to working with young people who are the victims of exploitation; promote effective supervision with an emphasis on diversity, reflective discussions and unconscious bias; review and re-launch the ‘Thematic Exploitation Communication Strategy’; review the multi-agency procedures with particular attention to the contextual safeguarding approaches and to ensure the pathway for receiving referrals, assessing, planning and interventions for places, spaces, and peer groups is clear; develop a greater understanding of the activity of organised crime groups both locally and cross border to identify entrenched and emerging networks and establish robust risk outside the home/extra familial harm pathways; foster flexibility in early help pathways to enable the practitioner that is most trusted by the family to remain as the lead practitioner and capture this within procedures and process documentation.
Keywords: adolescent boys, adverse childhood experiences, child criminal exploitation, education, gangs, violence
> Read the overview report

2024 - South East Wales - SEWSCB 1/2021 (Child D)

Death of a 15-year-old boy with cerebral palsy in August 2021, whilst in the care of his mother. Child D and siblings were on the child protection register due to neglect and poor home conditions. Child D’s grandparents held over-riding parental responsibility for him.
Learning themes include: understanding the child’s lived experiences; recurrent poor home conditions and neglect; risk assessments for carers understanding of a child’s care needs; delay in the delivery of specialist equipment; and impact of the COVID-19 pandemic.
Recommendations include: the safeguarding board should develop practice guidance on the lived experience of children with disabilities, to ensure that the voice of the child is actively heard; the safeguarding board to consider if information from GPs regarding children who are subject to safeguarding procedures, should be shared with pharmacists to monitor and share information as appropriate; the safeguarding board to consider the addition of a home conditions threshold to the existing neglect guidance, including photographs of home environments and a multi-agency approach to a cluttered environment; when a child is residing with a parent/carer who no longer holds over-riding parental responsibility, children’s services should complete risk assessments for the parent/carer to prove competence related to the care needs of the child; and regular assessments of specialist equipment should be undertaken, with clear escalation processes regarding the delivery of new equipment and the removal of old equipment.
Keywords: disabled children, parental responsibility, neglecting parents, home environment, coronavirus, child deaths
> Read the overview report

2024 – Southend - Isaac

Isaac was arrested on suspicion of murder of an elderly man in February 2023. Isaac was 17-years-old at the time with complex physical, medical and mental health needs.
Learning is embedded in the recommendations.
Recommendations include: improve understanding and early identification of autism in schools and to promote an inclusive culture; promote understanding of the integrated care system’s responsibility to develop a package of care that meets the needs of young people whose primary need relates to challenging behaviour or emotional and psychological needs; learning from this review should be used to inform the development of the all age autism outreach service, to support people with autism at risk of hospitalisation; in circumstances where young people with complex needs may pose a risk to practitioners, clear risk management plans need to be devised and shared, giving specific advice in relation to the young persons’ needs and triggers; assurance about the robustness of the competency and accountability framework for mental capacity in use across children’s services; partner agencies should collaborate to formulate a shared analysis of how the individual’s cognition function is impacted in different circumstances; improve access to secure beds and therapeutic accommodation that meet the needs of autistic young people; ensure that when a child in their care, who is placed at a distance and attending court, clear arrangements are in place for an appropriate adult to be in attendance to support them; and ensure that communication and consultation with parents of children in care is timely and proactive in respect of their care plan or developments with respect to their welfare.
Keywords: autism spectrum disorder, children in care, mental health, police, youth justice
> Read the overview report

2024 - South Gloucestershire - Children exposed to serious youth violence

Fatal stabbing of an adolescent boy in 2023, resulting in a conviction for murder for one boy and manslaughter for another two.
Learning includes: the importance of identifying and sharing ‘intelligence’ about children who have a history of serious youth violence, and recognising that there may still be a risk without evidence of involvement; the need to engage with all family members; effectiveness of responses to the national referral mechanism; monitoring a child’s drill music; difficulty in knowing and understanding the child’s lived experience; and the need for a clear serious incident response.
Recommendations to the partnership include: develop a critical incident plan with other partnerships in the local area; change the current status and terminology of multi-agency risk management plan (MARM) to child protection plan - risk outside of the home (CP-ROTH) to provide clarity that these children are subjects of statutory child protection planning; seek assurance about the outcome of the partnership intelligence management meetings (PIMM) review, to include an update on capacity, membership, remit, and focus; request that partner agencies consider how they will support staff to ensure that child victims of exploitation are prevented from being ‘criminalised’, including improved promotion of and uptake of relevant training; seek assurance around the work of the violence reduction partnership (VRP) in the local area, including consideration to how information on specific children, and perpetrators is shared regularly as well as the impact of the Online Safety Bill 2023 across the system. Also recommends that the national panel requests that government considers the need for a national standard operational procedure for responding to a critical incident.
Keywords: murder, child deaths, child criminal exploitation, contextual safeguarding, young offenders, violence
> Read the overview report

2024 – Stoke-on-Trent - Child B and siblings

Near-fatal incident to a 5-year-old male child in November 2022. Following a seizure, Child B was found to have adult medication in his system. Subsequent toxicology showed Child B’s two siblings had adult medication in their systems.
Learning themes include: family history and understanding predisposing vulnerabilities and risks; impact of adult issues on parenting and assessment of support needs; impact of adult medication on parenting; recognising neglect across universal and early help services; clear information-sharing and recording systems to inform threshold decisions; patterns of attendance for health and education provision; coordination of services, support, and information across universal services for children with additional needs; and understanding the child’s lived experienced.
Recommendations for the partnership include: evaluate the effectiveness of how learning about neglect is being embedded in practice, including good practice concerning predisposing and coexisting factors; strengthen practitioner skills that enable critical thinking and respectful challenge about neglect; ensure that previous referrals and historical information are used to triangulate information with all services involved with the family to consider the right level of need in threshold decisions; ensure professionals have knowledge of safeguarding the unborn baby procedures and are aware when to refer; review how the multi-disciplinary early years forum can be strengthened to improve the identification of neglect for children with additional needs and disabilities; and seek assurance from the integrated care board that there are robust systems in place to consider neglect by ensuring that children not brought for health appointments are regularly reviewed.
Keywords: neglected children, child neglect, prescription drugs, addicted parents, special educational needs, additional needs and disabilities, non-attendance
> Read the overview report

2024 - Stoke-on-Trent - Children C and D

Murder of an 11-year-old boy and his 7-year-old sister by their mother in June 2023.
Learning themes include: the importance of the role of fathers/male caregivers for children and how they can be engaged; consideration of possible cultural bias as a barrier to accessing services; understanding risk and behaviours in domestic abuse including female perpetrators; understanding of the impact of parental mental health issues on children and family functioning; and the significance of children not being brought for health and education appointments.
Recommendations to the partnership include: ensure that professional development allows staff to strengthen their skills in ‘professional curiosity’, including an exploration of any possible cultural, gender and/or neurodiversity barriers to accessing services; ensure there are regular opportunities to reflect on the role of fathers; provide training to strengthen knowledge in understanding risk characteristics and behaviours in domestic abuse, including coercive control, gender bias and consideration of male victims; ensure practitioners are alert to the need for early help for children and families who have additional needs and there are clear systems that identify emerging problems and unmet needs; ensure that when families access support services there are systems in place that identify and meet individual communication needs; establish clear guidance, and principles about working with the whole family and identifying support for adults with child-caring responsibilities; GPs should review in-person adult mental health medication at least annually; and the police should ensure that in situations of domestic abuse all children in the household are considered as victims and a clear risk management process means protective processes are in place while multi-agency risk assessment is undertaken.
Keywords: autism spectrum disorder, child deaths, culture, domestic abuse, filicide, parents with a mental health problem
> Read the overview report

2024 – Suffolk - Jake

Death of a 17-year-old boy from diabetic ketoacidosis, hyperglycaemia, diabetes mellitus and bronchopneumonia. It has been confirmed by the paediatrician that Jake’s death would have been prevented if health care had been sought over the weekend that he was ill.
Learning is embedded in the recommendations.
Recommendations include: schools should always pay specific attention to children with vulnerabilities and learning disabilities and consider that these children will require additional or specific support and services; deeper consideration should have been given to the rationale behind Jake’s threatening and challenging behaviour; the number and extent of the concerns across the four school’s recording systems should have prompted referrals to Customer First and MASH and at the same time, led to the completion of an Education, Health and Care Plan (EHCP); schools should always contact and communicate with parents when they have multiple and serious concerns regarding children’s behaviour and prior to implementing an exclusion; schools should give greater consideration to the implications of excluded children with vulnerabilities and challenging behaviour becoming invisible to services and effectively ‘going under the radar’; and social care should have ‘noticed’ the other children in the house and considered the risks and concerns for them and the implications of poor parenting and parenting capacity.
Keywords: childhood illness, exclusion from school, child deaths, children missing education, children with a learning disability, child behaviour problems
> Read the overview report

2024 – Suffolk – Molly, Isobel, Sophie

Neglect and physical harm of three children under 4-years-old. Molly, Isobel and Sophie were subject to six submitted safeguarding referrals and two completed social work assessments since July 2020. Agencies reported difficulties in contacting the parents, and concerns were raised around the children not being appropriately supervised. The family were also homeless. All three children have been removed from their parent’s care and are in long term foster care.
Learning: n/a
Recommendations are embedded in the learning and include: share information and ensure records are updated and current in order that all professionals working with children and families know and understand the work being undertaken across all agencies; to ensure that interpreters are always used where English is a second language; immediately escalate cases where lack of engagement is a regular occurrence and where parents are challenging; the need for professional curiosity to be shown when there are several calls regarding incidents of assault and injuries to children, consideration of family history and history of agency involvement when making decisions about referrals. Highlights some areas of good practice.
Keywords: information sharing, neglected children, parental attitudes, record keeping, siblings, homeless families
> Read the overview report

2024 - Swindon - Tristan

Hospitalisation of a 17-year-old boy in 2023 due to a very low BMI and a decline in his physical and mental health. In 2022 Tristan disclosed physical and emotional abuse by his father to school staff. Concerns escalated around Tristan’s weight, mental health and school attendance.
Learning themes include: response of agencies to poor school attendance, weight management and physical health needs, mental health needs and concerns around self-neglect, and support for young carers; parenting capacity, parental health and adopting a whole family approach; risk assessment in relation to health and appropriate use of escalation procedures; and the application of the Mental Capacity Act 2005, adultification, and transition planning for adulthood.
Recommendations include: children’s services to consider how to promote understanding of the needs and rights of young carers; the partnership to develop an adolescent safeguarding framework, to support practitioners to recognise and assess the harm experienced by older children; the local integrated care board to review the commissioning arrangements for young people with avoidant restrictive eating disorder (ARFID); the partnership to ensure that learning from this case is used to educate the professional network in respect of recognising and responding to the needs of boys with disordered eating; the partnership to review how the inter-agency escalation policy is being used and whether this is resulting in timely resolution on areas of dispute between agencies; and in complex cases, practitioners should collaborate to formulate a shared analysis of how the individual’s cognition function is impacted in different circumstances, to support frontline practitioners in undertaking mental capacity assessments that are decision and time specific.
Keywords: eating disorders, children with a mental health problem, emotional abuse, physical abuse, children as carers, adolescent boys
> Read the overview report

2024 - Telford - Alfie

Non-accidental injuries to a 4-month-old infant in 2021 whilst in the care of their parents. Bruising was identified during a routine health appointment and a later skeletal survey identified significant internal injuries. Alfie’s mother and father reported experiencing anxiety and depression at the time of the incident. Alfie’s father was subsequently convicted of grievous bodily harm and neglect.
Learning includes: the impact of COVID-19 on parental mental health; the need to 'see' fathers; information sharing and consent; and responses to risk.
Recommendations include: all efforts are undertaken to ensure fathers/partners are fully known and engaged in their unborn/new-born babies lives across universal and specialist services, and that father’s demographic details are checked regularly; fathers/partners are offered support and parenting intervention, particularly during the perinatal period; adult mental health services should work with children’s services to ensure consent to share information reflects the family’s situation, any support needs, and impact on parenting and children; consideration of the family’s situation and confidence in engaging in online or in-person therapies should inform the agreed intervention in a timely way; and policies on bruising in non-mobile infants should be reviewed to check for consistency with the evidence base and national guidelines.
Keywords: parents with a mental health problem, infants, physical abuse, fathers, child neglect, postnatal care
> Read the overview report

2024 - Telford and Wrekin - Neglect

Considers the local systems and practice where there are concerns that may indicate child neglect through learning from two cases. Following the death of a 4-week-old baby in Family 1, where there do not appear to be any suspicious circumstances, significant concerns were identified about the living conditions of the baby and their siblings. Family 2 were considered at a rapid review meeting after serious concerns emerged about the home conditions.
Learning includes: sharing information about a child’s history, a parent’s vulnerabilities, and concerns is essential when considering if a child requires support, an assessment, and/or a safeguarding response; professionals need to identify when there is an impact on children when they are having difficulties in meaningfully engaging with a parent; professionals need to explore a child’s lived experience and recognise the cumulative harm to children when they experience neglect over time; and when there is a ‘concealed’ pregnancy, information sharing, and a coordinated inter-agency approach is required.
Recommendations include: that the partnership implements a neglect strategy and toolkit to improve the understanding of neglect; the partnership to seek assurance that schools are aware of the need to and are accessing information available to them about a child’s history when they have concerns about the child or their family; and the partnership to ask agencies how they are ensuring the expectation that professionals making a referral in respect of a child are checking their own systems to ensure they are aware of background, previous concerns and are including that information.
Keywords: child neglect, infant deaths, home environment, parent-professional relationships, siblings, pregnancy
> Read the overview report

2024 - Telford and Wrekin - Neglect revisited

Considers the learning from a case where serious neglect was identified following the seemingly unrelated death of an 11-month-old girl in 2022.
Learning explores: practice when a family move between local authority areas; the need to consider any cultural and language issues when working with a family with dual heritage and where one parent grew up outside of the UK; the need to identify and ‘name’ neglect when there is developmental delay; and the identification of young carers.
Recommendations include: partner agencies to remind professionals of the need to be culturally aware and competent in assessments and direct practice; the need for professionals to be sensitively honest about any difficulties in understanding a parent when English is not their first language; the need to include unannounced visits in plans when working with a family where neglect and household conditions are a concern; and that the partnership considers how it can ensure improved and good practice regarding safeguarding children who move across local authority borders, including those who are children in need.
Keywords: child neglect, home environment, infant deaths, culture, language, siblings
> Read the overview report

2024 – Trafford - Child 20

Serious accident involving an unsupervised 4-year-old outside of the home who sustained a head injury in June 2022. Thematic analysis includes: think family; response to mother’s health, care and support needs, and to half sibling; the effectiveness of referral, care planning and escalation processes from early help to child in need or child protection; the response to neglect, including for adolescents; and the impact of Covid and any other organisational issue.
Learnings are embedded in the recommendations.
Recommendations include: consider how best to ensure that practitioners have access to information about parental health conditions during assessments and care planning especially for those conditions which are unusual or which may impact on their parenting; arrange multi-agency audits regarding safety plans, that they are developed and shared with other agencies, put into writing, effectively monitored and any lack of compliance is promptly addressed; arrange multi-agency audits regarding the response to contact with first response about children who are open to the integrated family support service or a social worker; all agencies working with children to review recording and communication systems to ensure that requests for escalation by other agencies, or internally within the council by IFS, are included in the child’s record in a way that facilitates management oversight of cumulative and/or chronic concerns; raise awareness that senior managers from other agencies other than social care can request that an initial child protection conference be convened; ensure social workers seek consent to share child and family assessments with other practitioners involved with the family; child and family assessments are repeated when the circumstances of individual children or their family changes significantly; and review the implementation of the introduction of impact chronologies.
Keywords: head injuries, parenting capacity, supervision, child neglect, alcohol misuse
> Read the overview report

2024 – Trafford - TRAFF-17

Rape of an adolescent girl in 2021. The perpetrator had previously served a 10-year prison sentence for raping an adult male.
Learning themes include: the effectiveness of the systems and activity to assess, monitor and manage the risks posed by the perpetrator; identifying and addressing children’s vulnerability to sexual abuse; and responses to Child 17’s health and educational needs.
Recommendations to the partnership include: seek evidence from the police that they have effective systems to ensure that the sex offender management unit (SOMU) identifies sex offenders who may pose a risk and shares information accordingly; consider how to improve the partnership strategic risk management arrangements; ensure practitioners are confident discussing sexual abuse with parents and children, raising awareness of ‘Sarah’s law’ and other police powers to share information about risky individuals; conduct an audit to ensure appropriate practitioners contribute to family support meetings led by intensive family support service (IFS) and that IFS involvement ceases at the right time with step-down support offered as needed; ensure the IFS has effective systems to monitor caseloads of practitioners and address adverse workloads; seek evidence that for education and health care plans (EHCPs) and reviews there are effective systems to collect and collate information from all agencies who may be involved with a child; seek evidence that staff in A&E and gynaecological services recognise and follow up circumstances which might indicate children are being sexually harmed. Additionally, recommends the Home Office look at developing national guidelines on maximum caseloads for SOMU supervising sergeants.
Keywords: mental health services, prison and prisoners, rape, sex offenders, special educational needs, additional needs and disabilities, unknown men
> Read the overview report

2024 – Warwickshire - Emily and Ryan

Explores the circumstances which led to a serious sexual assault of a 16-year-old girl that was looked after in supported accommodation by a 17-year-old boy who was also looked after in supported accommodation.
Learning includes: ethnicity and gender appear to be factors in child criminal exploitation; known risk factors around vulnerability don't always act as predictors; exclusion from mainstream school is seen as a trigger point for risk of serious harm; building a trusted relationship between children and practitioners is essential to effective communication and risk management; parental engagement is nearly always a protective factor; and the national referral mechanism is not well understood and is inconsistently used.
Recommendations include: develop a system and protocol for lead workers in complex cases, the issue is time allocation and professional support for anyone given the role of managing information and sharing intelligence in complex cases; the services for young people who have suffered domestic abuse should ensure that risk assessments completed by other agencies are included in risk assessments to fully understand the level of risk; consideration of the appropriateness of the DASH assessment tool where the victim and perpetrator are both legally children; ensure that awareness and knowledge of trauma-informed practice model are embedded in all assessment tools; where there are domestic abuse concerns between children and young adults who are subject to the national referral mechanism, these issues should be considered as part of an ongoing assessment of risk; and ensure that these assessments are proactively progressed and completed where there is a concern that a young person may have special educational needs or disabilities.
Keywords: child criminal exploitation, domestic abuse, children in care, rape, young offenders, social services
> Read the overview report

2024 – Walsall - Miles

Miles died at 18-months-old in 2019 and had been in foster care for the previous eight months with his mother whilst assessments, as part of Court proceedings, were taking place. Miles had considerable additional health needs which required daily care and attention.
Learning includes: regular and reflective supervision for foster carers is critical to avoid bias forming; ensure all professionals involved with a child remain alert to such biases being formed; when information about a child’s safety or welfare comes from an unexpected source it is important that the lead professional has access to all relevant information and is able to maintain a chronological overview; expectations between professionals needs to be clearly articulated; conducting strategy discussions as a single agency, or in the absence of information from other sources defeats the objective and undermines the collective effort to safeguard children; when children have complex health needs that require the involvement of multiple professionals it is important for the named lead professional to maintain some oversight of missed appointments; and notification systems and processes are an important and necessary feature for busy professionals working with large numbers of people.
Recommendations include: review notification systems to health partners, particularly general practitioner, when children become subject to child protection plan and/or looked after children; seek assurance about the process for ensuring all relevant professionals, especially health practitioners, are invited to strategy discussions on cases that are already open and have a lead social worker; ensure the revised regional guidance about the recognition, response and management of bruising and injuries to non-mobile infants is disseminated to all relevant professionals; and provide training about bruising and injuries to non-mobile infants done by organisations and practitioners in this regard; consider what can reasonably be expected, when information is provided, and the parents or carers have capacity; and ensure a shared agency and multi-agency understanding consideration should be given to the role and responsibilities of community mental health team and peri-natal mental health services (including eligibility thresholds) in respect of professional referrals at identified times of patient and family crisis.
Keywords: child deaths, children in care, teenage pregnancy, parenting capacity, information sharing
> Read the overview report

2024 – Warrington - Scarlett

Considers the effectiveness of services delivered to Scarlett who has been convicted, jointly with Eddie, of Brianna’s murder by multiple stabbings in February 2023.
Learning includes: the comprehensiveness of information sharing about the needs and circumstances of the child; the benefits of consulting and minutes of meetings between the schools and/or with parents so that mutual expectations and agreed actions are clear; the benefits of agreeing review arrangements between the schools, and with parents from the beginning; substance misuse includes the supplying of a drug as a ‘sweet’, i.e. without the person knowing what they are taking, is administering a noxious substance; parents worry about what children are accessing online and need support to access tools to help them monitor this, and tactics for conversations and negotiations with children; and school communities to promote safe online activity.
Recommendations include: undertaking the evaluation of the local ‘managed moves’ guidance; make recommendations to the Department of Education about what changes may be beneficial in the statutory guidance for managed moves, and that this should explicitly recognise the benefits of multi-agency involvement in the planning of them and that this should apply to all vulnerable children not just those who have a social worker; identify how best to promote local initiatives to support parents, school communities and practitioners working with children to safeguard children when they are online; and the need for police to make home visits to children who are suspected of administering a noxious substance (aka spiking).
Keywords: homicide, drug misuse, mental health, information sharing, school attendance
> Read the overview report

2024 - Warwickshire - Fara

Death of a 1-year-old infant in August 2020. Fara drowned at the family home whilst both parents were under the influence of drugs.
Learning themes include: parental substance misuse; asylum-seeking adults; engagement with fathers; importance of single assessment; cumulative impact of parental difficulties; professional curiosity; late presentation/potential concealed pregnancy; liaison between health and drug misuse services; role of GPs: role of housing providers; and criminal activity/anti-social behaviour.
Recommendations include: the partnership should continue to monitor the effectiveness of the family front door arrangement; multi-agency guidance for dealing with late presentations/concealed pregnancies should be prepared and awareness raised across agencies; a protocol should be developed to co-ordinate the involvement of substance misuse/drug treatment and health services pre and post-birth; the child death overview panel should consider how to raise awareness of the risks of serious harm and death to children when parents have consumed drugs or alcohol, from neglect and lack of care and of the dangers of children being left unsupervised; the partnership should prepare a seven minute briefing to develop practitioners’ understanding of the challenges facing asylum-seeking adults and their families; the partnership should seek assurance from partner agencies that they are meeting their legal requirements to provide interpretation, translation and signing services; and the police should report to the partnership regarding the resourcing and effectiveness of the intelligence processing unit, the safer neighbourhood team and the harm assessment unit.
Keywords: infant deaths, drowning, child neglect, asylum seekers, addicted parents, pregnancy, substance misuse
> Read the overview report

2024 - West Glamorgan - WG S65 2023 (Child A)

Significant drug overdose leading to the hospitalisation of a 17-year-old male and the death of a 28-year-old female in September 2022. Child A had contact with multiple agencies from 2021, due to concerns including untreated seizures, epilepsy, use of illegal substances, lack of parental care, his relationship with Adult B, and child criminal exploitation. He was placed on the child protection register under the category of neglect in October 2021.
Learning themes include: the role of gender bias; recognising and responding to the risk of exploitation; professional curiosity; disguised compliance; the impact of COVID-19; engagement with professionals; medical non-attendance; referral processes; trauma; and the importance of partnership working.
Recommendations to the partnership include: support practitioners and supervisors in better understanding what child sexual exploitation (CSE) looks like, including cases involving adult females and adolescent males; ensure all agencies recognise and act upon CSE as a modern slavery/human trafficking offence; re-issue partnership practice guidance on professional curiosity to all agencies; ensure all practitioners are aware of and follow the actions to be taken when children under safeguarding processes are not brought to health appointments; ensure a multi-agency approach is used to engage with children and families; ensure statutory timescales are met by all agencies; remind practitioners of the importance of checking records for accurate information; ensure all relevant agencies are included in practice review panels; consider incidents in context, and take a trauma-informed approach in responding; ensure practitioners receive enough support and supervision; and further agencies’ understanding of vicarious trauma.
Keywords: child criminal exploitation, child health, child neglect, child sexual exploitation, drugs, non-attendance
> Read the executive summary

2024 - West Sussex - Adult A, Child 1, Child 2, Adult B

Death of a family comprising two adults and two young children, all of whom died, by gunshot, in March 2020. Adult A, Child 1 and Child 2 were killed and Adult B, as the perpetrator, died by suicide.
Learning includes: the need for greater professional curiosity by police and health professionals about dishonesty and integrity, as well as the origins, impact and risk of recreational drug use on other household members; the need to improve systems, policy expectations and processes with sharing information between the GP and the police; and the need to raise awareness, in general, about the unpredictable and negative impact of recreational drug use.
Recommendations include: health professionals who are in contact with people reporting alcohol/drug use to consider the impact of substance misuse on the whole family; review the current timescale of holding a gun license for five years without any form of updating information, monitoring or refreshing of holder’s circumstances; and Home Office should revise the gun licensing guidance to state that all police licensing authorities, when seeking health/medical information about an applicant, should be sent a standard pro forma for GPs to complete.
Keywords: homicide, suicide, weapons, medical records, mental health, substance misuse
> Read the overview report

2024 – Wigan - Isaac, Sibling 1 and Sibling 2

Explores the experiences of Isaac, a 10-year-old boy, who reported that his two siblings had behaved in a sexually inappropriate way towards him, later disclosing he had been sexually abused.
Learnings include: children need to be enabled and supported to talk about child sexual abuse; help seeking behaviour needs to be responded to positively; careful thought needs to be given to how 'no further action' is communicated to a child or family; when children share concerns and then retract them, this requires appropriate professional analysis to consider what this means in the context of the child's needs and circumstances; there needs to be certainty about the threshold for action regarding sibling sexual behaviour; thought needs to be given about how 'no further action' in criminal justice processes is communicated to children and their families; confusion about whether professionals can talk to children about sexual abuse whilst criminal investigations are ongoing needs to be addressed; there needs to be more readily available support for children who have been sexually abused; the work of schools to meet the needs of children who have been abused should be included in child protection and child in need plans; professionals need to help children who have experienced sexual abuse understand the link between what has happened and the difficulties they are experiencing to avoid internalising a sense of 'something being wrong with them'; children need trauma focussed services to heal from sexual abuse; family dynamics need to be understood to make family healing and recovery possible; and the role of child protection conferene chairs in ensuring that child protection plans are actioned and fit for purpose is critical.
Recommendations are embedded in the learning.
Keywords: sibling sexual abuse, disclosure, information sharing, risk assessment, trauma
> Read the overview report

2024 - Worcestershire - Alfie

Murder of a boy in February 2021 by his mother’s partner, following a period of physical abuse and cruelty in the home.
Learning considers: assumptions around contact when new partners join families; professional understanding of domestic abuse; adults of concern who do not meet the threshold for public protection meetings; fixed thinking or confirmatory bias; effectiveness of the core group process; responding to physical abuse; issues around professional reliance on children disclosing abuse and harm; and how the safeguarding system responds to concerns from friends and neighbours.
Recommendations include: agencies should challenge their views and hypotheses in cases when there is no evidence to substantiate those views; safeguarding partners to ensure intelligence held on those involved in the lives of children on child protection plans is shared and used to reduce risk; the partnership to ensure that multi-agency staff are prepared for their role in core groups; the partnership to seek assurance that professionals know when a strategy discussion and child protection medical is required in relation to a child’s injuries, with care taken about the weighting given to the child's explanation; the partnership to provide support to professionals on distinguishing between the misplaced use of physical chastisement in responding to behavioural concerns and the use of physical abuse; the partnership to provide development for practitioners to promote an understanding of the relative weighting to be given to evidence of concern, professional judgement, and direct disclosure of harm; and the partnership to provide guidance to practitioners on how they can strengthen child protection plans by supporting family members and neighbours to formalise reports of concerns.
Keywords: murder, child deaths, unknown men, physical abuse, disclosure, medical assessment
> Read the overview report

Case reviews published in 2023

A list of the full overview reports and executive summaries added to the National Case Review Collection. To find all published case reviews search the national collection.

Case reviews describe babies', children's and young people's experiences of abuse and neglect. If you have any concerns about children or need support, please contact the NSPCC Helpline on 0808 800 5000 or emailing help@nspcc.org.uk.

2023 – Anonymous – Child A

Death of a 16-year-old girl. Child A may have died by suicide.
Learning focuses on: interagency working when there are disclosures of historical sexual abuse; the impact of sibling-to-sibling sexual abuse; partial disclosure of sexual abuse or assaults; responsibilities of private therapists to safeguard children; peer support and influence; and school transition from secondary to sixth form.
Recommendations include: a multi-agency reflective learning event to explore the application of research to improve responses to child sexual abuse; undertake a multi-agency audit of cases of sibling sexual abuse to inform the learning event; contact the British Association for Counselling and Psychotherapy (BACP) asking that members are reminded that their counselling ethical framework sets out directives to refer safeguarding concerns; encourage schools to regularly audit their child safeguarding records to ensure compliance with school transfer protocols; and consider how peer mentoring could be developed and used to support children and young people who decide not to proceed with allegations of historical abuse.
Keywords: child deaths, suicide, child sexual abuse, sibling abuse, adolescent girls
> Read the overview report

2023 – Anonymous - Child A

Serious injuries to a 2-year-old boy in November 2020. Child A was subject to a child protection plan at the time, having previously been subjected to other injuries.
Learning includes: professionals working with a family should fully understand the parental history held across agencies, including a full understanding of any learning difficulties; living with domestic abuse as a child can have an impact when a person becomes a parent; domestic abuse in the wider family may be a risk to a child; all professionals working with children need to be aware of and use the practice guidance for responding to bruises in non-mobile babies; if a child has an injury information should be shared widely with all professionals to ensure awareness of the whole picture and any patterns of cumulative harm; when babies and children are reported to have sustained accidents, professionals should not only consider neglect through lack of supervision, but also the possibility of physical harm; professionals need to be empowered to challenge each other; and for a child’s plan to be effective, a chronology of each agency’s involvement is essential.
Recommendations include: review and update the practice guidance for assessment, management and referral on bruising in non-mobile babies; review and update the professional disagreement and escalation policy; partner agencies consider introducing a requirement that individual agencies produce impact chronologies for all child protection conferences; and request that agencies work together to develop systems that allow identification (possibly via a trigger or alert) when there are repeated injuries on a child or young person.
Keywords: adults with learning difficulties, child protection registers, family violence, head injuries, hostile behaviour, parents with a mental health problem
> Read the overview report

2023 – Anonymous - Child E

Death of a 15-year-old-boy in July 2021. Child E was fatally stabbed by another 15-year-old-boy.
Learning focuses on: the involvement of young people in exploitation and knife crime and the potential for rapid escalation of violence; the heightened risk that children who have special educational needs, or who experience a disrupted education, may become involved in serious youth violence or may be exploited; helping children involved in criminal activity or at risk of exploitation who have suffered severe adverse experiences in early childhood; responding to the needs and circumstances of Black children and their families; and the role of social media in exploitation and the response of professionals.
Recommendations include: local safeguarding children partnerships (LSCPs) test whether there is effective response to the rapid escalation in violence that can occur when there is child exploitation or serious youth violence; LSCPs test the effectiveness of arrangements to promote better school attendance, and reduce rates of exclusion, among young people at risk of exploitation; LSCPs review the effectiveness of responses to families from Black and minority ethnic communities to consider how best to understand and discuss their experiences, values and perspectives; the Child Safeguarding Practice Review Panel should promote learning from the review of services provided to suspected perpetrators of serious youth violence and criminal exploitation, both through guidance issued by the panel and by seeking changes to the statutory guidance 'Working Together to Safeguard Children 2018'; consideration should be given to wording in the draft 'Police, Crime, Sentencing and Courts Act 2022' guidance on the review of offensive weapons homicides.
Keywords: child deaths, adolescent boys, violence, child criminal exploitation
> Read the overview report 

2023 – Anonymous – Thematic review of Infants Under 1 Year

Thematic review on infants under 1-year-old, covering seven rapid reviews from August 2019 to March 2020. Cases involve infants who suffered abusive head trauma, fractures consistent with non-accidental injury and concerns in relation to neglect, substance misuse and domestic abuse.
Learning includes: children aged 0-2-years-old are not always visible to services; the totality of commissioned services for infants needs to be mapped and a gap analysis completed in order to strengthen earlier identification of need and risk; the single point of access for children's services needs to be embedded and thresholds well understood and applied consistently; improving the knowledge and skills of practitioners to observe and assess the lived experience of pre-verbal and non-verbal children; information sharing continues to create challenges for professionals, including misunderstandings of data protection legislation; the need to understand and assess the emotional and physical risk to babies and children of being present in a household where there is known domestic abuse; professionals need to robustly consider the likelihood of future risk to children, considering how parental mental health concerns, substance misuse and domestic abuse can fluctuate over time; professionals should challenge colleagues if new information is not sufficiently considered which may lead to a safeguarding risk; fathers or co-parents need to be an equal part of assessments, support and plans in order to ensure that the needs and risks to a child are known and met; professionals need to know when a formal pre-birth assessment needs to be undertaken, and provide challenge if this does not happen.
Recommendations: N/A
Keywords: infants; head injuries; injuries
> Read the overview report

2023 – Barnsley – Child ‘T’

Death of a 9-week-old-boy in November 2018 from non-accidental injuries, including a very serious injury to his brain and fractured bones.
Learning includes: there were no obvious issues that would have suggested to staff working with the family that Child 'T' was at risk of abuse or neglect; with the exception of a missed pre-birth visit by health visitors, agencies did accord with their own policies and procedures and managers within public health and the midwifery service are taking action to resolve the communication issue; there is evidence of good practice in the record keeping by both midwives and health visitors; and staff in both agencies kept comprehensive records that clearly evidenced assessments they completed and conversations they had with parents to discuss known risk factors to babies.
Recommendations: makes no recommendations.
Keywords: general practitioners, fractures, homicide, infant deaths, non-accidental head injuries, record keeping
> Read the overview report

2023 - Berkshire West - David

Arrest of a 16-year-old boy arrested on suspicion of murder in November 2021. David was a looked after child who had been the victim of criminal exploitation.
Learning includes: developing positive, strengths-based relationships with parents and carers supports safety planning; robust, child centred, and focused support plans must be in place for Special Guardians and these need to be regularly reviewed and adapted; children and young people at risk of criminal exploitation need consistent professional involvement and relationships; safeguarding agencies need to regularly review their approach to child criminal exploitation by listening to the experiences of young people and applying this learning to practice; contextual safeguarding meetings should have the same 'status' in safeguarding partnerships as child protection case conferences; practitioners need to develop their understanding of culturally sensitive practice and consider how a young person might experience oppression, discrimination, and risk.
Recommendations include: test and evaluate the use of contextual safeguarding meetings; pilot a 'child safeguarding pathway' for exploited children and use the evidence to inform future practice; consider learning from other safeguarding partners and agencies who have developed effective contextual safeguarding practice, particularly implementing 'Signs of Safety' as a practice model; develop a safety planning toolkit which supports practitioners in their child criminal exploitation work; children's social care to test out having a single social work practitioner to support children experiencing exploitation; consider how to implement a trauma informed approach to practice, including how to support staff with vicarious and secondary trauma and develop arrangements for critical debriefing.
Keywords: child criminal exploitation, contextual safeguarding, adolescent boys, foster care, special guardianship orders
> Read the overview report

2023 - Birmingham - Adult A

Fatal stabbing of an adult in October 2020. A 14-year-old girl pleaded guilty to manslaughter on the grounds of diminished responsibility.
Learning themes include: identifying, understanding, and responding to the needs of those at greatest risk from children exhibiting the most harmful behaviour; the effectiveness of systems to protect those most vulnerable, particularly within the context of intersectionality, structural racism, adultification and extra-familial harm; understanding family dynamics, needs and history in its broadest context is vital; the importance of recognising and understanding the impact of trauma and abuse on children and utilising a trauma-informed approach; the importance of the continuity of care, support and information exchange when a child moves area; recognising that children involved in offending behaviours are vulnerable too and resolving their unmet needs is critical to reducing the risk they present to others; the need of all agencies to constantly question and challenge themselves on how well they understand a family and how effectively they are working, both with the family, within their own agency and with each other; a child at risk of being permanently excluded should trigger a multi-agency safeguarding response; and housing authorities should consider risk and vulnerability when placing vulnerable individuals and families into accommodation.
Recommends that: “Working Together to Safeguard Children, 2023” strengthens the importance of housing being involved routinely in multi-agency arrangements to safeguard children.
Keywords: abusive children, child behaviour problems, child criminal exploitation, exclusion from school, homicide, youth justice
> Read the overview report

2023 - Blackburn with Darwen - Child F

Death of a 16-year-old boy in December 2020 by three young people over a drug debt. All four young people had a history of involvement in either drug supply at street level and or involvement in anti-social behaviour and violence between young people.
Learning includes: understanding safeguarding within adolescence as a developmental life stage; the importance of considering the dual identities of young people as victims and perpetrators of harm; practitioners needing to hold the concepts of the autonomy of the young person and their dependence in healthy tension; the role of poverty and inequality as a driver for harm and adversity; the importance of providing a personalised and tailored response; the role of adultification – seeing children as older and more responsible than they are chronologically or developmentally; whether the current legal and policy framework facilitates or inhibits effective responses to extra familial harm; the importance of a trauma informed approach to working with young people where practitioners look for what lies beneath a young person’s behaviour; the connection between young people’s trauma and unmet developmental needs; and viewing trauma through developmental and relational lens enables better sense making of young people’s worlds and the impact of their experiences.
Recommendations include: commit to the implementation of the national exploitation principles when published; develop a range of early intervention services to support children and families at risk of or in the early stages of child criminal exploitation; ensure that practice always explores the strengths within the immediate and wider families of children at risk of or being criminally exploited; and recruit workers with the personal skills to undertake relational work with children and families and gives them the training to develop those skills further and time to develop relationships with children and families which do not preach or judge.
Keywords: child criminal exploitation, drugs, exclusion from school, police, risk taking
> Read the overview report

2023 – Bradford – Babies who sustained injuries

Three cases where babies sustained injuries believed to be non-accidental in 2022. Considers and compares the learning from previous reviews with the learning in respect of the 2022 babies, to enable reflection on the impact they have had on practice and safeguarding systems in the partnership, and where progress is still required.
Learning themes include: impact of a parent’s own vulnerabilities, including their poor childhood experience of being parented and on-going mental health issues; domestic abuse and violent behaviour, both historic and on-going; thresholds for neglect, including consideration of accidental injuries as a sign of neglect and understanding of cumulative harm; consideration of the child’s lived experience; the need to engage with and consider the father of a child, or the partner of a mother who lives with, or spends a lot of time with the family (including same sex partners); the need for relationship-based practice, with children, with parents and the wider family and across agencies.
Recommendations include: to ask the national Child Safeguarding Review Panel to request that the Department of Health provides clear clarification to GPs regarding how they can safely and legally record information on adult records when there has been domestic abuse; consider alternative models of professional challenge, for example Portsmouth Safeguarding Children Partnership’s model ‘Re-think’; help professionals to ensure that practice is both culturally and individual family sensitive and that safeguarding responses are consistent, including professionals working with families having a safe space to consider their own values and biases.
Keywords: adverse childhood experiences, bruises, family violence, infants, parents with a mental health problem, unknown men
> Read the overview report

2023 - Bradford – Child A

Death of a 7-year-old boy in the summer of 2020. Child A was struck by a car and killed at a time when there was no one at his home address caring for him. Also addresses the neglect of Child A and his two siblings by their mother.
Learning themes include: identifying and assessing neglect; thresholds for intervention for child protection enquiries; impact of parental mental ill health on parenting capacity; barriers to hearing the children's voices; the inclusion of extended family assessments and interventions; use of formal routes by agencies to escalate concerns; issues arising from diversity and intersectionality and how these may have influenced service delivery; and impact of Covid-19 on service delivery.
Recommendations include: update and re-launch the existing neglect strategy, associated tool kit, and training strategy; audit the effectiveness of the multi-agency response to neglect as part of the Quality Assurance Framework; review and relaunch the inter-agency escalation policy and provide clarity for practitioners on when to use it; ensure ongoing work from all agencies includes the child's voice and experience (including family relationships); oversee the development of a 'Think Family' joint protocol with the partnership's safeguarding adult's board; ensure that all partners train their practitioners to be confident dealing with families where domestic abuse is a factor, and that the training strategy includes the importance of professional curiosity about all relationships and exploring potential ongoing risks when parents separate; and provide a training programme for practitioners covering intersectionality for families who experience multiple oppressions.
Keywords: child neglect, ethnicity, voice of the child, family violence, parents with a mental health problem, professional curiosity
> Read the overview report

2023 – Bradford - Sara, Edvina and Danuka

Neglect of female siblings aged 11-months-old, 1-year-old and 6-years-old. A home visit found the two younger children living in significantly neglectful circumstances with unexplained injuries. The eldest child was not in the accommodation at the time and was found to be physically unharmed.
Findings include: the importance of professionals working in a culturally competent way; the importance of robust consideration of the need for pre-birth assessments and pre-birth early help and support plans; the need for a proactive, holistic, and robust response to domestic abuse to increase safety for survivors and their children; the need for professional recognition and response to the early signs of neglect of young children by their caregivers; and an analysis of responses to referrals, completion of assessments, child in need processes and multi-agency working.
Recommendations include: produce guidance on working in a culturally competent way, including information about the culturagram framework; the Child Safeguarding Practice Review Panel look into why neglect tools developed over the last ten years are not having an impact on practice; seek information from the Child Safeguarding Practice Review Panel on what work is underway to address the lack of guidance about the appropriate response to referrals and information from family, the public and anonymous sources; and seek clarity about when and in what circumstances child and family assessments are shared with agencies who will be supporting children subject to child in need plans.
Keywords: child neglect, siblings, culture, poverty
> Read the overview report

2023 – Bradford - The Siblings

Covers an 18-month period of a parent suffering complex and enduring mental health problems including intrusive thoughts about harming their own children.
Learning themes include: mitigating the risks of harm to children where parents have mental health difficulties; the impact of the parent’s mental health difficulties on the children; ensuring that children with disabilities and differing communication styles are supported and heard; young carers and help-seeking behaviour; and stability in practical living arrangements and attachment relationships.
Recommendations include: update the guidance ‘Children at Risk where a Parent has a Mental Health Problem: Inter Agency Safeguarding and Child Protection Procedure’ to include the needs of children specifically and what help and support they might need, including children with disabilities and the requirement for a young carers assessment and factors to consider; update practice expectations to take account of the needs for children with disabilities, making clear that children with disabilities will have many professionals and family members who are experts on a child’s preferred communication style; make clear the circumstances in which child and family assessments will be shared with agencies who will be supporting children who are subject to Child in Need plans; update the guidance regarding Child in Need meetings to consider timetabling requirements so that all those agencies working with a family can attend and make clear that the decision to end a Child in Need plan should not be made without a clear step-down process.
Keywords: children as carers, children with learning disabilities, child safety, non-verbal communication, parents with a mental health problem, siblings
> Read the overview report

2023 - Bromley - Patrick

Evaluates Patrick’s journey through the care and criminal justice systems between 2016 and 2022 (12-18-years-old). Patrick experienced 17 placements in two years, mental health problems and routinely went missing from home, care and education. His violent behaviour and criminal activity led to placements in secure settings.
Learning themes include: preventing permanent school exclusions; adultification of children; understanding and applying ‘intersectionality’; mental health support for children in secure settings; ongoing support for children in semi-independent living; escalation about education; and the child’s voice being central to effective help and protection.
Recommendations include: seek reassurance on the effectiveness of early help when children are at risk of exclusion from school, including intervention when there are adverse childhood experiences; develop policy, guidance and training on adultification and intersectionality; through ongoing engagement with children placed in secure settings, ensure their experiences of the placement are routinely established with concerns addressed; local children’s services and police to provide reassurance about the effectiveness of return home/return from missing interviews for children placed both in and outside of the borough; revisit recommendations from the ‘Leo’ case, ensuring the provision of support for young people displaying risk factors for violent offending; ensure children in secure settings and semi-independent living have access to a trusted adult; review the standards expected for personal education plans for children placed in secure settings; ensure CAMHS support is appropriately prioritised for children in care and/or secure settings; and develop means of direct engagement with children in secure settings to hear their voice.
Keywords: exclusion from school, placement breakdown, secure accommodation, children with a mental health problem, voice of the child, adverse childhood experiences
> Read the overview report

2023 – Cambridgeshire and Peterborough – M family

Disclosures of sexual and physical abuse by three children in M family against their mother’s partner on 23rd September 2020. The family moved to the local authority area on 1st October 2020.
Learning themes include: information sharing protocols between local authorities; risk assessment including the risks that may be posed by male care givers/household members; children living in households where domestic abuse exists; lived experience of the child; victim support, including timely and appropriate support for children who have been victims of or are at risk of child sexual abuse; working with families unwilling to accept support; support for practitioners.
Recommendations include: children’s social care services should ensure that when a child or family moves into the area, and a request is made for case responsibility to be taken on, a request is made for information outlining historical involvement with children’s social care, and the provision of this information is robustly challenged where appropriate; compile a template for use by practitioners within their assessments which prompts for the consideration of all family members and their roles within a unit and their relationships with one another; hold a facilitated workshop with frontline practitioners from police, health, children’s social care and education to enable the partnership to explore good practice and better understand the barriers to capturing and using the voice of the child; gain the feedback of frontline practitioners within their agencies regarding the possible barriers to working with families who refuse support or display a reluctance to engage with services.
Keywords: abused children, child sexual abuse, family dynamics, family violence, information sharing, voice of the child
> Read the overview report

2023 – Camden - Children G

Hospitalisation of an infant who required critical care in November 2022. A home visit was conducted as it was known the infant had siblings ranging between 2 and 13-years-old; the children were taken into care the following day.
Learnings are embedded in the recommendations.
Recommendations include: the need for time and space to be made for collective problem solving where there is uncertainty; multiagency communication to be strengthened with records confirming that all agencies are invited to meetings and there is a recorded discussion prior to closing S47 enquiries; reinforcement of the expectation that children are seen and spoken to alone within the S47; chronologies need to be seen as ‘live’ tools - referred to and reviewed prior to every decision making meeting; ensure a good quality, full and accessible history on each record and that this is shared with agency partners; in complex cases, particularly where there has been movement across local authority boundaries or information is fragmented it is proposed that a multiagency chronology is compiled; consideration of a CSCP multi-agency learning event to focus on how professionals work with parents who are resistant to intervention; strengthen the understanding/working relationships with NHS digital GP health providers and raise awareness of their role through the safeguarding partnerships; and multi-agency audit of all children known to CSSW/Early Help who EHE are to identify risk and share best practice to take place locally.
Keywords: child neglect, transient families, voice of the child, home visiting, infants
> Read the overview report

2023 - Cardiff and Vale - Toby

Fatal stabbing of a 17-year-old boy in August 2019. Four individuals were subsequently convicted of murder, and three individuals were found guilty of manslaughter. Prior to his death there had been numerous safeguarding concerns around Toby’s involvement in and continued risk of child criminal exploitation (CCE).
Learning themes include: safeguarding during adolescence; information sharing and early intervention; reporting concerns, challenging decision making and escalating when required; young person’s disengagement from education, employment and training; and public protection notices submission and sharing.
Recommendations include: develop training to include guidance on safeguarding concerns that arise during adolescence, and how a young person develops to understand risk and consequences; children’s services must consider the impact of exploitation on siblings as part of referral and assessment; review current support available for young people at risk of exploitation; education must always be part of safeguarding considerations, particularly where a young person is educated outside of mainstream school placements; all agencies must ensure appropriate follow up when they make a referral in relation to a young person at risk and consider appropriate professional challenge if they do not agree with the decision making; all agencies involved in meetings considering young people at risk of CCE must consider relevant historical information, mapping of associations and identified escalations in concerning behaviours held by their own agencies which must then be considered jointly by all involved agencies.
Keywords: child criminal exploitation, child deaths, gangs, county lines, children missing education, drugs
> Read the overview report

2023 – Central Bedfordshire – Baby Euan

Death of an 8-month-old boy in December 2021. Baby Euan had injuries that were believed to be non-accidental.
Learning includes: a need for professionals to understand what the child’s daily life was like; working with families where their engagement is reluctant and sporadic; a need to share information in a timely and appropriate way; the need for more learning around themes of culture and ethnicity, including a focus on intersectional analysis into race, disability, and health conditions; and a need for front-line practitioners to be more alert to the signs and symptoms of controlling and coercive behaviours and be able to highlight possible triggers and subtle inferences and make appropriate referrals.
Recommendations include: the partnership should seek assurance from all agencies that they always include the voice and lived experience of a child in their actions and assessments; seek assurance from partners to ensure that they are pursuing alternative ways of engaging families when there is resistance to bring a child to a health appointment; ensure that front-line staff can recognise the signs and symptoms of coercive and controlling behaviour as a form of domestic abuse; and ensure partners understand what the meaning of intersectionality is and that they are embedding this into their agencies procedures and actions of their frontline practitioners.
Keywords: infant deaths, non-accidental head injuries, non-attendance, ethnicity, transient families, parent-professional relationships, health
> Read the overview report

2023 - Central Bedfordshire - Daniel and Sophie

Death of an 8-month-old infant in June 2023 from suspected abuse and neglect by his mother. Services were previously involved with Daniel’s older sibling and the family moved three times within the review period.
Learning themes include: the quality and effectiveness of risk assessment and safety planning; children in need of support, or at risk, transferring across organisational boundaries; and knowing and understanding the child’s day to day experiences.
Recommendations include: update the local children’s services joint protocol on children subject to child protection plan moving between local authority boundaries to include children that are subject to child in need processes; provide guidance that sets minimum expectations about the quality of transfers; promote the use of ‘day in the life’ assessment tools to help practitioners gain a better understanding about a child’s lived experiences, and the quality of care they are receiving from parents/carers; remind practitioners about the importance of assessing a child’s age and stage of development to make an informed decision about whether a child for whom concerns have been raised, are spoken with to gain their views; and promote awareness of procedure and guidance in relation to prebirth planning and assessments.
Keywords: infant deaths, child abuse, child neglect, parenting capacity, transient families, voice of the child
> Read the overview report

2023 – Cheshire East – Child J

Death of a 26-day old boy in November 2021 as a result of unsafe, co-sleeping. At the time of his death, he was being cared for by his father in the home of his mother.
Learning includes: a need for safe sleep guidance to be seen as the business of all professionals, to be covered as part of multi-agency planning, and for guidance and advice to be shared more widely than the mother; a need for pre-birth assessments to be completed in a timely way, clearly address risk factors and safety plan to mitigate risks; a need for multi-agency planning meetings to provide an opportunity for information sharing, development of safety plans and appropriate professional challenge as well as professional curiosity; a need for professionals to consider and engage fully with both parents to inform assessment and develop safety plans.
Recommendations include: seek assurance that safer sleep messaging is embedded into multi-agency safeguarding practice; seek assurance that fathers are fully involved and engaged in assessment and planning processes; and seek assurance that there is a robust approach to Child in Need planning.
Keywords: infant deaths, sleeping behaviour, professional curiosity, safety measures, fathers, family violence
> Read the overview report

2023 – Cheshire East – Child K

A 17-year-old girl exposed to significant and serious harm between June 2021 and January 2022. Child K made several serious and life-threatening attempts to self-harm during this period and experienced multiple placement moves.
Learning includes: multi–agency planning meetings should provide an opportunity for information sharing, development of safety plans, co-ordination of care planning and appropriate professional challenge; when children are the subject of numerous multi–agency planning meetings the most appropriate forum for this should be agreed; appropriate placement identification needs to be supported by a co-ordinated multi-agency approach and consideration of joint commissioning, particularly when children and young people have complex and multiple needs; and frontline workers who are working with children in the context of significant risk need working conditions and a culture that promotes well-being and creates a safe supportive environment.
Recommendations include: when children are cared for and there are significant safeguarding risks, the frequency of care planning meetings should reflect the needs of the child and professionals should hold each other to account; collaborative working to ensure the child is at the centre of all decision making; agreement of the multi–agency safeguarding plan before hospital discharge following a serious incident; gateway meetings and the use of the risk stratification tool to support co-ordination of multi–agency plans for high-risk children to be safely supported in community settings; and the corporate parenting board addresses multi–agency approaches to joint commissioning arrangements for complex and vulnerable children where there are significant safeguarding concerns and how agencies work together to identify placements and manage risk.
Keywords: children in care, placement breakdown, self harm, children at risk, interagency cooperation, child mental health
> Read the overview report

2023 – Coventry - Anya

Discovery of a 2-year-old girl at home alone after her mother had died in the family home in March 2022.
Learning themes include: inter-agency communication and information sharing; how risk was understood and how safety planning was achieved; and consideration of Anya’s daily life.
Recommendations include: consider the implications of using the emotional harm category in child protection planning, as opposed to the neglect category; raise awareness of the importance of paying attention to the language used in safeguarding work; support multi-agency practitioners in understanding and recording a child’s lived world with particular reference to children living in households where there is domestic abuse and/or substance misuse; ensure that practitioners and managers are fully aware of private fostering regulations, the limitations of written agreements and the legal steps required to secure a child with connected carers where there are concerns about a child’s safety; contingency planning that includes legal action to safeguard a child should form a consistent part of the child protection plan; learning from this CSPR, about the need to promote an equal partnership of fathers and extended families in safeguarding children, should inform future service design; local domestic abuse services should demonstrate how the voice of the child, in cases of domestic abuse, is understood and reflected in service provision; and review how cultural competency is promoted as a practice model in relevant policies, training and supervision.
Keywords: alcohol misuse, death, domestic abuse, ethnicity, mothers, neglected children
> Read the overview report

2023 – Croydon - Chloe

Death of a 17-year-old girl, Chloe, by suicide when in a state of mental crisis.
Learning includes: the need for resources to be available to support families in a child’s early years; language used by professionals to describe help seeking behaviour can infer judgement or nuanced negative undertones; the importance of family, friends and kinship for children who are looked after; the importance of a sense of self for children who are looked after.
Recommendations include: consider how to build a child’s sense of identity using existing processes; assess progress made following the vulnerable adolescent thematic review, with a particular focus on how trauma-informed practices are being enacted in services provided, and are supporting the multi-agency workforce; guided by the national reviews, embed relevant learning in mental health and wellbeing services for survivors of CSA; ensure the therapeutic work a child needs is detailed in a child’s care plan; criminal compensation should be pursued for all children who have been the victim of sexual abuse; identify opportunities to provide support to carers in the local area and for this scaffold of care to be detailed in a child’s care plan; consider how to reduce false transition points within agencies (including the private and voluntary sector) to maximise opportunities for practitioners to build consistent relationships with children; promote the briefing by the NSPCC on findings from young people who complete suicide, in particular the advice that suicide threats should be routinely assessed for motivation and level of intent.
Keywords: child deaths, child sexual abuse, child sexual exploitation, children in care, suicide, trauma
> Read the overview report

2023 – Croydon - Thematic review: serious youth violence

Thematic review focussing on seven children/young people who were charged in association with the unlinked deaths of three children in 2021. Recognises that children or young people involved in serious youth violence often experience the dynamic interplay of being both a victim and a perpetrator.
Learning considers: the children’s experiences of involvement with statutory services at an early age; domestic abuse; difficulties in parental/carer relationships; mental ill health; exclusion from education; offending behaviour; missing episodes; poverty; intersectionality; adultification; support provided to the children/young people and reasons why support ceased; the voice of the child, their daily life, and reasons why support may not have been accessed or effective; the experiences of the children’s families (including the families of the children who died); community support provision; and the experiences of front-line practitioners.
Recommendations include: the partnership to actively seek evidence to demonstrate how the 10 key principles of K.I.D.S. V.O.I.C.E.S. (knowledge, identity, duplication, stick with it, voice, outcomes, innovate, community, education, spaces) are being applied across multi-agency services, schools, panels and strategy forums, and seek evidence of impact; the voices of children and young people, family members and the community should be actively sought to achieve co-production in the future design of services; and the partnership to highlight the national issues raised in this CSPR with relevant national bodies such as the Child Safeguarding Practice Review Panel.
Keywords: voice of the child, violence, contextual safeguarding, child criminal exploitation, exclusion from school, interagency cooperation
> Read the overview report

2023 - Derby and Derbyshire - MDS20 and PDS20

Serious neglect of two young people from two separate families.
Learning themes include: disguised compliance and professional curiosity; escalating concerns at an earlier stage; the welfare of pupils who become long term absent from school; identifying potential neglect of young people and assessing the abilities of parents to respond appropriately; safeguarding pupils who are the subject of applications to be electively home educated; the voice of the child and action taken following repeated concerns from a parent followed by cancelled appointments; ensuring the safety of children whilst they are on CAMHS waiting lists; parental mental health and its impact on their ability to address the neglect of the young person.
Recommendations include: all child protection training should remind practitioners that procedures and guidance apply to all children irrespective of age; include the risks related to prolonged periods in bed into existing child protection training; consider how practitioners/managers can be supported to reframe the concept of service users ‘failure to engage’ to that of how can practitioners work persistently and creatively to engage children and their carers; work with schools to identify training packages/requirements for attendance workers and seek to strengthen the arrangements for assessing the welfare of children not in school; ensure that all agencies understand the routes to an Early Help Assessment and that such assessments are completed where required; and ensure that all practitioners are familiar with, and use where appropriate, the Graded Care Profile along with other tools that can be used when undertaking assessments.
Keywords: adolescent development, body weight, children missing education, child neglect, depression in childhood, maternal depression
> Read the overview report

2023 - Dudley - Safeguarding children when there are adults in the family who pose a sexual risk

Three siblings potentially at risk from two known sex offenders in their family.
Learning includes: professionals working with children should be aware of adults in a family who may pose a sexual risk; when assessing the ability of a parent to protect their children from a risky adult in the wider family, there needs to be an understanding of the relationship, contact and whether the adults, as well as the children, have been groomed; if there is no conviction for child sex abuse, there can still be a risk to children from an individual of concern; child protection procedures need to be used when information is shared that a person of concern is having contact with children; professionals need to be curious about a child’s behaviour and consider other indicators of sexual abuse even if they don’t disclose abuse.
Recommendations include: seek assurance about the use of the complex and organised abuse procedures in cases where there is a risk of child sexual abuse in the wider family; ensure that the relevant professionals and carers of children are aware of the risk to children in care of technology being used to locate and contact them; request agencies consider how to improve professional awareness and practice in respect of how perpetrators may conceal their abuse, how a non-abusing parent/carer may be complicit or unaware of abuse and how to work with children when they do not disclose sexual abuse but are likely to have been exposed to it.
Keywords: abuse allegations, child sexual abuse, grandparents, grooming, siblings, sex offenders
> Read the overview report

2023 – Durham - Katie and Diallo

Thematic review based on the deaths of two children from different families aged 3-years-old and under from head injuries. Diallo’s mother and Katie’s mother’s partner were charged with murder. The timeframe includes the period of national lockdown between March 2020 and March 2021.
Learning themes include: knowing the children and understanding their experiences; cross-boundary working and information sharing; professional curiosity and critical thinking; and race, ethnicity, and culture.
Recommendations include: the partnership to strengthen practitioner skills that enable respectful enquiry and curiosity and facilitate open conversations with families about parenting, relationships, and their own lived experiences; the partnership to ensure services that support adults who are parents follow a ‘whole family’ approach, with clear pathways to early help and preventative services; the partnership to consider how early opportunities to share information and triage family needs can be most effectively used across early help, health visiting and GPs; the partnership to ensure practitioners and systems can demonstrate in records, assessments, and interventions that race, ethnicity, and culture directly inform the family's narrative; the police to assure the partnership that its decision-making and outcomes relating to ‘Claire’s law’ and ‘Sarah’s law’ disclosures where children are identified, comply with national police standards and legislation; the local multi-agency service to ensure it demonstrates professional curiosity when separated fathers share worries about their children; and the local NHS foundation trust to raise the recording issue of the child electronic system removing a record of tasks nationally.
Keywords: head injuries, coronavirus, professional curiosity, culture, early intervention, child deaths
> Read the overview report

2023 – East Sussex - Child V

Non-accidental bruising and fractures to a 7-month-old infant in August 2018 leading to the arrest of Child V’s parents. Child V’s parents were living in temporary accommodation and both experienced difficult childhoods with domestic abuse a feature.
Learning themes include: the impact of living in temporary accommodation on the child; the impact of single-agency and multi-agency working; professional awareness of parental substance misuse; professional awareness of the legal processes concerning care proceedings; the role of GPs as part of the child protection planning process; recognising and understanding domestic abuse and the risks to small children; sympathy for parents leading to optimism; importance of full investigations of all injuries to infants; and workload pressures in the safeguarding system.
Recommendations include: receive progress reports from agencies where there were single-agency limitations, specifically regarding workload pressures, invitations to child protection conferences, GP recording practices and children under one being examined; improve practice regarding GP input to conferences, housing involvement in child protection plans, and the use and recording of strategy discussions; re-launch the protocol regarding ‘Unexplained Injuries to Young Children’ focussing on the importance of strategy discussions and medicals; consider whether safeguarding procedures around domestic abuse include enough focus on the risks of physical harm to young children and infants and how emotional harm may manifest; consider whether services for perpetrators of domestic violence include provision for couples where there is evidence of mutual abuse; and review whether current escalation policy is sufficiently understood by managers across all agencies.
Keywords: injuries, physical abuse, family violence, substance misuse, temporary accommodation, optimistic behaviour
> Read the overview report

2023 - East Sussex - Family CC

Significant neglect of a large sibling group by their parents.
Learning themes include: working with parents who are highly resistant/hostile to agency approaches or display disguised compliance; safeguarding children who are electively home educated in the context of neglectful parenting; relevance of neglect/abuse of animals when assessing risks to children; relevance of family history when screening for service delivery; and role of voluntary sector agencies in providing support to vulnerable families.
Recommendations include: review processes for professionals working with resistant parents with sufficient focus on understanding the relevance of family history and the lived experience of the child; request that health agencies consider the issue of fabricated illness in this context and require health professionals to not rely solely on evidence reported by parents; adapt child social care audit processes so that any child protection plan that ends after three months is audited by a senior manager; develop the neglect policy and training for professionals to consider the needs of children who are electively home educated, with any concerns triggering an assessment of parenting skills; request all agencies review their recording systems to ensure that workers screening referrals or starting assessments can review the wider family history and any previous agency involvement; consider how to better involve voluntary sector agencies in the multi-agency safeguarding processes; and consider whether multi-agency safeguarding assessments have sufficient focus on fathers and other significant males.
Keywords: neglected children, home education, neglecting parents, parental involvement, voluntary organisations, voice of the child
> Read the overview report

2023 – Enfield – Andre

Fatal stabbing of an adolescent boy. At the time of his death, Andre was subject to a child protection plan and to a youth referral order with intensive supervision and surveillance. The incident took place in a park where Andre should not have been due to an exclusion requirement as part of this order.
Learning includes: to work effectively to support a parent in becoming a consistent protective factor where a young person is facing risk in the community, practitioners must understand the history and trauma of the past and current vulnerabilities in the parent’s life which contributes to their style of parenting; relational practice with individual young people needs to sit within a strategic approach of developing community-based assets.
Recommendations include: prioritise and focus on acknowledging and reflecting upon what good culturally competent and anti-discriminatory practice is and how to embed it in safeguarding practice; ensure that multi-agency assessments and planning of children include an assessment of parenting in that goes beyond the practical capacity to provide care and explores the parent-child relationship in the light of the family’s history of vulnerability and risk; ensure strategic oversight of the operational multi-agency arrangements for responding to young people who experience significant adversity and risk in different contexts; ensure that the nature of engagement with families is reflected upon, and that effective engagement is evidenced in changes made in the family.
Keywords: child deaths, contextual safeguarding, gangs, home environment, murder, weapons
> Read the overview report

2023 - Enfield - Nadja

Forced marriage of a 14-year-old girl in 2020 by her parents to a man aged 27-years-old, who on the same day as that ceremony went on to rape and physically abuse her.
Learning is embedded in the recommendations.
Recommendations include: when there is the need to seek expert advice to support the work with children and families, the need to engage with an expert should be taken into account when setting the timescale for assessment in order to ensure that sufficient time is given to support this work; children should not be seen at home or in the presence of family members when making enquiries into forced marriage or parents contacted and alerted in advance of initial assessments, this puts the child(ren) at greater risk, as per the ‘Home Office Practice Guidelines for Forced Marriage’; a professional interpreter should always be used to support the work with children and young people; review the arrangements for monitoring attendance and escalating concerns for children who are missing education, and test these against the possibility of some future event resulting in the closure of school buildings and lessons moving online; where there is an allegation of rape of a child, the forensic examination of smart devices should be a priority action; when a Forced Marriage Protection Order is made, consideration should be given to taking fingerprints, DNA sample and photograph and whether the order can be beyond the child’s 18th birthday; and explore how cultural competence and professional curiosity can be promoted through easy timely access to relevant advice.
Keywords: adolescent girls, disclosure, forced marriage, interpreters, professional curiosity
> Read the overview report

2023 – Essex – Child C

Death of a 17-year-old girl in October 2020 by suicide.
Learning includes: the importance of understanding the interplay between physical and mental health needs and neurodiversity; the importance of agencies taking a whole family approach; autism diagnosis in adolescence can result in social, emotional and cognitive needs in childhood not being addressed in agency responses.
Recommendations include: child and family assessment and child in need plan should be the recognised and expected mechanism for coordinating a whole person approach where a child/young person has complex needs; disabled children should be recognised as children in need in their own right when living in a family environment where there are multiple stressors affecting their siblings; consideration should be given to how to achieve an environment which supports critical reflection and challenge in multi-agency work with complex families; social care practitioners should be aware of the protocol supporting implementation of s117 Mental Health Act 1883, this should be updated in relation to young people, including the mechanism for accessing necessary funding; parental responsibility and next of kin should be clearly recorded and guidance provided as to how this should inform decision making; all agencies should increase awareness of neurodiversity including recognising signs, indicators and impact on the young person, promoting positive self-identity, identifying when a formal assessment may be offered; guidance on the use of virtual meetings should ensure that the circumstances of each child and young person are assessed, to mitigate any risks associated with using this approach.
Keywords: autism, suicide, child mental health, family dynamics, mental health services, siblings
> Read the overview report

2023 – Essex – Child I

Death of a 15-month-old child who was found by father caught in a high chair, became asphyxiated and subsequently died.
Learning: is embedded in the recommendations.
Recommendations include: consider developing criteria for professionals meetings to be formally integrated into local child protection procedures to provide a multi-agency reflective space to consider risk and support for families; develop a multi-agency substance misuse strategy to provide clarity on the impact of different substance misuse, particularly cannabis on parenting capacity and guidance for practitioners in relation to escalation and effective interventions; consider how to support practitioners to manage the interface with one plan arrangements for children with special/additional needs within early help arrangements; consider the learning and undertake a multiagency self-assessment and any resulting actions from the national panel's thematic review ‘The myth of invisible men’ (2021) to support practitioners in improving the engagement, involvement and assessment of male carers; and consider the learning from this review and the national panel's review ‘Child protection in England’ (2022) to ensure that the views of family members are always considered in assessments of risk.
Keywords: home environment, parenting capacity, risk assessment, accidents, substance misuse
> Read the overview report

2023 – Gloucestershire - Child C

Child sexual abuse of a 16-year-old adolescent by their male foster carer. Between 2016-2020 Child C made several disclosures concerning an older child in their foster family, the female foster carer, and the male foster carer. Child C had experienced early trauma through neglect and abuse by their birth family.
Learning considers: listening to the child, hearing their voice and seeing their true experience; not placing judgments on the accuracy of child allegations; enabling early disclosure of concerns by children; explaining to children what is appropriate treatment in the foster placement and how to raise concerns confidentially; acknowledging that ‘terrible things can happen’ to children in care; and providing a consistent trusted professional for children in care, aside from those who have caring responsibilities.
Recommendations include: the local authority to lead on talking to children about healthy relationships so children in care understand appropriate treatment in their foster placement; professionals to ensure the role of the trusted professional or adult is explicit within the children in care planning process and never seen as being undertaken solely by a foster carer; to review all single agency training so the voice of the child is present and for agencies to provide evidence of impact on practice; practitioners to be confident in always being alert to the potential for, identifying and responding to signs of child sexual abuse; and the local authority to undertake a review of its allegations management processes to address concerns relating to an adult focus within statutory functions.
Keywords: child sexual abuse, children in care, foster parents, voice of the child, child abuse identification, disclosure
> Read the overview report

2023 – Greenwich – Child C and D

Death of two children as a result of a house fire, believed to have been started by their mother, in March 2021.
Learning includes: practitioners should think more holistically about families and consider all the presenting needs; recognition of practitioners’ role and responsibilities for parents caring for children with disabilities and how legislation and guidance can support their work; assessment of the impact of domestic abuse and its emotional effects on family members; practitioners to be cognisant of the impact of intrusive thoughts and for those to be risk assessed at an early stage; understanding children’s day-to-day lived experiences; and the support that families receive from their faith and from their church should be assessed as a vital part of their support network.
Recommendations include: ensure awareness of revisions to existing protocol with front-line practitioner events and audits of practice; ensure that carer's needs are sufficiently considered and assessed in line with the expectations of parent carer assessments; review training strategy to ensure that all partners equip their practitioners to be confident when dealing with families where domestic abuse is (or has been) a factor; ensure assessments and ongoing work includes the child's experience and emotional impact of these experiences as well as the child's voice; and professionals should be equipped with cultural competency together with an understanding of intersectionality to properly identify and consider these factors when assessing and managing the risk to children.
Keywords: family violence, filicide, fire, mental health services, parenting capacity
> Read the overview report

2023– Guernsey and Alderney – John

Examines the involvement of agencies and services with a young adult. There were concerns around John exhibiting harmful sexual behaviours, which reached a criminal threshold.
Learning includes: early identification, plus early and targeted intervention are important in helping children through childhood, transition positively into adolescence and onto adulthood; assessment of risk and safety planning, in cases of potential harmful sexual behaviours (HSB), needs to be viewed as a multi-agency activity but with a clear lead role coordinating the combined efforts of all professionals involved; supporting young people that have experienced adversity in their lives, and who go on to follow negative pathways through adolescence, is achievable by developing meaningful and trusting professional relationships.
Recommendations include: information sharing guidance for practitioners providing services to children, young people, parents and carers should be reviewed by explicitly naming all the signatories of the guidance so that it carries greater authority and weight, it should also be strengthened with practice examples to aid professional understanding about when information can legitimately be shared; online procedures should be reviewed and, where necessary, strengthened to reflect practice relating to HSB and specifically the practice challenges for professionals when responding to those children & young people who are victims of abuse but also pose a risk to others; use of professional challenge and escalation guidance should be further promoted to all professionals; and oversee the implementation of the action plan arising from the NSPCC audit, and should work together to identify, and where possible remove, any barriers to implementation.
Keywords: adverse childhood experiences, harmful sexual behaviour, information sharing, victims, interagency cooperation
> Read the overview report

2023 - Hartlepool and Stockton-on-Tees - Child Joe

Considers the multi-agency safeguarding responses in relation to child criminal exploitation (CCE) in respect of a young person who was involved in a serious and violent incident where he severely harmed a male as part of a robbery.
Learning includes: recognising and understanding CCE; strengthening knowledge, skills, and confidence in working with children and the family network affected by extra-familial harm and criminal exploitation; appreciating the significance of predisposing vulnerabilities, adversity, and developmental issues such as cognitive ability; robust advocacy for children cared for by the local authority missing from education and in need of additional support for their learning needs; recognition and challenge of victim-blaming language as a barrier to protecting children; and appreciating and responding to ‘reachable moments’ to engage with children where they may be more receptive to engagement and change.
Recommendations include: the statutory partners to provide clear leadership and challenge about victim blaming culture and response when working with children involved with CCE; the statutory partnership to consider the long-term impact on the mental health of children involved in CCE; the safeguarding partnership to consider the development of multi-agency reflective practice forums facilitated by subject experts/operational leads for exploitation; and the safeguarding partnership to seek assurance from the police that there is a clear and unified risk management framework that is arranged around the child, built on evidence-based practice.
Keywords: child criminal exploitation, grooming, professional attitudes, secure accommodation, crime, child behaviour
> Read the overview report

2023 – Islands - John

John was a young adult, whose issues relating to his childhood and adolescence indicated opportunities had been missed to provide support and protection.
Learning includes: early identification, plus early and targeted intervention are important in helping children through childhood, transition positively into adolescence and onto adulthood; balancing the needs of children who are at risk alongside managing them when they pose a risk to others and not unnecessarily criminalising them, is a perennial practice dilemma; assessment of risk and safety planning, in cases of potential harmful sexual behaviours, needs to be viewed as a multi-agency activity but with a clear lead role coordinating the combined efforts; and supporting young people that have experienced adversity in their lives is achievable by developing meaningful and trusting professional relationships.
Recommendations include: the partnership’s 2019 Information Sharing Guidance for practitioners should be reviewed by explicitly naming all the signatories of the guidance so that it carries greater authority; it should also be strengthened with practice examples to aid professional understanding about when information can legitimately be shared and disseminated to all relevant agencies and briefing sessions provided to frontline practitioners and managers; procedures should be reviewed and, where necessary, strengthened to reflect practice relating to harmful sexual behaviours and specifically the practice challenges for professionals when responding to those who are victims of abuse but also pose a risk to others; the use of professional challenge and escalation guidance should be further promoted to all professionals; and the partnership should continue to oversee the implementation of the action plan arising from the NSPCC audit, and should work together to identify, and remove any barriers to implementation.
Keywords: provision of services, mental health, risk taking, harmful sexual behaviour, professional curiosity
> Read the executive summary

2023 – Kent – Baby T

Death of a 7-week-old boy in December 2020 while co-sleeping with his mother.
Learning includes: N/A
Recommendations include: propose a practice model recognising a continuum of risk of sudden unexpected death in infancy (SUDI), with support reflecting the differing needs of all families, including those with identified, additional vulnerabilities; promote safer sleeping within a local strategy for improving child health outcomes; multi-agency action to address pre-disposing risks of SUDI for all families, and with targeted support for families with identified additional risks; review existing 'reducing the risks to babies' NICE guidance with a view to developing a local policy; produce a briefing paper for multi-agency circulation that highlights the predisposing and situational risks of SUDI and appropriate guidance and referral pathways; audit current understanding and use of motivational interviewing across partner agencies and explore what training is already being offered; and incorporate safer sleep arrangements into threshold guidance.
Keywords: sleeping behaviour, sudden infant death, postnatal depression, substance misuse, interagency cooperation
> Read the overview report

2023 – Kingston Richmond – Child V

Death of a young boy in the summer of 2021, thought to be due to a chronic health condition. At the time of Child V’s death there was also evidence of malnutrition.
Learning themes include: awareness and management of Child V’s health condition; response to medical neglect including not being brought to medical appointments/accessing support offered; and response to domestic abuse.
Recommendations include: ensure all practitioners working with children with health conditions have a good understanding of how it affects the health and development of the child, and any risks of mismanagement; adapt safeguarding processes and procedures to support practitioners to request information about the needs of children with medical conditions through each stage of safeguarding activity; support practitioners to have the skills to confidently explore how the cultural background, attitudes and beliefs of any carer affects care of the child, including each parent’s attitude to health conditions and treatment; ensure there are clear arrangements to ensure the co-ordination of healthcare for those children with complex health conditions who are particularly vulnerable or where there are emerging concerns about medical neglect; consider best practice in parental education about health problems and how to recognise and respond when parents are struggling to meet a child’s health care needs, including exploring the reasons for missed appointments; make representations to NHS digital about the benefits of adding a Was Not Brought (WNB) code to all NHS recording systems to help identify those children who may be vulnerable to medical neglect.
Keywords: Asian people, child deaths, children with a chronic illness, malnutrition, medical care neglect, non-attendance
> Read the overview report

2023 – Kirklees – Paul – Child Q

Death of a 15-year-old-boy in August 2021 from complications due to multiple, non-accidental rib fractures.
Learning includes: the need for all professionals to understand the challenges of being a new arrival to the UK; the importance of understanding relationships in families and a full background history where new arrivals are concerned; the need for professional curiosity and allowing practitioners the freedom and space to exercise it; concerns around domestic abuse in families over lockdown during the coronavirus pandemic, and whether they may be under pressure not to report.
Recommendations include: ensure that practitioners have the training to be able to understand the challenges for a new arrival into the UK, including how to access health, education, and support services; ensure that practitioners can access information from originating countries to assist in the care of children arriving in the UK; ensure that support is being provided to practitioners to provide resilience within the workforce; ensure the workforce have been given the tools and training to support children and young people coming out of the pandemic to aid their recovery; ensure that where professionals have identified risks within families that the risk is thoroughly assessed and recorded; ensure multi-agency assessments of risk are taking place on which plans of action are based; the National Panel are to engage with the border force to explore the processes in place when a child or young person enters the UK and gain clarity on how safeguarding concerns are identified and communicated to the relevant local authority.
Keywords: abused boys, child deaths, fractures, physical abuse, provision of services, voice of the child
> Read the overview report

2023 – Leeds - Ruby

Long term sexual abuse of female child by her legal guardian. The abuse was only detected after the female disclosed that she was pregnant and requested a termination, where genetic testing established that her legal guardian was the father.
Learnings includes: education establishments to review and scrutinise a child’s casefile when the child has transferred in from another school and has had children’s social work services involvement, been subject to a child protection plan and/or has been or is still subject to court proceedings; seeking to raise awareness of the concerns resolution process across a wider range of police departments to ensure that colleagues understand how to access guidance on how to pursue resolutions when one agency perceives risk to be higher than another; review how information is shared between children’s social work services, police safeguarding teams, and a public protection officer; and reinforce the importance of professional curiosity when working with children and families.
Thematic analysis includes: professional curiosity/disguised compliance; management of complex cases; trauma-informed practice; the voice of the child and her lived experience; understanding barriers to disclosure; and the effects of the Covid pandemic on the support offered.
Keywords: child sexual abuse, sex offenders, disguised compliance, guardianship, professional curiosity
> Read the overview report

2023 – Lewisham - Lilo

Fatal stabbing of a 17-year-old in 2021. At the time of his death, Lilo was a Child in Need who had a diagnosis of autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), as well as limited mobility because of a moped accident.
Learning themes include: access to education and delays in assessments for Education Health and Care Plans (EHCPs) and the experiences of neurodiverse Black boys in education; recognising and responding to risk in the context of extra-familial harm; understanding the impact of trauma in the context of extra-familial harm and wider trauma; and understanding the impact of trauma on the workforce.
Recommendations include: education must undertake a review of the EHCP process; the local safeguarding children’s partnership should commission further learning to improve professional understanding across all agencies to ensure a better understanding of trauma, intersectionality, adultification bias and neurodiverse children in the context of extra-familial harm, always considering language and framing of children; ensure that the voice of the child is heard and integrated into planning; ensure that all social workers and managers can recognise and respond to extrafamilial harm, especially for children with additional needs; improve the quality of support and child protection responses, with increased understanding of the role of a statutory safeguarding partner; improve the quality of record keeping and assessments; child and adolescent mental health services should introduce multi-disciplinary review meetings when a child is referred more than three times and does not meet threshold for intervention as well as monitor and improve access and support for Black and ethnic minoritised children.
Keywords: adolescent boys, autism, Black children, child deaths, child mental health services, contextual safeguarding
> Read the overview report

2023 - Luton - Thematic review

Fatal stabbing of a 16-year-old boy in June 2021. In the preceding months there were other assaults and multiple exclusions from school; gang associations and conflicts were also known about.
Learning includes: multi-agency response to risk, including sensitivity when working in a diverse population and understanding subtleties associated with gang networks; the background and profile of the young people, including effective early intervention, recognising that complex cultural and relational dynamics require insight from those with lived experience, the importance of early identification of additional educational need and/or learning disability, and balancing the use of exclusions from school; and frameworks for assessing risk, threshold decisions and interventions, including acknowledging the cultural role of extended family and providing support for young people when taking a case to prosecution.
Recommendations include: to map and evaluate arrangements for identifying and responding to contextual safeguarding and safeguarding children at risk of violence and criminal exploitation, and examine whether there are differences in how some children might receive a ‘safeguarding’ response versus those that may receive a ‘criminal justice’ response; to understand whether there are other young people with unassessed or undiagnosed learning difficulties who are not having their needs met; to ensure that all key agencies are fully informed about core child protection processes; to refer children to the MASH who are on the cusp of being permanently excluded from education and where there are contextual safeguarding concerns; to improve the offer of mediation with young people and their families that are at high risk of harm through culturally competent service providers; and to ensure that processes are followed within educational settings where there are known risks to pupils from gang associations.
Keywords: gangs, criminal exploitation, contextual safeguarding, children with learning difficulties, exclusion from school, diversity
> Read the overview report

2023 - Manchester with Trafford - Child N, B, YK

This review considers three young people, two of whom were fatally injured with the third suffering serious injuries, following two separate knife crime incidents. The incidents took place in July 2020 and November 2020.
Learning includes: the importance of earlier multi-agency intervention; the importance of understanding the impact of earlier life experiences, trauma and loss; the importance of sharing accurate information and ensuring prompt multi-agency responses, utilising critical moments more effectively and completing assessments and convening planning meetings in a more timely fashion; accurate and timely information sharing within and between schools; and holistic and creative planning to ensure that young people remain in education.
Recommendations include: promote the use of the National Referral Mechanism and review its effectiveness for vulnerable children in relation to safeguarding from criminal exploitation; the partnership should be assured by school leaders that arrangements regarding fixed term and permanent exclusions consider issues of vulnerability or risk of harm; and be assured that effective quality assurance systems are in place which ensure that records accurately reflect the correct spellings of names, dates of birth, addresses and family details.
Keywords: early intervention, ethnicity, child criminal exploitation, children missing education, weapons, exclusion from school
> Read the overview report

2023 – Medway - Isabel

Death of a 3-month-old infant in March 2022. It is thought Isabel’s death was an accident linked to an unplanned sleeping environment where drugs and alcohol were present. The mother’s extended family were known to services regarding domestic abuse.
Learning themes include: responding to the needs of the child, including the unborn child; safeguarding procedures around co-sleeping; consideration of the pre-birth assessment pathway; male figures in the family and father’s engagement with antenatal and post-natal services; recognition of potential indicators of abuse; issues arising from moving to different local authorities; parents’ previous involvement with adult or children’s services; disguised compliance; response to lack of engagement and Did Not Attends (DNA); interaction of services during the antenatal and perinatal period; and assessment of parental needs including domestic abuse, mental health issues, substance misuse and difficulties with housing.
Recommendations include: review the antenatal pathway to ensure the referral system identifies concerning families of unborn babies; oversee a review of the local maternity safeguarding hub; ensure all partner agencies have systems to actively consider fathers and other significant males in assessments; review practices about how safe sleeping messages are delivered; oversee an audit of multi-agency practice in relation to domestic abuse at the front door; oversee partner agencies’ reviews of their supervision practices and ensure managerial oversight of decisions in relation to children and unborn babies where there are safeguarding concerns; and ensure robust liaison between Midwifery services and GPs for pregnant women, including exchanging information about both parents (and partners) during pregnancy.
Keywords: sudden infant death, sleeping behaviour, substance abuse, disguised compliance, family violence, antenatal care
> Read the overview report

2023 – Merton – Franklyn

Death of a 4-month-old boy in 2022 from an out of hospital cardiac arrest. Franklyn was born with a life-limiting disability and complex health needs.
Learning includes: the importance of a holistic trauma-informed practice model as a planned action by the network of professionals; a need to continually build strong relationships with families, adopting a family-focused, compassionate approach which accords parents respect and recognition; and an intersectional approach is needed to understand the unique challenges faced by families.
Recommendations include: the adoption of a trauma-informed model of support; gather and analyse feedback from those with lived experience in the ongoing development of bereavement and loss services; family focused communication in assessment practice; and the partnership to take note of issues of bias and how they play out in safeguarding around children with complex needs.
Keywords: children with disabilities, Black people, trauma-informed practice, health, infant deaths, communication
> Read the overview report

2023 – Mid and West Wales - CYSUR2/2020

Sudden unexplained death of a 12-week-old infant in spring 2019.
Learning themes include: the cumulative risk factors of domestic violence, substance misuse and mental health; assessment and support of children of looked after children and care leavers; co-sleeping; and housing.
Recommendations include: develop further policy and practice guidance in respect of the professional responsibilities for referral, assessment and support provided to young parents in and leaving care; all areas who support statutory childcare teams (including support to parents) should ensure that an understanding of safeguarding responsibilities and the statutory duty to report concerns for children or adults at risk is embedded in day to day practice, including domestic abuse incidents and referrals for unborn children; children’s services should review the process of recording and responding to multi-agency referral forms (MARFs) on open cases to ensure they are formally recorded on the child’s record; the safeguarding board should ensure that all agencies’ internal information sharing policies and practice guides are up to date in line with current legislation, policy and procedures, and all staff are able to access ongoing training in the context of safeguarding; there should be a housing strategy for care leavers that ensures a holistic response and robust multi agency partnerships to meet the support needs for individuals and families; the Teaching Health Board should provide clear, service specific guidance for practitioners to follow in response to domestic incident notifications; ensure that there is an effective local response to reduce the risk of SUDI to support local/regional multi agency learning and development in this area of work.
Keywords: adolescent fathers, adolescent mothers, housing, sleeping behaviour, sudden infant death, termination of care
> Read the overview report

2023 – Milton Keynes – Children N and O

Fatal stabbing of a 16-year-old-boy by a 17-year-old boy in November 2020. Child N and Child O knew each other through peers but had no contact until a few days before the murder.
Learning themes include: agency responses to both boys criminal activity; the complexity of working with vulnerable children with links to gangs, who have police, social work and youth offending service (YOS) involvement, especially when a child is in care and moves placements between local authorities; the importance of education as a protective factor for children; and the importance of practitioners having strong relationships with young people as a significant factor in reducing offending behaviour and improving outcomes in general.
Recommendations include: supporting the development of arrangements which will result in detailed operational multi-agency, multi-disciplinary risk management pathways for individual children most vulnerable to being involved in violent incidents due to their involvement in gangs, including children moving areas for their own protection; supporting the development of more alternative educational and training options for children who have disengaged or been excluded from school; reinforce with practitioners the importance of young people having strong and enduring relationships and recognising the impact on young people when practitioners change; ensure risk assessment checks are completed for every potential change of address prior to accommodation being confirmed; improve information sharing arrangements between the Criminal Justice Liaison and Diversion (CJLD) service and the YOS; and improve the availability of placements for children at risk in the community.
Keywords: child criminal exploitation, children missing education, exclusion from school, family violence, gangs, murder
> Read the overview report

2023 – Norfolk – Child AK

Death of a 4-week-old girl while co-sleeping with her mother. The services provided to Child AK’s siblings are included in the scope.
Learning includes: the risks posed by neglect; the impact of neglect on the children’s lived experience; family dynamics and the role of the fathers in the lives of children; the impact of domestic abuse on children; understanding the risk of physical harm within a family, especially with regards to ‘physical chastisement’; the risks of substance misuse within the family; the impact of Covid-19 restrictions; use of language by services, practitioners and managers.
Recommendations include: the revised Norfolk graded care profile (GCP) must be used when there are concerns about child neglect and an audit of neglect cases from across the child’s journey used to assess how it impacts on planning and interventions within 12 months; babies born into large sibling groups receiving interventions should be recognised as increasingly at risk; to produce and promote sector specific good practice guides on working with fathers and father figures; to write a position statement about ‘physical chastisement’ and substance misuse and be clear about how to promote and endorse these; professionals should be mindful of the extent of current and historic substance misuse and the impact on the unborn child as well as any existing sibling groups, including financial impact, parental ability to regulate mood and neglectful and/or emotionally abusive parenting.
Keywords: child neglect, infant deaths, parenting capacity, sleeping behaviour, threshold criteria, voice of the child
> Read the overview report

2023 – Northamptonshire – Child Ba

Death of a 3-week-old baby in June 2020. At the time of their death Child Ba was co-sleeping with their mother who was intoxicated through alcohol and had taken cocaine.
Learning themes include: the child’s voice and lived experience; alcohol use and misuse; unsafe sleeping arrangements; the step down process and basis for decisions; the impact of over optimism by professionals; safeguarding within East Midlands Ambulance Service (EMAS); and the impact of Covid-19 restrictions.
Recommendations include: ensure that all professionals have a better understanding of the implications and risks associated with parental alcohol misuse including historical alcohol misuse and how this is harmful to children; ensure parents and carers are aware of safe sleeping advice through the ‘Every sleep a safe sleep’ campaign; consider implementation of the National Panel’s suggested ‘prevent and protect’ practice model for reducing the risk of SUDI; seek assurance that step down procedures are operating effectively and rigorously; consider what needs to be put in place to support grandparents, and other family members, who are acting as a protective factor to parental risks to safeguarding children; and training partners in the ‘Signs of Safety’ model of practice which includes all family members that are to be regarded as a protective factor.
Keywords: alcohol misuse, child neglect, family violence, prison and prisoners, sleeping behaviour, sudden infant death
> Read the overview report 

2023 – Northamptonshire – Child Bi

Death of a 6-week-old infant. It is believed that ChiId Bi was overlaid by an adult sharing the same bed.
Learning themes include: response to concealed pregnancy; safe sleeping; working together to safeguard children and decision making about level of intervention, including child protection or child in need plans; managing parental non-engagement and hostility; and children's voice and lived experience.
Recommendations include: the partnership reviews their guidance and procedures on concealed pregnancies, with more focus on why the parent might have concealed the pregnancy, and how to ensure hypotheses are shared and recorded even if parents deny the pregnancy was concealed; multi-agency audits on: public protection notices, the timeliness of strategy meetings after referrals on open cases have raised safeguarding concerns, and children not made subject to child protection plans at initial child protection conferences; a multi-agency task group to consider how detailed descriptive language is used when sharing information about a child's voice and lived experience, especially at child protection conferences, and considering how to convey relevant content from police body worn cameras; the police force review the timeframe, nature and level of detail shared with social workers and at child protection conferences about incidents of domestic abuse with previous partners, to ensure that effective decisions about risks to the children of new partners can be made; and partner agencies review the guidance on recording and reporting threatening or abusive behaviour to include sharing details about incidents with statutory partners and education agencies.
Keywords: infant deaths, sleeping behaviour, pregnancy
> Read the overview report

2023 – Northamptonshire – Child Bj

Suicide of 13-year-old male in March 2022. He had for several years displayed physical and verbal aggression to himself and others, self-harm and suicidal ideation. A number of agencies had various involvements with him.
Learnings is embedded in the recommendations.
Recommendations include: ensure that agencies and professionals know and understand how they can utilise the Early Help Framework and how they are expected to contribute to individual cases; the need for individuals and agencies to ensure that they work collaboratively and make best use of available resources to be able to effectively engage with Early Help assessments; seek assurance from partners that the pathway for service provision to children that self-harm and have suicide ideation is updated and wider than just those children that attend hospital settings, to include, if possible, those children suffering from acute emotional distress, including those children suffering from chronic school phobia; ensure that all frontline staff working with children and young people who are 10-years-old and over are supported to access learning related to suicide prevention and ensure they are aware of the findings from the National Child Mortality Database study into child suicide; ensure that frontline staff who are affected by the suicide of a child that they are/were working with, are suitably signposted for support for themselves; and ensuring that the child's voice is captured in cases of acute emotional distress, including those self-harming and expressing suicide ideation, and the child is at the centre of all planning.
Keywords: suicide, voice of the child, self esteem, aggressive behaviour, anxiety, bullying
> Read the overview report

2023 – Northamptonshire – Children N and O

Death of 16-year-old boy who was stabbed in the street and fatally injured by a 17-year-old boy in November 2020.
Learning includes: young people who have disengaged from education can be motivated to obtain employment; referral orders can be effective in supporting young people and reducing their offending behaviour; prompt and effective liaison between police youth offending service (YOS) and children’s social care in both local authorities when a child involved with gangs moves to live in another area; usefulness of better arrangements for criminal justice liaison and diversion (CJLD) to have timely access to background information about the children they see in custody; usefulness of CJLD staff sharing information with YOS about the children they see in custody as standard practice; awareness of the employer’s responsibility to do a risk assessment for any employee working in construction who is under 18; when children subject to a care order are placed with parents at short notice a statutory review should be held to discuss this and ensure the meeting and care plan includes attendance or a contribution from all practitioners working with the child and parents; deterioration in behaviour and increase in risk can be very swift if young people involved with gangs in one area connect with gangs in a new area; children vulnerable to being involved in violent incidents due to their involvement in gangs need to be supported by detailed operational multi-agency; the importance of practitioner and agency records being clear; and where children have moved areas to keep them safe from gangs the importance of reciprocal information sharing between police forces if they are different in the host and home authorities.
Recommendations include: embedded in the learning.
Keywords: child deaths, aggressive behaviour, exclusion from school, gangs, risk management
> Read the overview report

2023 – North East Lincolnshire – W Siblings

Neglect and abuse over several years of seven siblings aged between 16-years-old and 1-year-old. The siblings’ circumstances were discussed at a rapid review meeting in early September 2021 after suspected sunburn injuries which were the subject of a police criminal investigation.
Learning includes: importance and workload implications of focussing on individual children within larger sibling groups; behavioural and emotional symptoms of persistent neglect and how they are reflected in risk statements such as the signs of safety scaling; the importance of considering children’s lived experiences when the cumulative effect of neglect and the impact on children’s development and well-being is a factor; the importance of chronology and holistic assessments; need for GP practices to be involved in enquiries and assessments; procedures for escalating concerns about children through internal systems and how they can be linked with local partnership escalation pathways; importance of a clear strategy for responding to neglect that is owned by all respective organisations; the importance of providing trauma-informed early intensive help for parents who have experienced trauma in their own childhood; and aligning legal and child-based risk discussions.
Recommendations include: the Director of Children’s Services (DCS) should satisfy themselves with the effectiveness of signs of safety in supporting effective assessment and management of risk for children; DCS should ensure that advocates for children can be appointed and are routinely considered in complex and/or longstanding cases involving neglect; DCS and Director of Legal Services should ensure appropriate arrangements are in place for social workers to seek emergency protection for children when necessary.
Keywords: child neglect, neglect identification, parenting capacity, physical abuse, siblings, voice of the child
> Read the overview report

2023 – North Wales - Wrexham 2020/1

The child was found unresponsive at the family home, a subsequent coroners inquiry recorded a verdict of death by misadventure.
Learning includes: the need to promote a multi-agency response to bullying, in relation to specific incidents and in relation to the development and implementation of school and local authority action plans following the school health research network; and the National Guidance does suggest that the decision to exclude should include consideration of whether the incident may have been provoked, e.g., by bullying or by racial or sexual harassment, all incidents should consider if they are out of character for the child and those involved.
Recommendations include: awareness sessions to promote regional understanding of adoption support framework and good practice guidance; develop guidance regarding approaching adopters when siblings require placing; secondary schools to provide evidence to the chief education officer regarding the dissemination and implementation of the child and adolescent mental health services (CAMHS) self-harm pathway; review documentation and referral process from the school to the school nurse; raise awareness of who can refer to CAMHS and the preferred route for receipt and recognition of referrals; promote a multiagency understanding and escalation of the school health research network data; develop multiagency guidance response to supporting the emotional health and wellbeing of children who experience bullying; and review the process of information sharing between the school nurse and any special health file.
Keywords: adverse childhood experiences, voice of the child, bullying, self harm, risk assessment
> Read the overview report

2023 – Nottinghamshire - David and Daniel

Harmful sexual behaviour between 11-year-old and 14-year-old male siblings who were in a long-term foster care placement.
Learning includes: professionals in looked-after and fostering teams need to feel confident about how to respond to child sexual behaviour; relevant professionals need to be aware of and confident to use recommended professional frameworks and toolkits; euphemistic or imprecise language can be unhelpful in understanding whether behaviour is normative or concerning; understanding that early neglect, trauma, exposure to abuse, poor attachment, and the development of inappropriate sibling relationships seeking support are some factors that create latent conditions for harmful sexual behaviour; not all siblings are best served by living in their family group; and social work professionals should maintain professional curiosity with foster carers and not assume that experienced and well-regarded carers are managing the situation and responding appropriately all of the time.
Recommendations include: ensure that the policy and practice guidance about the use of any measures of control, monitoring or restraint of children living in family-based settings and residential care is being effectively implemented; ensure that social workers in looked after children's services receive the appropriate training in harmful sexual behaviour (HSB) and that they access support from HSB specialist practitioners when appropriate; ensure that the learning and improvement board give sufficient priority to the role of the Independent Review Officer, to be assured that it is performing in line with policy expectations and making an impact on children’s outcomes including effective and timely escalation responses.
Keywords: children with learning difficulties, foster children, foster parents, harmful sexual behaviour, sibling abuse
> Read the overview report

2023 – Nottinghamshire - Harlow Academy

An Ofsted inspection of a special educational needs school carried out in January 2022 raised a number of serious safeguarding matters. Ofsted concluded that pupils were not being kept safe and were at risk of immediate and imminent harm.
Learning includes: a need for the Department for Education (DfE) to strengthen processes for matching academy sponsors to special schools; there was sufficient information for Ofsted to decide to undertake a no notice inspection of the academy earlier; the need to put in place a process to address the multiple safeguarding concerns about the care of children in the academy; and a need for agencies to recognise that regardless of what Ofsted would do they have a responsibility to take action to safeguard the children.
Recommendations include: the DfE to revise its process for identifying academy sponsors for special schools; professionals should always consider what other routes they should explore when a referral about a child or about the behaviour of an adult does not meet the safeguarding criteria they use; and the partnership should agree a document for parents and carers that outlines how to raise concerns in relation to children with disabilities and what to do if these concerns are not responded to.
Keywords: special schools, management and organisation, institutional care, inspection, children with multiple disabilities, education
> Read the overview report

2023 – Nottinghamshire - VN21

Multiple injuries to a 3-year-old girl between 2020-2021. There were four episodes of unexplained injuries, with two episodes requiring significant medical treatment. Alison and her siblings became looked after children in 2020.
Learning: N/A
Recommendations include: obtain information from the local authority on the difficulties of securing placements for children; ensure the pathways for communication between children's social care and NHS acute children's services are clear, clarifying who can provide authoritative information about safeguarding concerns, including the progress of child protection enquiries, related medical assessments, and the treatment and health of looked after children in acute hospital settings; seek assurance that transfer arrangements between acute health services include explicit reference to safeguarding concerns where these are present; and develop a SMART action plan to address how new concerns for looked after children are responded to, including effective multi-agency communication and consistent application of the relevant procedures about strategy discussions and discharge planning meetings.
Keywords: injuries, health services, foster children
> Read the overview report

2023 - Oxfordshire - Child G

Young person Child G experienced trauma and instability at an early age, including emotional and sexual abuse, and a lack of certainty about who was there to look after her. As a teenager this manifested in mental health issues and substance misuse, leading to her becoming care experienced and subject to sexual exploitation.
Learning points include: practitioners to develop an understanding of ‘trauma-informed practice’ to identify the emotional abuse of adolescents and recognise the impact of fractured attachments; a move from ‘what is wrong with you?’ to ‘what has happened to you?’ in responding to children and young people who have experienced abuse and neglect; awareness of the damaging effect of victim blaming and pathologising language; ensure definitions and advice clearly outline the unacceptability of children being physically punished, with practitioners challenging parents who suggest this is an appropriate disciplinary approach; recognise the importance of a child or young person’s relationship with one or two trusted professionals; where child sexual exploitation is suspected, assessments should consider risks which emerge from vulnerabilities arising from past abuse, loss and trauma; schools to ensure that any decision to exclude a pupil (subject to a child in need plan or protection plan) is only done after a discussion with the multi-agency team; consider what practitioners and managers can do to support help seeking behaviour in children and young people; and professionals to maintain a questioning and curious response to what they are told or see.
Recommendations are embedded in the learning points.
Keywords: child sexual exploitation, physical punishment, emotional abuse, language, children with a mental health problem, trauma-informed practice

2023 - Oxfordshire - IFSA Thematic Review

Summarises key findings and learning points from cases of intra-familial sexual abuse (IFSA), including sibling sexual abuse.
Learning points include: acting on early concerns, using the Strengths and Needs Form; remaining alert to the possibility of all types of bias including ‘unconscious gender bias’ and female abusers; awareness of how practice can be influenced by family social status; considering the viewing and sharing sexual images online in the context of family history and response to trauma; effective communication, with practitioners both sharing and seeking information, and using clear language; using available tools to identify different types of IFSA, for example a multi-agency chronology; ensuring that assessments consider and include the whole family and that all children in the family have been seen individually and had their voices heard; analysing parental motivations and capacity as part of risk assessments; reflecting on the impact of inter-generational abuse on parenting capacity and the need for practitioners to be trauma aware; understanding practitioners’ confidence levels around specific types of IFSA, especially sibling sexual abuse; consideration of what additional support may be needed when ending work with a family if parents are vulnerable; encouraging fathers to be included and participate in discussions; the impact of Covid-19 on families and service delivery; and the need to update the national practice of categorising abuse in the child protection process when there are multiple risk factors, for older children, or where there is intra-familial (sibling) abuse.
Recommendations are embedded in the learning points.
Keywords: sibling abuse, child sexual abuse, cycle of abuse, harmful sexual behaviour, family dynamics, child abuse images
> Read the overview report

2023 - Pan Dorset - Brian

Stabbing of adolescent boy who was taken to intensive care in a critical condition. There have been escalating concerns about Brian’s risk to extra-familial harm and he has been involved in several criminal incidents and escalating youth violence, individually and with his peers.
Learning includes: assessments should be holistic and focus on the risks from inside and outside of the family home and that these are not mutually exclusive; children and young people at emerging risk of extra-familial harm could benefit from targeted interventions that address those risks at an earlier stage, including from Early Help services; the level of skill, expertise, and knowledge of practitioners outside of the complex safeguarding team (CST) needs to be enhanced to enable them to manage the risks and needs from extrafamilial harm; schools, colleges and learning establishments have a key role to play in addressing extra-familial harm alongside safeguarding partners; emerging intelligence about children and young people needs to be shared appropriately across the safeguarding system; children, young people, parents, carers, and wider family should be actively engaged in safety planning; the voices of children need to be heard and responded to and the culture of working alongside children and young people encouraged; youth justice and safeguarding systems should work in tandem; and practitioners need to develop their understanding of neurodiversity and the impacts that childhood experiences can have on children and young people.
Recommendations are embedded in the learning.
Keywords: child neglect, gangs, exclusion from school, social deprivation, information sharing
> Read the overview report

2023 - Pan-Dorset - Charlie

Focuses on Charlie’s life between October 2019 and February 2022, when Charlie was a child and transitioning to adult services. Charlie was diagnosed with high functioning autism and generalised anxiety disorder.
Learning is embedded in the recommendations.
Recommendations include: all partners should ensure that their staff and teams are aware of the diversity of organisations in relevant agencies and partner organisations, moving away from generic terms such as local authority or health; review the current training on child sexual abuse, ensuring that when professionals are working with a disabled children who are the victims of or witness of sexual abuse the course highlights the increased risk these children are living with due to a broad range of disability; ensure their workers are aware of the vulnerabilities of children who have a disability and are electively mute or non-verbal; assurance that disguised compliance and being able to recognise this early as well as being aware of what actions to take when sporadic and reluctant or disguised compliance is suspected is embedded in training; monitor attendance at child protection conferences to ensure conferences are quorate with sufficient agencies present to enable safe decisions to be made, escalation should be made immediately; and ensure where there is a medical diagnosis offered as an explanation for the presenting features of neglect, all aspects of the child’s health and wellbeing should continue to be considered to avoid the potential for diagnostic overshadowing.
Keywords: child neglect, autism, voice of the child, transition to adulthood, home visiting
> Read the overview report

2023 - Pan-Dorset - Samuel, Shay and Joy

Three siblings, Samuel (17), Shay (15) and Joy (13), known to services as potential victims of criminal exploitation. In 2022 Samuel was involved in two altercations and received knife wounds. In December 2022, Shay was arrested regarding an assault with a knife which led to another arrest for class A drug possession.
Learning themes include: working with the family, alongside the wider contextual issues regarding child criminal exploitation and serious youth violence; evaluation of assessments and interventions; the role of schools; use of knives and police and criminal justice interventions; use of social media and agency assessment of its significance; extra-familial harm versus criminal activity; use of the National Referral Mechanism (NRM); and managing the needs and risks of siblings.
Recommendations include: adopt the term ‘extra-familial harm’ to describe ‘child exploitation’; review the existing system of alerting senior managers to ‘high risk’ children in children’s social care; ensure that front line practitioners have a clear understanding of adolescent development and the impact of ACE’s/trauma; consider a multi-agency learning audit for children involved in the Section 47 process where there is an extra-familial harm concern; school leaders should review the effectiveness for children of separate ‘on site’ alternative learning provision; embed training on children’s use of social media and its associated risk factors into existing training; ensure one safeguarding partner takes sole responsibility for tracking children subject to the NRM process; and where extra-familial harm is evidenced ensure siblings are appropriately assessed and interventions are put in place.
Keywords: adolescent boys, drugs, child criminal exploitation, children missing education, exclusion from school, violence
> Read the overview report

2023 - Perth and Kinross - Child G and Child D

Concerns the hospitalisation of two babies from separate families who were both found to have sustained significant harm. Child G’s urine toxicology was reported as positive for cocaine and Child D suffered multiple fractures consistent with non-accidental injuries. Child G and their parents were known to multi-agency child protection services and agencies. Child D’s mother experienced housing, unemployment, and mental health stressors.
Learning considers: child protection policy for children admitted to hospital who are on the child protection register; drug exposure to babies and children in a hospital setting; recognition of disguised compliance; identifying risk to unborn babies; recognising indicators of physical abuse; professional curiosity; supervision of children being cared for in hospital who are subject to a child protection investigation; and understanding of skeletal surveys.
Recommendations for the child protection committee include: ensure that disguised compliance is included in inter-agency child protection staff learning and development opportunities; ensure that inter-agency training programmes and new employee inductions include professional curiosity themes; and ensure there is a multi-agency policy in place for the supervision of babies and children in hospital settings who may have been abused or neglected. Recommendations for the NHS trust include: develop guidance on ‘suspicion of poisoning’ from substances and share concerns promptly with the child protection team and police; appoint a single-point-of-contact when a child is transferred to another health board area where there are child protection concerns; ensure NHS staff are adequately trained in recognition and response to physical abuse; and ensure the unborn baby protocol is embedded into day-to-day practice.
Keywords: infants, physical abuse identification, children of addicted parents, disguised compliance, professional curiosity
> Read the overview report

2023 – Sandwell – Young Person SC

Death of a 17-year-old boy as a result of multiple stab wounds sustained.
Learning is embedded in the recommendations.
Recommendations include: seek assurance that there are formal processes to collect and analyse data around fixed or permanent exclusions and managed transitions; undertake a review of the themes and patterns of behaviour which constitute a 'persistent breach of school behaviour policies' and provide evidence of the effectiveness of approaches used to prevent exclusions for those who are overrepresented and at risk of exclusion from education; undertake work to understand young people's experience of alternative provision in the borough, especially young people with complex needs, being exploited/at risk of exploitation or who are disproportionately affected by exclusions; undertake a consultation process with Black and ethnic minority children, practitioners, community groups and families to understand the reluctance to engage with early help services and devise an action plan which addresses the barriers; undertake a review of referrals received, support offered and take-up of services for ethnic minority groups; and assurance that school behaviour policies have clear guidance and a definition of 'persistent breaches and school exclusion' and that they are based on guidelines provided by the Department for Education (DfE) regarding behaviour and discipline in schools.
Keywords: child criminal exploitation, exclusion from school, gangs, parents with a mental health problem, youth justice
> Read the overview report

2023 – Slough - Harry

Possible neglect of a boy since birth until an incident in January 2019 when he was 11-years-old. Harry was seen with facial injuries by staff at a local leisure centre where he attended alone. Police were initially unable to contact his mother and she was later arrested for neglect.
Learning themes include: the voice of the child; recognising the signs and symptoms of neglect in children, the assessment of risk and enhanced professional curiosity; supervision, sharing information, communication and record keeping; professionals working together, compliance to policies and procedures and escalation processes; disguised and varied compliance; and child protection medical examinations.
Recommendations include: be assured that all partners keep focussed on the child or young person, and that a professional meeting can be called by any partner to ensure communication and challenge of safeguarding concerns; review and update the local ‘Multi-Agency Threshold Guidance ’; make sure all staff utilise the available ‘Neglect Strategy and Tool’ to assist in identifying the signs and symptoms of neglect and abuse and to take immediate and necessary action if required; ensure agencies’ record keeping systems are robust, accurate and efficient for purpose and staff are complying with policy; ensure staff are supported and trained in dealing with difficult and confrontational parents or guardians; include within child protection training the range of options practitioners can take, including legal advice when a parent or guardian refuses consent to a child protection medical.
Keywords: Black children, child neglect, disguised compliance, hostile behaviour, medical assessment, physical abuse
> Read the overview report

2023 – Solihull – Baby JS

Death of 4-month-old-baby after being found unresponsive in bed with its mother.
Learning includes: reinforcing messages about potential risks to a child’s safety of alcohol use by parents, even where there is no dependency; adequately managing every stage of the social care response from screening to the allocation of support; allowing for disclosure of domestic abuse by female perpetrators at routine domestic abuse screenings of pregnant women and new mothers; ensuring multi-agency co-ordination takes place as soon as the need for early help is identified and before a threshold for social care involvement is met; and keeping the lived experience of the child central to practitioners’ work.
Recommendations include: learning from the National Review into SUDI in families where children are considered at risk of significant harm should be fully implemented in their area; changes introduced to the referral process should be monitored to ensure all cases are being appropriately screened; relevant partner agencies should review their internal systems and guidance around making and following up referrals including providing feedback to all referrers in a timely way; screening questions used for domestic abuse should be reviewed and if necessary reframed to avoid any unconscious bias; action should be taken to ensure that all practitioners are confident to explore situations involving domestic abuse, including establishing who is using abusive behaviours and who is the victim; and communication around the potential risks to a child’s safety of alcohol use by parents should be reviewed and strengthened.
Keywords: alcohol, family support services, family violence, parents with a mental health problem, sleeping behaviour, sudden infant death
> Read the overview report

2023 – Southampton - Stephen

Chronic neglect of an 8-year-old boy in 2021, discovered after the police executed a warrant with regards to Stephen’s stepfather and attended the home address. The police raised concerns around poor home conditions as well as Stephen’s presentation. Stephen’s mother reported that Stephen was autistic, did not like wearing clothes, and was being electively home educated.
Learning themes include: the impact of the COVID pandemic and the response of services to the family; the impact of ‘was not brought’ to health appointments; information sharing and professional challenge; professional curiosity; and the importance of following statutory guidance.
Recommendations to the partnership include: raise awareness amongst partner agencies of ‘Working with resistant parents guidance’, to reinforce its importance as a tool for working with children who are vulnerable; remind practitioners of the importance of considering a child’s lived experience of their home environment and to question whether the care offered to a child is ‘good enough’ to guarantee their safety, health and wellbeing; ensure that provision of bespoke, professional therapeutic intervention is in place for a child after their return to the family and/or if they remain a looked after child; remind practitioners to verify accounts provided by parents/carers and to ensure that information is shared within and between agencies to enable a holistic approach to safeguarding children; consider sharing information between the local NHS Trust and early years to identify children who have not been brought for their health review at age two and who have not taken up the offer of two-year funding.
Keywords: child neglect, home education, home environment, non-attendance, family reunification, professional curiosity
> Read the overview report

2023 – Southampton – Uma

Rape of a 14-year-old in 2022. Uma was vulnerable due to a history of being sexually abused in the family environment.
Learning themes include: early identification of those at risk of exploitation; the importance of seeking information about a child’s history when they have lived in another area; language used about vulnerable children; retracted allegations; impact on the child when professionals change; and responding to children at risk of exploitation when they go missing.
Recommendations include: ensure that the learning from this review informs the other work being undertaken on a similar theme; consider what can be done differently to ensure the early identification of children on a trajectory to exploitation and provision of multi-agency support and preventative/educative work; raise with other local safeguarding children’s partnerships and agency partners the need for system wide support for practitioners in respect of good practice when working with children who are exploring their gender identity; get detailed feedback from the police on the work being undertaken in respect of missing children; ask agencies to provide information on progress and challenge in respect of the language used in respect of vulnerable children; ask the relevant partner agencies to provide assurance regarding what is being done to prevent school exclusion for children who are at risk of exploitation.
Keywords: abuse allegations, children in care, child sexual abuse, child sexual exploitation, online abuse, rape
> Read the overview report

2023 – Southampton - Willow

In January 2023, a 16-year-old made a number of non-recent reports of sexual assault and rape against adult males. All of these reported incidents took place whilst Willow was in care.
Learning explores: the reporting and review of missing child episodes, including appropriate use of the Philomena protocol, the grading of missing episodes, and use of the ‘3 in 90’ procedure; the use and grading of the child exploitation risk assessment framework (CERAF) tool; listening to the voice of the child or young person; the convening of strategy discussions and compliance with ‘Working together to safeguard children 2023’; and the support and training of carers with regards to the risks outside the home (ROTH) for vulnerable children or young people.
Recommendations include: assurance from statutory partners of compliance with ‘Working together to safeguard children 2023’ to ensure that the appropriate professionals are invited to and are attending strategy discussions; allocated social workers and supervising social workers to ensure that alongside generic training for carers, each young person has a package of support in place tailored to their individual needs; assurance that the language used in respect of children, young people and their families is appropriate and not derogatory or victim blaming; and asks the relevant partner agencies to provide assurance regarding what is being done to prevent school exclusion for children who are at risk of exploitation.
Keywords: children in care, child sexual exploitation, abuse allegations, runaway adolescents, voice of the child, foster care
> Read the overview report

2023 - South East Wales - Child E

Death of a boy aged 9 years and 11 months in November 2021. He was found unresponsive in the family home with a scarf around his neck.
Learning themes include: co-ordination of assessments and plans; the significance of family history; understanding of the child’s lived experience; professional differences; the presence of inappropriate sexual behaviour, especially in younger children, as a potential indicator that they are experiencing or have experienced child sexual abuse; and systems and processes around care and support plans and opportunities to progress to strategy discussion and child protection enquiries.
Recommendations include: consider developing practice guidance on the lived experience of the child to assist practitioner insight, to ensure that the voice of the child is actively heard and to support effective action to safeguard children and young people; consider raising awareness across all agencies of the Multi-Agency Practice Guidance, Resolving professional differences; consider raising awareness across all agencies of the Multi-Agency Chronology Guidance; consider strengthening the written guidance around Multi-Agency Supervision; consider developing a regional protocol for responding to harmful sexual behaviour by children and young people. Recommendations to the local authorities include: consider enhanced management oversight and review of cases where children and families are supported on a care and support plan for extended periods; consider how the views of education and school can be represented in child protection processes that take place during school holidays.
Keywords: abuse allegations, child behaviour problems, child deaths, harmful sexual behaviour, parents with a mental health problem, residence orders
> Read the overview report

2023 – South Gloucestershire and Bath and North East Somerset – Baby M

Significant injuries, thought to be non-accidental, to a 3-month-old baby in May 2022. There are likely lifelong health implications as a result of the injuries sustained.
Learning themes include: identifying and responding to the vulnerability of babies; pre and post birth levels of need; the importance of understanding contextual parental factors; keeping a focus on the child when there are moves between areas; the role of housing providers in understanding risk; health services information sharing; record keeping; and critical thinking in practice.
Recommendations include: health recording systems should include a holistic assessment of a child’s needs which includes contextual maternal and paternal family factors; ensure all health professionals have access to information and guidance when assessing any adults who may be care experienced; implement training for NICU staff about increasing confidence and knowledge when working with domestic abuse; further embedding the ICON ‘babies cry, you can cope’ programme and increasing awareness of non-accidental injury in babies; ensure effective transfer of information between areas and services; develop a communication pathway between midwifery, health visiting, and GPs to ensure the learning from this review is included in the standard operating procedure (SOP) so that it adequately covers families that move between areas; and safeguarding supervision arrangements for community health professionals should ensure there is a safe space for critical thinking in practice, promote professional curiosity, and enable a trauma informed approach to the family’s needs when working with a pre and post birth situation.
Keywords: adults in care as children, homeless families, housing, low income families, maternal depression, neonatal intensive care units
> Read the overview report

2023 – South Gloucestershire – Family A

Mother of three children under 5-years-old convicted of father's murder. Murder was witnessed by one of the children.
Learning includes: assumptions about domestic abuse can lead to plans for children that are not reflective of their experience and do not mitigate risk; fathers need to be considered and involved in assessments and plans for their children, even in cases of domestic abuse or where the father does not live with the children; professionals must have a full understanding of a parent's history and vulnerabilities and consider the impact of this when undertaking assessments and working with families; practice and systems need to be child centred and consider a child's lived experience so that work with a family is not dominated by adult issues; Covid-19 is likely to have had an impact on the family and support provided to them.
Recommendations include: consideration of the findings of the Child Safeguarding Practice Review Panel's 'Multi-agency safeguarding and domestic abuse briefing paper' (2022); ensure that the requirement for timely assessments and the need to understand the nature of the abuse in each relationship is covered in domestic abuse training; ensure that partner agencies specifically request and record details of the GP for all children and adults in a household and that information is shared with all GPs; information about domestic abuse orders and plans should be shared with all professionals working with children in the family.
Keywords: murder, family violence, fathers, assessment, information sharing
> Read the overview report

2023 - South Lanarkshire - Young Person C and Young Person D

Murder of a 16-year-old girl after being reported missing from care in November 2021. Young Person D’s 19-year-old brother Young Person C was found guilty of her murder in July 2023 and sentenced to life imprisonment.
Learning themes include: placement decision making and sibling assessment; management of sexual abuse allegations and subsequent legal proceedings; child victims of sexual abuse; harmful sexual behaviour; working with young people at risk of significant harm; transitions in throughcare and health/mental health services; and support structures for workers working with young people with challenging behaviours and needs.
Recommendations to the child protection committee (CPC) include: where a decision has been taken not to place siblings together, it should be ensured that permanency decisions have a robust evidence base and that any variation in the care plan is recorded and under constant review by relevant agencies; there should be a comprehensive multi agency risk assessment and risk management framework for working with young people displaying harmful sexual behaviours; the implementation of a contextual safeguarding approach should be considered to include young people up to the age of 18-years-old, and include care experienced young people who are supported by Continuing and Aftercare; a positional statement should be requested from CAMHS as to the future development of services for young people up to age of 18-years-old who are not care experienced; and CPC should request that work is undertaken to identify the need for a practice forum for practitioners to bring high risk and complex cases for discussion.
Keywords: child deaths, harmful sexual behaviour, sibling relations, permenancy planning, children in care, child behaviour problems
> Read the overview report

2023 - South Tees - Angel

Death of a child in the first weeks of their life. The cause of death has not been established at the time of the report being published. Angel and their siblings were on a child in need plan due to a history of domestic abuse, physical abuse and neglect.
Learning includes: the need for agencies to recognise that children who live in the area are their responsibility, including children who have just moved into the area; the need for robust and timely information seeking and sharing when a family move into an area, without relying on a parent’s self-reporting; the need for improvements in practice when children on child in need plans move to another area; the need for curiosity and vigilance in identifying the impact of moves of home area on children; increase professional confidence in introducing the use of interpreting services when a family do not speak English as a first language, and where there are potential cultural differences to be explored and understood; consideration of the impact of a family coming from a minority culture on their engagement.
Recommendations include: reinforce that children with a safeguarding history who move area are potentially some of the most vulnerable children, seeking assurance from partner agencies that systems acknowledge local ownership and meet the needs of these children; remind professionals of the value and importance of using interpreting services, including provision of the cultural awareness required to work in a meaningful way with families; and ensure health visitors are involved in assessments and planning for unborn children.
Keywords: infant deaths, transient families, culture
> Read the overview report

2023 – Staffordshire - Alex

Intrafamilial child sexual abuse of a 12-year-old girl by her father which had started when she was around 6 years old. The father is a registered sex offender and had served a custodial sentence having admitted sexually abusing a 14-year-old girl.
Learning includes: the need for detailed knowledge and robust information sharing in respect of any historic concerns and potential on-going risks when a known sexual offender is living with, or having contact with, children; the need for all professionals to understand the complexity of working with families where there is a risk of sexual abuse; the importance of schools in providing a safe space for children to be supported; and the need for professionals working with children and families to have adequate and appropriate knowledge about perpetrators of intrafamilial sexual abuse.
Recommendations include: that the partnership asks partner agencies to ensure there is a focus for the whole system on the development of staff to enable them to work with children where sexual abuse in the family environment is an issue; that the partnership informs the relevant partner agencies of the expectation that they robustly consider their response when concerns are shared by a person who is not a professional; and that the partnership seeks assurance about the mechanisms in place across the relevant partner agencies that ensure that decision making considers previous assessments and the family history that is available in their own agency and in other agencies.
Keywords: intrafamilial child sexual abuse, abusive fathers, sex offenders, risk management, nonabusive parents, information sharing
> Read the overview report

2023 – Staffordshire - Beta

Covers the period Sept 2018 until June 2021 when there was a disclosure of sexual abuse by a girl against her stepfather. The family had been well known to services since 2012. Beta and her siblings had been subject to child protection plans historically and there had been a previous Serious Case Review following the death of a sibling.
Learning themes include: the need for conversations around risk, including people’s perception of risk, the different risk assessments, and the interface between them; ensuring all partners are informed, and a multi-agency approach taken when a local authority contests a Special Guardianship Order (SGO), or there is a change in circumstances within a family unit; making sure children always remain the focus and are central to processes so that if adults caring for children experience medical issues, grief etc, consideration should always be given to the impact on the children; ensuring all partners are aware of a family being involved in a SCR/CSPR and that records reflect that; building trust, providing opportunities for children to disclose, and asking the right questions at the right time; professional curiosity and considering issue of disguised compliance; where multiple types of abuse are taking place, making sure attention is given to each form of abuse rather than allowing one type of abuse to overshadow the other; and ensuring the voice of the child is heard.
Recommendations are embedded in the learning. Highlights examples of good practice.
Keywords: child sexual abuse, child neglect, disclosure, risk assessment, special guardianship orders, step parents
> Read the overview report

2023 – Staffordshire - Child I

Intra-familial sexual abuse and indecent images of a 2-year-old child by their maternal uncle, which came to light in June 2022. There was a history of intra-familial and inter-generational sexual abuse within the wider family and further allegations were subsequently made.
Learning themes include: professional response to inter-generational and intra-familial sexual abuse; understanding the significance of family history, particularly where there is a history of harmful sexual behaviour and abuse; sharing cross border historic information; professional application of a Think Family approach to safeguarding concerns, including an understanding of the wider family and the family culture; professional knowledge of specialist sexual abuse support services, such as the Lucy Faithfull Foundation, and how to access them; identifying barriers which prevent professional curiosity and helping professionals to overcome them; agencies reviewing risk management of complex family circumstances; managing the potential risk of a person reported to have carried out child sexual abuse who is not charged and/or convicted; understanding the lived experience and voice of a non-verbal child; and the impact of the Covid-19 pandemic on support services.
No formal recommendations. Question-based learning incorporated in the learning themes.
Keywords: voice of the child, child sexual abuse, intergenerational transmission of abuse, extended families, sexually abused children, child abuse images
> Read the overview report

2023 – Stockport - Dylan

Life changing injuries to a baby, thought to be non-accidental. The incident is subject to an ongoing police investigation at the time of the review.
Learning includes: parental vulnerabilities and the potential impact on parenting; the need to consider if neglect is an issue when a child has emerging special needs; maintaining a focus on the child and their lived experience over time; processes and practice that safeguards babies who have unexplained bruising; the impact on children of a parent’s mental health difficulties; the effective and robust consideration of fathers/non-birthing partners; and parental engagement, including understanding the barriers to meaningful engagement.
Recommendations include: seek assurance from partner agencies about the impact of the on-going focus on working effectively with fathers and non-birthing partners; seek assurance that professionals understand and assess the impact of mental health and trauma on parenting, including the development and use of a clear mental health pathway for safeguarding in pregnancy and after the birth of a child; ask the relevant partner agencies for an update on the work undertaken to improve the response to bruising in non-mobile babies; seek assurance on how agencies are balancing high support with high challenge when required; request an update from the relevant partner agencies on work being undertaken in respect of using chronologies which incorporate the history of siblings and parents to inform safeguarding work; seek assurance from agencies regarding work being undertaken to ensure increased use of the Graded Care Profile by trained professionals, and for this to be monitored and appropriately challenged.
Keywords: bruises, fathers, infants, injuries, parents with a mental health problem, police
> Read the overview report

2023 - Stockport - Molly

Assault of a teenage girl in a residential children’s home. The incident is subject to an ongoing police investigation at the time of the review.
Learning themes include: managing the risk of harmful sexual behaviour (HSB) in residential settings; support for adoptive parents; support available for families where child to parent violence is a feature; child blaming language used by professionals; and placement sufficiency and impact on finding placements for children with complex needs.
Recommendations include: the national working group reviewing the adoption support arrangements should take action to ensure that the needs of adopted children are addressed at key transition points, such as when they move area or school; consider developing a pathway to support an effective professional response to child to parent violence; seek assurance that partner agencies have guidance which addresses victim blaming language and ensures that professionals record with the child in mind on the understanding that the child may one day ask to see their records; suggest to the National Panel that they consider concerns about the impact on children and young people of the cost and shortage of appropriate placements for traumatised children; when seeking placements for children the commissioning team should seek reassurance about harmful sexual behaviours; propose that the children’s home develop a harmful sexual behaviours policy and systematic approach to keeping children safe from sexual harm; identify whether other LSCPR’s have highlighted a lack of guidance within children’s homes about HSB and whether this issue is currently being sufficiently addressed through Regulation 44 Visits.
Keywords: adolescent girls, abusive adolescents, adoption, harmful sexual behaviour, record keeping, residential child care
> Read the overview report

2023 – Surrey – Child Rowen

Death of a 4-month-old-boy in Spring 2022. A post-mortem found that Rowan died from sudden unexpected infant death syndrome. His parents were children themselves at the time of Rowan’s birth. Mother was 13-years-old and father was 14-years-old.
Learning themes include: the importance of parenting and pre-birth assessments; recognising that the parents were themselves children and the support offered to young parents; child protection planning; and professional advice on safe sleeping.
Recommendations include: ensure all practitioners read the briefing ‘Learning from Pre-Birth Assessments’; if a vulnerable baby is living in the care of grandparents (with or without the presence of their parent), an assessment of their parenting capabilities and skills should be a pre-requisite before any such placement is made, especially if the child is subject to a child protection plan; when parents are children themselves, their needs and wellbeing should be recognised, and considered a priority, together with that of the need to safeguard their child; explore the possibility of young, teenage mothers being offered the services of the perinatal mental health team when it is evident that their health and wellbeing is at risk; GP practices should be informed when a child is subject to a child in need plan, to ensure that relevant safeguarding information is shared; seek assurance that the framework concerning safe sleeping is embedded for use by practitioners and that it includes a requirement that professionals visiting the home ask to see where a baby is sleeping.
Keywords: adolescent fathers, adolescent mothers, adverse childhood experiences, county lines, exclusion from school, sudden infant death
> Read the overview report

2023 – Suffolk - Samantha

Murder of a 12-year-old girl and her mother in September 2022. Samantha’s father was found guilty of both murders.
Learning themes include: risk analysis in respect of domestic abuse; recognition of Samantha’s verbal and non-verbal cues; support for parents; impact of the Covid-19 pandemic; and exploring cultural issues.
Recommendations to the partnership include: conduct a multi-agency audit in respect of domestic abuse case referrals to determine whether thresholds are being appropriately applied; provide guidance for children’s practitioners on where to record information which relates to one parent and is not to be shared with the other parent for confidentiality reasons; where a parent’s perception of the level of risk to a child is relied on to formulate the professional risk analysis or safety plan, this should be carefully explored and challenged by the multi-agency risk assessment conference (MARAC); all partner agencies should refresh their training offer in respect of domestic abuse to ensure practitioners are equipped to look for and identify patterns of coercive and controlling behaviour and how this may present in the context of a child’s situation and learning needs; the integrated care board should review what mental health, mediation and counselling services are available across the wider partnership to perpetrators of domestic abuse; partner agencies should use supervision and training to challenge stereotypes in respect of parenting roles for men and women; develop a strategic approach to tackling extremist misogyny and toxic masculinity; and ensure that frontline practitioners can access advice in respect of the cultural experiences of people from different countries or religions.
Keywords: autism spectrum disorder, child deaths, children with a learning disability, culture, domestic abuse, murder
> Read the overview report

2023 - Surrey - Maple

Suspected suicide of a 15-year-old in September 2021. Maple self-harmed for several years and made three attempts to end their life during their teenage years. Maple and their brother were made the subject of a child protection plan for neglect when Maple was 12.
Learning themes include: celebrating difference and building belonging; responding to neglect and cumulative harm; and multi-agency responses to children with mental ill health.
Recommendations to the partnership include: ensure gender identity is a key strand of equality action planning across all agencies; review its neglect strategy to consider what is needed to strengthen early identification and responses to neglect, and multi-agency responses to children with mental ill health who may have experienced neglect; lead on developing a shared multi-agency framework/practice model to guide multi-agency work with children with mental ill health, including the importance of engaging and supporting families; make representation to the relevant national qualifying authorities raising the importance of the training and support provided to practitioners in understanding and responding to adolescent mental ill health and wellbeing; and consider how confidence may be built in the children’s workforce in talking to children at risk of self-harm/suicide and how the availability of safe places may be promoted/facilitated.
Keywords: adolescents, child deaths, child mental health, child mental health services, gender identity, suicide
> Read the overview report

2023 - Surrey and Gloucestershire - Ash

Suicide of a 17-year-old boy in 2021. Police found prescribed and unprescribed medication, a ‘burner phone’ and a BB gun in Ash’s room. Ash had an ADHD diagnosis and was known to children’s social care and police due to concerns around criminal exploitation.
Learning themes include: multi-agency understanding of the child’s lived experience, mental health and the impact of parental conflict; effectiveness of information sharing; criminal exploitation and contextual/adolescent safeguarding; elective home education and child protection; medical or psychological assessments in the private sector; cross border working; understanding known behaviours in relation to past trauma and present risks; and impact of ADHD on learning and daily functioning.
Recommendations include: partnerships to work with parents to explore barriers to open dialogue with statutory agencies; all agencies to evaluate the quality of supervision, particularly around professional curiosity, elective home education, and consulting all adults with parental responsibility when parents are separated; relevant bodies to remind private consultants to comply with GMC and NICE guidance on who must contribute to the safe transfer of patients between healthcare providers; ask the Department for Education to consider placing a duty on parents to inform the local authority when a child is being home educated and if the child moves to a different local authority; develop multiagency elective home education safeguarding procedures for children at risk of criminal exploitation and ensure practitioners can recognise the signs of exploitation; and where there are concerns, ensure that risk assessments are based on the full facts of the case and the voice of the child is obtained.
Keywords: suicide, child criminal exploitation, contextual safeguarding, home education, family conflict, drugs
> Read the overview report

2023 – Swindon - Alan

Accident and emergency presentation of a 16-year-old boy in March 2021 following a social work visit. The home visit revealed significant neglect and malnourishment.
Learning focuses on: multi-agency barriers and enablers to safeguarding adolescents from neglect including the application of mental capacity assessments; strengthening child protection processes for older teenagers who are experiencing neglect; the use of threshold criteria; the escalation procedure; and the impact of the Covid-19 pandemic on the child’s well-being, parenting capacity and the multi-agency response to the child.
Recommendations include: agencies providing intervention at the early help level of need should feel like their voice is heard with authority and respect across the system; decisions about step-up and downs should be informed by multi-agency perspectives of those professionals involved with the child, and not taken solely on the grounds of threshold definition; decisions should be flexible with a willingness to use the skills and expertise in both early help and social care together; existing practice guidance on neglect should be reviewed, adding guidance for practitioners about working with adolescents who are difficult to engage with; the escalation process and its implementation should be reviewed to ensure it encourages both the airing of concerns about children and an expectation that those concerns will be received positively and responded to proactively; and procedures should focus more on expected behaviours and responses, on promoting the importance of escalating concerns within the system and include an approach to managing ‘stuck’ cases.
Keywords: adolescent boys, autism, child mental health, emotional neglect, medical care neglect, threshold criteria
> Read the overview report

2023 - Waltham Forest - Kubus

Death of a 15-week-old baby boy in July 2021. Kubus died while sleeping on an inflatable mattress along with his mother and was sleeping on his stomach.
Learning includes: pregnancy care through antenatal, perinatal and postnatal stages; housing; disclosure of domestic abuse; cultural competence; inaccuracies in documentation and record keeping; communication and escalation pathways; and risk assessment processes embedded during Covid-19, which may have contributed to reduced visibility and support.
Recommendations include: explore the barriers and operational challenges to having contemporaneous accessible electronic records, with a view to identifying solutions to prevent gaps in information sharing which can lead to risk and result in harm; gain assurance that operational systems are robust in ensuring they hold the most recent contact information for service users; commission and sustain Identification and Referral to Improve Safety (IRIS) provisions in primary care; ensure that staff understand the cultures of the demographic that they work with; if English is a second language ensure that information delivered and received is checked to avoid miscommunication and consider an offer of an interpreter if necessary; recognise the importance of including fathers in assessments, whether absent or living in the household; and ensure that accurate quality documentation is maintained, irrespective of the challenges posed to staff.
Keywords: culture, family violence, housing, language, sleeping behaviour, sudden infant death
> Read the overview report

2023 – Wandsworth - Lloyd and Mark

Death of a 16-month-old boy due to non-accidental injuries in August 2019. Mother's partner was charged with murder and Mother was charged with causing or allowing the death of a child.
Learning focuses on: the effectiveness of local multi-agency safeguarding children thresholds and pathways; the child's lived experience; the formulation and management of child protection plans and core groups; working with parents who are reluctant to engage; the impact and management of house moves on safeguarding systems; responses to domestic abuse; parenting education; parental drug and alcohol misuse; and the use of written agreements.
Recommendations include: agencies, midwifery services and adult services review their assessment guidance and procedures to ensure curiosity about and consideration of the welfare of other household or family members, especially children under 5-years-old; a review of the protocol for re-housing families where children are subject of child protection plans to minimise moves away from the borough and key safeguarding networks, except where a move is essential to safeguarding a child or parent; relevant staff in partner agencies to have sufficient training in domestic abuse awareness, including the use of risk assessment tools and when to refer a case to a Multi-Agency Risk Assessment Conference (MARAC); a review of the use of written agreements with families when they are not part of agreed Child Protection Plans or Public Law Outline work, with guidance needed on when to share information about these agreements with key partner agencies.
Keywords: child deaths, physical abuse, injuries
> Read the overview report

2023 – Warwickshire - Anna

Suicide of a 21-year-old mother in October 2019. Anna had a baby at 15-years-old and both Anna and her daughter were considered as ‘children in care’. Anna had long-term physical and emotional difficulties, including personality disorder.
Learning considers: effective information sharing to support both the parent and child; a ‘Think Family’ approach; collective consideration of the bigger picture; assessing a parent’s physical and mental health needs; non-attendance of appointments and the decision to discharge; a trauma-informed approach; and the role of corporate parent.
Recommendations include: children’s services to consider how they have the skills and knowledge to support people with personality disorder and for all front-facing staff to have appropriate training; the establishment of a multi-agency task and finish group to address the gap in information sharing and better embed the ‘Think Family’ approach; relevant agencies, including the police, to consider the impact of their actions related to the protection of children on vulnerable adult family members; those working with children to be aware of the role that social care can play in supporting adults with care and support needs; seek assurance that the Escalation Protocol is fully embedded and being used effectively across all agencies; consider reviewing existing supervision methods, with a focus on the use of reflective practice and evidence-based processes; the partnership to produce short briefings on the issues of disguised compliance, the rule of optimism (around ‘new partners’ joining vulnerable families) and the poor care of pets; and to ensure step up/down processes are effective in cases where family mental health concerns have been identified.
Keywords: adolescent mothers, suicide, borderline personality disorder, non-attendance, children in care, trauma-informed practice
> Read the overview report

2023 - Warwickshire - Simon

Suicide of a 16-year-old boy in March 2021. Simon suffered a serious fall in 2018 which left him with a brain injury which is said to have affected his behaviour and led to mental health problems.
Learning includes: assessment of risk which considers the cumulative effect of adverse childhood experiences; effectiveness and closure of child in need plans; dealing with allegations of sexual abuse; voice of the child in decision making; cultural and language challenges; impact of Covid-19; and the relationship between brain injury and mental health.
Recommendations include: the partnership should seek assurance on effectiveness of child in need plans in the context of providing support to young people at risk of suicide and how these relate to other relevant plans; local children services and partners should review the process of receiving and responding to notifications under section 85 of the Children Act 1989; police should provide assurance that victims, and where appropriate parents, reporting offences of rape and sexual assault are appropriately updated and offered support; consider how learning on this review links to the Exploitation Strategy and is used to help develop a trauma informed approach for child sexual abuse; where there is a risk of suicide, to consider a ‘Think Family’ approach, with particular consideration to areas of culture; the partnership should consider a multi-agency audit on the use of interpreters; the partnership should seek to embed a new model into the CAHMs contract to move towards a needs led approach; and all professionals should seek to work with families when proposing measures involving the removal/storage of items potentially used to cause harm.
Keywords: suicide, abuse allegations, child sexual abuse, children with a mental health problem, interpreters, children in need
> Read the overview report

2023 – West Glamorgan - N56

Covers the period from December 2018 to December 2019 when Child X attended the hospital following identification of his injuries which were consistent with shaking.
Learning themes include: multi-agency working; information sharing between health professionals; the importance of separating fact from opinion when recording; domestic violence; professional curiosity; and use of the strategy meeting.
Recommendations include: agencies should strengthen their guidance and training provided in respect of recording information to ensure relevant individuals are identified clearly in recordings whilst also differentiating between self-reported information and diagnosed conditions; midwifery and health visiting services should be reminded of the guidance and importance of effective communication and information sharing between their services; all key agencies should be reminded of the importance of their involvement at the Initial Strategy Meeting; training around working with families who are experiencing domestic abuse should include the importance of involving fathers and extended family to fully assess risk and maximise opportunities for better outcomes; if the referring agencies are not content with the proposed action they must challenge the decision and if necessary escalate their concerns by implementing the Multi-Agency Protocol for the Resolution of Professional Differences; and panel members should be reminded of their responsibilities in the Child Practice Review process which includes that all key professionals involved in the case are invited to the learning event to maximise discussion and learning.
Keywords: eyes, family violence, infants, record keeping, shaking, parents with a mental health problem
> Read the overview report

2023 – West Glamorgan - N63

Neglect of a sibling group of six children covering the period from October 2018 to November 2020.
Learning themes include: cross border working; neglect of neglect and focussing on parental support rather than parenting capacity; extra familial harm; voice of the child and advocacy.
Recommendations include: local authorities should have clear policy and practice guidance to ensure safe and timely sharing of information when children’s names are not on the child protection register, and use of the Resolution of Professional Differences Protocol if this is not being complied with; local authorities should consider each child’s circumstances fully when allocating workers to ensure the risks of extra familial harm are not absorbed within the wider family dynamic; each organisation should consider advocacy through a broader lens such as non-instructed advocacy and use a trauma informed approach when considering an appropriate advocate; practitioners should ensure children are seen on their own, away from parents and carers, in an environment where they feel safe, so that the child can speak about the circumstances which have prompted safeguarding concerns; paediatric review should be considered and requested earlier in neglect cases and become standard practice for all child protection neglect cases which do not show significant progress when they reach second review conference stage; all practitioners should have access to training on disguised compliance and demonstrate professional curiosity and respectful uncertainty; all professionals should understand the significance of children missing appointments; and all agencies should ensure relevant representation at multi-agency meetings includes professionals with the relevant expertise and knowledge, to inform decision making processes.
Keywords: child health, child neglect, dentists, non-attendance, neglect identification, parenting capacity, transient families
> Read the overview report

2023 – West Lothian – Child F

Non-accidental injuries to a 2-week-old-infant. During the mother’s pregnancy, a range of services had been working with the parents and the unborn baby’s name had been placed on the child protection register in 2022.
Learning includes: pre-birth support for vulnerable pregnancies including the vulnerable pregnancy service should be reviewed and a clear pathway established; transfers between duty and child protection team, and practice teams should be more timely; child protection plans should be more explicit and focus on the specific interventions to address identified risks; and decision-making at child protection case conferences should take account of risks, vulnerabilities and the likelihood of future significant harm.
Suggestions for the child protection committee to discuss include: setting up a working group to review practice in relation to earlier allocation of cases of unborn babies and pre-birth assessment completed by practice teams; identify specific actions within child’s plans to include frequency and purpose of all contact with the family and clarity about the role of each professional involved including when interventions start and finish; the quality assurance subcommittee should observe child protection case conferences/planning and should also consider the role of reviewing officer; consider awareness raising about bail conditions and the need to confirm changes reported by the perpetrator; and consider awareness raising about the use of restricted access information and how it is taken into consideration when making decisions.
Keywords: adolescent parents, decision making, parents with a mental health problem, physically abused infants, Scotland, youth justice
> Read the overview report

2023 - West Sussex - Hazel and Lilly

Death of a 16-year-old girl in 2021. Hazel took her own life. Hazel and her sister Lilly received multi-agency services in response to concerns about maternal care in childhood and in response to emerging mental ill health in adolescence.
Learning themes include: understanding and responding to the risk of suicide as a safeguarding concern; safeguarding children across multi-agency boundaries; schools knowing children and understanding risks; caring for traumatised children; the importance of family networks; paying attention to the language used when recording what children say; and the impact of the coronavirus pandemic.
Recommendations include: seek representation from services to understand how the risk of suicide and the impact of related factors are understood, and what service changes are in place that prompt a timely safeguarding response to children in real time; consider how a trauma-informed culture across the multi-agency partnership is being implemented, including how parents/carers of children are supported to understand the impact of trauma on the child and family; evaluate how wider family and kin-networks feature in safeguarding activity, including involvement in safety planning; consider what changes may be needed to enable the sharing of a child’s story across services to minimise re-traumatisation, and how nominated trusted adults might be supported to understand a child’s lived experiences; and make representations to the relevant national qualifying authorities, raising the importance of training and support for practitioners in understanding and responding to adolescent mental ill health and wellbeing, and the impact of secondary trauma.
Keywords: adolescent girls, suicide, child mental health, trauma
> Read the overview report

2023 - Wigan - Elliot

Concerns a 12-year-old boy who was made the subject of an Emergency Protection Order in 2021. Elliot attempted suicide in his respite care placement and was admitted to hospital, where he communicated extreme distress through self-harm and violent behaviour towards staff.
Learning considers: understanding of Mental Health Act assessment processes; child and adolescent mental health services (CAMHS) support to the paediatric ward; hospital as a ‘place of safety’; children’s social care (CSC) support and placement provision; planning and escalation procedures; and service re-design and planning around managing children and young people with complex needs.
Recommendations include: local NHS foundation trusts should clearly outline the process for a child to be referred for a Mental Health Act assessment, criteria for inpatient CAMHS admission and the routes for professional challenge when there is a disagreement; a joint Health and Social Care Escalation Policy should be developed to ensure that when there is a risk of a child remaining on a general paediatric ward inappropriately, there are clear processes to alert senior leaders; the local Mental Health NHS Foundation Trust should review out of hours psychiatry provision for children; the local Hospitals NHS Foundation Trust should consider developing a ‘safe place’ where children who have been admitted can be assessed and cared for; CSC should explore the provision of suitable registered residential therapeutic placements; staff should develop skills to reflect on how children communicate through their behaviour, interaction and physical presentation, and how this can be used to plan their care; and the development of a joint health and social care escalation policy, ensuring the focus remains on the child.
Keywords: emergency protection orders, child mental health services, self harm, physical restraint, placement, children’s rights
> Read the overview report

2023 – Wirral - Noah

Death of a two-year-old boy in May 2021 from natural causes due to a bacterial infection. There had been prior social care and multi-agency involvement with the family and issues of parental neglect, domestic abuse and alcohol abuse by the children’s father.
Learning includes: consideration needed of the level of support given to victims of domestic abuse who repeatedly resume relationships with perpetrators; better promotion and oversight of use of the Graded Care Profile (GCP2) tool is required; a need to review how support is delivered and co-ordinated for families with complex needs; and a need for better use of professional curiosity with families, particularly in relation to disguised compliance.
Recommendations include: ensure all multi-agency professionals are aware of, and have access to training and resources for the systemic practice model; examine the role of Multi Agency Risk Assessment Conference and how wider support for victims of domestic abuse is managed; ensure the use of the GCP2 tool in all cases of suspected or known neglect; and highlight the features and impact of disguised compliance and parental alcohol misuse on safeguarding children.
Keywords: child neglect, family violence, disguised compliance, home environment, alcohol misuse, non-attendance
> Read the overview report

2023 – Wirral - Ollie

Death of a 13-week-old boy in February 2021. Ollie's death was the result of a co-sleeping incident with his father which resulted in brain injury. Prior to his death, toxicological analysis of Ollie's urine revealed the presence of cocaine, which resulted in an interim care order for Ollie and his siblings.
Learning themes include: identification of and response to neglect; the importance of home visits to identify poor living conditions; the effectiveness of safer sleep messages; the impact of parental mental health and substance misuse concerns as additional stressors in the family; the role of disguised compliance; and the impact of Covid-19 on supporting families and the capacity of services to respond to their needs.
Recommendations include: recommendations for the local safeguarding children partnership include: publish a multi-agency neglect strategy with actions to improve the awareness, understanding, assessment, and response to neglect, and how neglect interacts with parental mental health and substance misuse; review and update the approach to safer sleep messaging as part of a new prevent and protect model for preventing sudden unexpected deaths of infants (SUDI); develop a campaign targeting casual substance misuse amongst parents and carers and warning of the dangers to their children; undertake a review of the local impact on families of Covid-19, lockdowns and the absence of face-to-face visits; and deliver a series of locality based information events for parents and carers with access to advice and guidance.
Keywords: sudden infant death, sleeping behaviour, parents with a mental health problem, drug misuse, child neglect, coronavirus
> Read the overview report

2023 - Wolverhampton - Thematic Review - Knife Crime

Thematic review in response to three incidents of serious youth violence (SYV) that occurred between April and June 2022. Incorporates 929 survey responses from young people aged 11-18-years-old, capturing their views of knife crime.
Learning themes include: prevention and education; demography and problem profiling, including gender and ethnicity, cannabis misuse, cumulative harm, and carrying a weapon to feel safe; partnership working and information sharing; assessment and risk management; and understanding the voices and lived experiences of young people.
Recommendations include: provide specialist training to ensure that practitioners understand the concepts of adultification and intersectionality, their relationship to SYV, exploitation and knife crime, as well as the intersection between poverty and SYV, and the role that social media plays in the amplification of issues; provide support so practitioners understand how intra and extra familial experiences interface and increase likelihood of risk; help practitioners to identify when a child may be ‘freelancing’ and the harms associated with this concept; support schools to facilitate them carrying out effective peer mapping; give children access to relatable practitioners with lived experience, including male practitioners; use local intelligence to better understand the drivers that underpin weapon carrying behaviour in females and the role of females in co-offending peer group contexts; develop educative strategies to ensure that information reaches those not in full time or mainstream education, including home educated young people; align the violence against women and girls (VAWG) and exploitation agendas to recognise how gender roles and socialisation intersect with SYV; and develop a children’s substance misuse strategy.
Keywords: child criminal exploitation, drug misuse, weapons, violence, contextual safeguarding, risk assessment
> Read the overview report

Case reviews published in 2022

A list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2022. To find all published case reviews search the national collection.

Case reviews describe babies', children's and young people's experiences of abuse and neglect. If you have any concerns about children or need support, please contact the NSPCC Helpline on 0808 800 5000 or emailing help@nspcc.org.uk.

2022 – Anonymous – Adam

Death of a child in a road traffic collision in 2020. Adam was believed to have been at risk of criminal exploitation at the time of his death.
Learning includes: always follow safeguarding procedures to assess and manage the risk of harm to a child in parallel with any criminal investigation; practitioners should professionally challenge and escalate any decisions that they do not agree with; ensure the risks and the impact of non-engagement to the child have been assessed before closing a case and consider escalating the concerns if those risks are still prevalent.
Recommendations include: practitioners need to be able to distinguish between factual information and hearsay evidence that needs to be utilised to inform a risk assessment; consider adverse childhood experiences (ACEs) and trauma informed practice as a strategic priority together with the need to provide training on the impact of ACEs on children, including where there has been a history of criminality; adopt the Child Safeguarding Practice Review Panel's recommendation that all safeguarding partnerships have an understanding of the nature and scale of the problem of child criminal exploitation, and are able to identify children engaged with and at risk from criminal exploitation; strategic partners to agree and implement a contextual safeguarding response that will engage and empower members of the community.
Keywords: child deaths, child criminal exploitation
> Read the overview report

2022 – Anonymous – Anya, Rosa, Whitney and Lena

Intrafamilial sexual abuse and neglect of four girls in an extended family over a number of years.
Learning focuses on: identification of intrafamilial child sexual abuse; harmful sexual behaviours and siblings; intrafamilial sexual abuse by women; enabling children to talk about child sexual abuse and responding appropriately; understanding help seeking behaviour; the sexual abuse of disabled children; recognising the importance of safe adults and the non-abusive parent and family; understanding the motivations and behaviours of adults who pose a sexual risk to children; responding to adult disclosures of sexual abuse in childhood; responding to the needs of parents with learning disabilities; assessment of the connection between parental learning disability and neglectful parenting; the importance of understanding family history.
Recommendations include: consider the appropriate commissioning of services for children who have experienced child sexual abuse and for families who are supporting children in the aftermath of child sexual abuse; reinforce the importance of children's access to appropriate therapy while police investigations are continuing; develop guidance regarding complex and historic abuse investigations; remind police of the importance of considering a range of risk management measures including sexual risk orders; local and regional safeguarding procedures regarding child sexual abuse need to include the requirement to undertake criminal injuries compensation processes and raise with children and their parents the Victims Right to Review scheme.
Keywords: child sexual abuse, child neglect, incest, harmful sexual behaviour, parents with learning disabilities
> Read the overview report

2022 – Anonymous – Babies with injuries

Two cases of non-accidental head injuries and bruising of 14-week-old infants. A bruise was observed on Baby 1 two months prior to injuries. Baby 2 was in the care of their father at the time of the incident.
Learning includes: advice on safe sleeping and safe handling needs to be provided to both parents; professionals need to consider how they can meaningfully engage with fathers, including those who do not live with the child; awareness of the impact of having a new baby on fathers as well as mothers; if information about a new baby is not shared directly with a health visitor, it cannot be guaranteed with current systems that all important information will be known by them; even a small bruise on an infant needs to be recognised as a potential warning injury by professionals; family members should not have unsupervised contact with their child in hospital if a non-accidental injury may be the reason for attendance.
Recommendations include: use learning from the next national child safeguarding practice review to explore what can be done to improve the involvement of fathers in work with families with new babies; undertake work to provide a better understanding of the role of fathers and the need to engage with fathers, and consider projects in other parts of the country; seek assurance from partner agencies regarding knowledge and use of the injuries in non-mobile babies policy.
Keywords: infants, physical abuse, non-accidental had injuries, bruises
> Read the overview report

2022 – Anonymous – Charley

Murder of a young child by their mother's partner.
Learning includes: investing time both strategically and operationally in improving work with fathers will contribute significantly to the welfare of children, their families and communities; practitioners would be helped and supported in responding to the complexities of domestic abuse through the introduction of a practice model that systemically helps the whole partnership and external stakeholder to work to a holistic domestic abuse informed approach; a decision to cease multi-agency planning in totality without the necessary consideration of threshold step down risks children being exposed to escalating harm without adequate review mechanisms; no assessment that considers risk of domestic abuse should be accepted as complete without exhausting all options to include the person reported to have carried out the abuse.
Recommendations include: strengthen the multi-agency approach to domestic abuse by exploring and adopting a specific practice model that provides a perpetrator based, child centred, and survivor strengths approach; ensure that robust step-down and transfer processes that promotes independence at a pace that supports embedding of change are in place; develop a plan to publicise and generate the use of Clare's Law by educating both professionals and the community; ensure that step down and maintenance support is built into the commissioning of domestic abuse services to support sustained change for both victims and perpetrators.
Keywords: child deaths, family violence
> Read the overview report

2022 - Anonymous - Child 9

Child sexual abuse in the context of child sexual exploitation and trafficking of a 14-year-old child over a significant period of time. The abuse was perpetrated by males ranging from older adolescents to adult men, who were known either to Child 9's mother or some of her relatives.
Learning includes: frequent local movement around education providers is an indicator of risk; the use of victim blaming language is careless and should be avoided to ensure the presenting behaviour is seen as a representation of the child's distress; there should be no delay in monitoring and information sharing when vulnerable children who live in a cross boundary area are subject to elective home education or are missing education; practitioners in urgent care centres should always be prepared to "think the unthinkable", and finding the time to secure communication with a child alone should be a central focus; the use of hypothesis in safeguarding assessment and planning is crucial; attendance and active participation in child protection meetings should be a priority for services to ensure effective information sharing.
Recommendations include: highlights the ongoing development needs of the multi-agency workforce when working with children who have escalating and complex safeguarding needs, working with troubled children, hypothesis in safeguarding work, reflective supervision and the use of victim blaming language in safeguarding work; ensure that responsive restorative services are available for children who are victims of rape and sexual assault; examine issues and demonstrate improvements around children missing education and children subject to elective home education.
Keywords: child sexual abuse, child sexual exploitation, child trafficking
> Read the overview report

2022 – Anonymous – Child A

Death of a 12-year-old child by suicide in 2020.
Learning includes: wider consideration of issues relating to children electively home educated (EHE), children from the Jehovah's Witness faith, child and adolescent mental health services (CAMHS) and triage arrangements and information sharing in tertiary hospitals.
Recommendations include: consider how to engage local faith communities to undertake a proportionate Section 11 process to provide assurance to the safeguarding children partnership on the effectiveness of those arrangements; the local authority EHE team continue to lead the work on improving the identification and assessment of children who are electively home educated and ensure the voice of the child is included; engage with the Department for Education in the development of local guidance for schools on children electively home educated; request the National Safeguarding Practice Review Panel considers the recommendations from the Independent Inquiry into Child Sexual Abuse (IICSA) report and its final report on the safeguarding arrangements within religious faiths to ensure they are addressed and implemented at a national level; alert the National Child Safeguarding Practice Review Panel, and contact all child death review leads, to raise awareness of the need for child death review processes requiring referrals to the coronial process to be explicit about any potential safeguarding concerns.
Keywords: suicide, home education, religion
> Read the overview report

2022 – Anonymous – Child G

Attempted suicide by a 7-year-old child at the family home. Sixteen months prior to this event, Child G had disclosed that they had been sexually abused on two occasions by their stepfather.
Learning includes: it is important to continue to communicate with children about their world; professionals need to be reflective in the context of what may be a change in the child's priorities rather than adhere exclusively to an adult assumption of what the child requires; consider a more judicious use of care planning forums when there is lack of clarity about what the options are in reducing risk within families; there should be more effective planning, assessment and recording at all stages of the achieve best evidence (ABE) process.
Recommendations include: for agencies to consider the importance of not making assumptions about the source of a child's distress in the absence of speaking to the child directly, and the clarity about a plan to work together concerning how the child's needs are met while awaiting specialist assessment; ensure that procedures for convening multi-agency meetings are followed, to allow for clearer planning and communication between agencies; ABE interviews should be carefully planned and appropriately documented, in line with expected good practice and guidance, and there should always be consideration as to whether a further strategy meeting is required following the ABE interview.
Keywords: suicide, child sexual abuse, disclosure, interviewing
> Read the overview report

2022 – Anonymous – Child N

Life-threatening injuries to a boy in August 2020. Child N fell from a second-floor window and sustained serious injuries
Learning includes: work with families should demonstrate an understanding of the impact race, culture and religion can have on parents' behaviour; agencies should obtain contact details of a parent not living in the household and should engage them in important decisions regarding their child, unless there is a reason not to do so; practitioners require the knowledge and skills to promote engagement with families who are resistant to co-operating with services offered; for children experiencing neglect there can be a range of factors which mean that incidents have some element of forewarning; the category of harm should reflect the risks to the child, which should be articulated in the child protection plan; statements for family court proceedings should articulate all the risks of harm to a child.
Recommendations include: consider how agencies can develop practitioners' knowledge and skills in working with resistant families; when a section 47 enquiry is initiated all circumstances should be reviewed to ascertain if the threshold is met for a joint agency investigation; undertake a review of safeguarding training to ensure that cultural awareness and sensitivity is promoted; the child protection service should undertake an audit of the categories of harm identified for children who are subject to child protection plans to ascertain if the categories reflect the identified risks.
Keywords: child neglect, injuries, autism
> Read the overview report

2022 – Anonymous - Children O, P and Q

Three siblings aged between 6-15-years-old who experienced a significant domestic abuse incident in August 2021. The abuse was perpetrated by their father against their mother and lasted over 11 hours in the family home.
Learning includes: agencies should be cognisant of the assessment, chronology, and history of families, before making judgements about risk based upon the decisions of others; children’s case closure should highlight ongoing support offered to the family and identify risk factors which would result in the case being escalated and re-assessed; agencies need to follow up and follow through when parents are tasked with self-referring for agency support or services; significant low attendance at school should at least prompt an early help assessment; supervision should consider gender bias and ensure that discussions focus on the risks presented by both parents; agencies working with children and young people would benefit from hearing from domestic abuse survivors and their experiences of statutory interventions.
Recommendations include: agencies should alert the multi-agency safeguarding hub (MASH) if it is known or becomes apparent that children have been the subject of care proceedings or child protection planning in another local authority; safeguarding partners should consider how learning from the Covid-19 pandemic is embedded into organisational forward plans; raise practitioner awareness of young carers and their routes for support, and the link between the young carer role and neglect; child protection plans, child in need plans and early help plans need to reflect the actions that safeguarding agencies take if parental relationships and contact is resumed without formal agreement.
Keywords: family violence, physical abuse, abusive fathers, substance misuse
> Read the overview report

2022 – Anonymous – Daisy

Life-threatening injuries to a 4-year-old girl who was struck by a road vehicle in June 2021. Police commenced an investigation into possible neglect following reports of mother being intoxicated at the time.
Learning includes: disproportionate/issues of professional optimism in the context of substance abuse addiction and domestic abuse; the voice of the child and the child's journey was not understood by all professionals; engagement and communication with the family was not always/could have been more robust and concerns raised by relatives were not given/could have been given adequate weight; the family's history, including an older sibling being subject to a Special Guardianship Order, should have been considered more when assessing parenting capacity; engagement and service delivery were impacted by COVID-19.
Recommendations include: ensure families are systematically used to inform decision-making, information sharing and managing risk, with extended families able to contribute to the plan for a child; ensure a full understanding of a family's history is collated and this is considered in all assessments; children placed on Special Guardianship Orders with family members must be comprehensively included in assessments and planning; police should ensure that incidents of domestic abuse are linked to the same family network so that the cumulative impact is understood and risks can be assessed; partner agencies working with adults must share information with relevant children's professionals where there are concerns which could impact on parenting capacity.
Keywords: accidents, injuries, child neglect, family violence, alcohol misuse, information sharing
> Read the overview report

2022 – Anonymous – Family M

Death of a 5-year-old child in November 2018 due to injuries sustained in a serious and reckless incident at the family home.
Learning includes: gathering and analysing family history, which includes history of contact with services, is a core task when working with children and families; it is important that appropriate empathy towards the parents does not cloud professional judgement or challenge; supervisors and managers should consider how busy frontline workers make trade-offs in order to resolve goal conflicts and cope with uncertainty and system pressures, and ensure this does not compromise children's welfare and safety; the language used to describe services, forms, tasks and activities carries weight and can create expectations; exploring and reconciling differing perspectives about the risks a child or family is experiencing is a necessary task when operating in a multidisciplinary context; when working with parents who are, or become, resistant it is important that expectations are transparent about the professional response to such resistance and that these are clearly stated from the outset; when new, and potentially serious information emerges about risk to children the response should be measured and match the level of seriousness; when undertaking assessment work, professionals should be alert to all risks that children may face, and not make assumptions about mothers naturally being protective.
Recommendations include: to ensure the learning is disseminated across the multi-agency safeguarding partnership.
Keywords: child deaths, children at risk, mothers, maternal behaviour, language
> Read the overview report

2022 – Anonymous – Joshua

Neglect and sexual abuse of an 8-year-old boy by two associates of his mother. The abuse took place prior to and during the time he was subject to a child protection plan.
Learning includes: the need to assess and understand parental ability to protect when making decisions around supervised contact; limitations of an evidence-based response to child sexual abuse (CSA); importance of requesting and sharing police intelligence at the earliest opportunity; the need for the development of a strong and robust response to CSA that is not a purely evidence-based approach and includes the provision of appropriate tools and training; recognising when the Graded Care Profile 2 (GCP2) tool should be used to help identify and address neglect; understanding the purpose and effectiveness of written agreements and assessing whether they should be used within current practice; the importance of perpetrator disruption.
Recommendations include: develop an overarching multi-agency strategy for responding to CSA; develop a CSA training programme for practitioners across the multi-agency partnership; review the way in which multi-agency meetings facilitate the discussions and recording of confidential information and how that information is shared with families to facilitate an increased understanding of the risks; explore and understand rationale for not sharing information with parents and carers, and ensure that the information not shared is kept to a minimum.
Keywords: child neglect, child sexual abuse, police, neglect identification, information sharing
> Read the overview report

2022 – Anonymous – Marie

Death of a 16-year-old girl in January 2020 by suicide.

Learning includes: the need for a clear model for managing high risk self-harming young people; ensure clarity between professionals about responsibilities to coordinate, and ensure timely information gathering and effective intervention; the importance of a family assessment to provide background context and allow opportunities to assess parenting capacity; ensure concerns and worries raised by a child are considered and investigated; ensure professionals exercise professional curiosity to ask more questions and understand what a child has experienced, and to learn what other agencies know; and ensure initial early interventions are appropriate for meeting the child’s needs.
Recommendations include: update the local documentation on self-harm and suicidal thoughts to develop an interagency “team around the child model and procedure” to assess and intervene with young people where moderate and high risks have been identified, ensuring that there is clarity about coordinated multi-agency care with clear plans and timely reviews; for young people where moderate and high risk of suicide has been identified, there should be a dedicated range of preventive and treatment resources available without long waits; and consider whether a new local response should be developed to prevent further deaths when a young person has died by suicide, considering new models for enhanced joint working and integrated provision emerging nationally.
Keywords: suicide, adolescent girls, child sexual abuse, professional curiosity, voice of the child, information sharing

> Read the overview report

2022 – Anonymous – Pippa

Death of a 15-year-old girl in September 2018 by suicide. Pippa was subject to a care order and lived in a care home at the time of her death.
Learning includes: the importance of considering how childhood experiences can impact the behaviour and vulnerabilities of troubled adolescents; child sexual abuse in the family will often come to the attention of agencies because of a secondary presenting factor, which then becomes the focus of intervention; practitioners need to proactively assess and engage with all significant men in a child's life; where child sexual exploitation is suspected, risk assessments need to consider risks which emerge from vulnerabilities arising from past abuse, loss and trauma; professionals need to maintain a questioning and curious response to what they are told or what they see; a lack of knowledge among professionals about the evidence base related to risk indicators for adolescent suicide could leave them ill-equipped to discuss or recognise signs and respond accordingly.
Recommendations include: support the development and implementation of a multi-agency framework for work with vulnerable at-risk adolescents; ensure that agencies have systems which can evidence robust managerial oversight of actions, decisions and plans relating to work with adolescents; ensure that practitioners have regular supervision from a senior manager, safeguarding lead or an appropriate external source; provide learning and development opportunities about adverse childhood experiences, trauma and familial child sexual abuse; audit the effectiveness of meetings to ensure that they lead to improved and timely outcomes for children and young people.
Keywords: suicide, adolescents, children in care, child sexual abuse, professional curiosity
> Read the overview report

2022 – Anonymous – Riley

Life-threatening injuries to a 17-year-old boy. Riley was hit by a car and assaulted by the driver.
Learning includes: recognise and reflect on cumulative risk, including parenting history and adverse childhood experiences; the need for active communication between agencies involved in assessing need; undertake joint assessments to ensure all needs are identified; see a child's behaviour as their way of communicating and be reflective about what the behaviour could be telling us; use language that recognises a child's behaviour as a means of communication; recognise the impacts of neglect and trauma, understanding how this can manifest in adolescence; not overloading a child with referrals/workers but considering what needs to be prioritised and who is the best person to deliver; understanding a child's needs, and being needs led rather than service led; practitioners work together to respond to multiple needs such as underlying learning needs and child protection concerns; creativity about where and how appointments take place to maximise engagement and attendance.
Recommendations include: a review of children who have disengaged with school/ learning to ensure that robust multi-agency plans are in place to meet their needs; explore the use of a communication passport which can be reviewed at key stages in a child's life, so all agencies understand the strategies needed to engage with a child with additional needs; consider the partnership's approach to adolescents receiving hospital treatment.
Keywords: injuries, adolescent boys, contextual safeguarding, family violence, crime
> Read the overview report

2022 – Anonymous – Ruby

Death of an infant girl in 2020 found to be an accident, linked to an unplanned unsafe sleeping environment. Ruby was on a child protection plan due to risk of neglect when she died.
Learning focuses on: awareness of a parent's history; considering and involving fathers; assessing wider family members who play a key role in supporting or safeguarding a child; sharing concerns about the impact on a child of changes of circumstances; the impact of alcohol and substance misuse on children and unborn babies; safer sleeping advice; using virtual technology for key meetings; strengths-based models of assessment and planning; avoiding over-optimism and losing focus on the child; knowledge of multi-agency safeguarding procedures and professional confidence in challenging when they are not followed.
Recommendations include: promote the involvement of fathers; ensure that the implementation of sleep assessments includes bespoke explicit and detailed safer sleep advice, including an explanation of why vulnerable babies are more at risk of sudden unexpected death in infancy (SUDI); ensure that key meetings such as child protection conferences being held by video conference or telephone have the optimum involvement of parents; ensure that professionals have the knowledge and confidence to challenge other agencies, including the use of escalation policies; consider how to ensure that accurate information about medication being prescribed to a pregnant woman is available to all health professionals working with the family.
Keywords: infant deaths, sleeping behaviour, substance misuse, fathers, optimistic behaviour
> Read the overview report

2022 – Anonymous - Young Person Joe

Fatal stabbing of a 15-year-old boy while intervening to protect another young person during a robbery in 2019. Concern about the family had escalated throughout 2018 particularly in relation to Joe and his sister being at risk from criminal and sexual exploitation.
Learning themes include: the family context; understanding and managing risk; partnership working; and management oversight.
Recommendations include: agree, implement and monitor the impact of a relationship-based, trauma-informed practice model across all agencies which includes an approach to working with fathers; review the current training and development opportunities regarding disabled children, to ensure professionals are clear about the threshold for access to services and the impact on parents of caring for a disabled child; review its approach to the provision of services which create diversionary activities and resources to mitigate the ‘pull’ of exploitation; engage the council in a review of and relaunch of the Young People at Risk Strategy to specifically incorporate a review of existing child protection systems in relation to extra familial harm and a transitions protocol for children moving from primary to secondary school; reinforce the early help and social work practitioners’ understanding of their ‘key worker’ role through training, development, and supervision; agree a model approach to supervision and training across all agencies that supports the development of professional curiosity in all practitioners to ensure a greater understanding of the lived experiences of children; and children’s social care should develop a protocol with housing providers which clarifies processes and thresholds for housing transfers on safeguarding grounds.
Keywords: child criminal exploitation, child deaths, contextual safeguarding, exclusion from school, housing, pupil referral units
> Read the overview report

2022 – Argyll and Bute – Child A

Explores the circumstance around the suicide of a 17-year-old boy in February 2021.
Learning includes: ensure that communication between CAMHS and partner agencies is robust and that the needs of the child/young person (YP) are fully understood by all partners involved in the child/YP’s care, for those YP at risk the CAMHS manager should consider agreeing a process for a child’s planning meeting prior to discharge from the service with partners to ensure information is being shared and plans are being regularly updated to reflect changes in circumstances; the initial work undertaken by both the Child and Adult Protection Committee’s in the development of the Young Person Support and Protection Procedures needs to be built upon and discussion between Children and Adult Heads of Service should take place to progress this joint work; review and refresh local practice guidance and ensure that practitioners are trained in the model in the Getting it right for every child (GIRFEC) practice guidance and are confident in its use; review current IRD thresholds and satisfy themselves that professionals understand the threshold and that situations are being appropriately assessed and managed when concerns are raised by any partner; and review existing Early and Effective Intervention (EEI) guidance with a view to amending practice guidance to include the gathering of information about all children within a family home where there are concerns about the impact of an individual’s behaviour on other children within the family home.
Recommendations are embedded in the learning.
Keywords: child deaths, child mental health, education, family functioning, suicide
> Read the overview report

2022 – Barnet - Leo

Large number of unexplained injuries to a 3-year-old boy in April 2021. Leo was assessed to be showing signs of neglect of his physical care. Children's social care and universal services had been provided across two local authority areas.
Learning themes include: assessment of injuries to young children and the need for child protection medicals; holding the child and their experience in mind; consideration of child protection processes while a child is subject of a supervision order and the role of the lead professional at step down to universal services; supporting parents who experience mental health problems; information sharing with busy GP Practices; case supervision and multi-agency management across two local authorities; maintaining significant relationships for care leavers being rehoused; the need for a wider perspective in domestic abuse work; work with care leavers as parents; and the impact of Covid-19 on service provision and identifying vulnerable families.
Recommendations include: seek assurances that the role and skills of the lead professional are understood and embedded within any team around the family arrangements, especially when a case is being closed to social care and the lead professional role is not held by a dedicated early help specialist; a standard child protection data sharing form is sent to GPs for completion and that this is a form based on the template developed by the National Named GP Group; to develop best multidisciplinary practice guidance where services are provided across more than one local authority, to ensure that the needs of children and their parents who are care leavers are met; and to review the skills of frontline practitioners in supporting the emotional attachment between carers and children.
Keywords: child neglect, injuries, parents with a mental health problem, termination of care, children’s services, information sharing
> Read the overview report

2022 – Bedford - Thematic review of serious youth violence

Thematic review commissioned following two cases of serious youth violence (SYV) which led to the death of one adolescent boy and the serious injury of another adolescent boy in 2018. For both the young people involved there were concerns about the misuse and selling of drugs and potential involvement in gangs. The cases are considered in relation to service responses, informing a wider case audit of young people identified as vulnerable or at risk of SYV.
Learning themes include: home life and family backgrounds characterised by extreme levels of violence and physical abuse; peer groups and gang involvement; school histories with exclusions and school moves; neighbourhoods as key contexts of harm; and harmful online contexts.
Recommendations include: the local safeguarding children board should ensure that early risk indicators arising from adverse childhood experiences (ACEs) are identified and responded to through early help assessments; schools and alternative education providers should carry out assessments where there are concerns about peer groups or harmful behaviours and develop intervention plans; the board should seek assurance that schools are preventing exclusions at the earliest opportunity and when young people are permanently excluded from school and being placed in alternative education provision they are provided with immediate wrap-around support for the transition; interventions with young people and families to address the impact of SYV and CCE should be evidence based, sensitive to ACES and the experience of trauma, and characterised by flexible, persistent and relational working.
Keywords: adolescent boys, adverse childhood experiences, child criminal exploitation, child deaths, child mental health, children in violent families
> Read the overview report

2022 – Berkshire West – Aiden

Severe burns and injuries to a 1-year-6-month-old boy in December 2019. Medical opinion was that the injuries were non-accidental, and were likely to have been inflicted or were due to a significant lack of supervision and neglect.
Learning includes: experiencing significant trauma, adversity or loss as a child may contribute to parenting capacity being compromised; where there are multiple risk factors, the importance of thoroughly assessing each one to understand which needs might be associated with which risks; practitioners should link and analyse facts about parental issues which may have an impact on a child’s safety, with records reflecting thinking processes; the importance of consistency and continuity of social workers, to build trust and to monitor any developments that may negatively impact a child; the importance of revising initial assessments about a child’s circumstances, as failing to review these may result in risk to the child; chronologies can be key for understanding needs and risks, and can support assessment and risk management.
Recommendations include: consider an audit of open cases where anonymous referrals are made, to ascertain the quality and effectiveness of the assessment and response; consider a multi-agency audit on how thresholds are applied by children’s services in cases where there are concerns about unborn children; raise the profile about the need for practitioners to be professionally curious about male associations with vulnerable women.
Keywords: burns, injuries, parents with a mental health problem
> Read the overview report

2022 - Berkshire West - Serious Youth Violence

Serious incidents in early 2021, including the fatal stabbing of a teenage boy and an adult. One adult and six young people were convicted of offences including murder and manslaughter.
Learning includes: difficulties identified in school attendance and behaviour, and the professional response; the involvement of boys in criminal behaviour in early adolescence and the response of services; patterns of social care and early help service involvement, team allocation, assessment, and thresholds; child and adolescent mental health (CAMHS) and other specialist health services; and incidents of violence against girls and women.
Recommendations include: services should jointly develop a ‘problem profile’ of serious youth violence and child exploitation; services should evaluate the profile of children at risk of exploitation to provide a better understanding of any disparities in service provision and outcomes associated with race, ethnicity, and disability; there should be improved information sharing with schools about pupils who may be at risk of exploitation; the time taken for cases involving young people to be investigated and resolved should be reduced; the role that the Pupil Referral Unit can play in combatting child exploitation should be reviewed; the number of professionals who are involved with children and young people should be reduced; there should be earlier referral and engagement with CAMHS for children who are at risk of school exclusion; and the role of speech and language services in relation to young people at risk of entering the youth justice system should be reviewed.
Keywords: adolescent boys, adverse childhood experiences, child criminal exploitation, children missing education, gangs, young offenders
> Read the overview report

2022 – Birmingham – Hakeem

Death of a 7-year-old boy from asthma in November 2017. Hakeem’s mother was convicted of gross negligence and manslaughter.
Learning includes: confusion by professionals around significant harm thresholds for neglect where a child has a chronic medical condition that is being poorly managed by a parent; a lack of communication between those responsible for non-school attendance and children’s social care which resulted in the two processes not taking account of the neglect that Hakeem was experiencing; little professional understanding of the daily lived experience of the child, resulting in a lack of assessment of what Hakeem’s reality was like and the level of neglect experienced; failure by agencies to consult and inform the birth father of the growing concerns for the child, resulted in professionals not adequately taking account of his ethnicity and background, alongside the potential for extended family support.
Recommendations include: where children have had hospital admissions for chronic conditions there is a robust discharge plan that includes identifying if any other agencies are involved; improvement work on engaging fathers includes those who may be on remand or serving prison sentences and makes appropriate reference to their ethnicity and family support networks; need for pharmacists to have specific safeguarding training that makes links between parental drug misuse, prescription medical equipment and childhood asthma.
Keywords: child deaths, child neglect, children with a chronic illness, drug misuse, father-child relationships, manslaughter
> Read the overview report

2022 - Blackburn with Darwen, Blackpool and Lancashire - Child AB

Two siblings, aged 15 and 6-years-old, removed from their mother’s care in May 2020. There was an investigation concerning sexual offences against the children involving an unrelated male who had been sent images of Child B by his father. The father was at the time a convicted sexual offender having been found guilty of downloading indecent images of children in 2014.
Learning themes include: the child protection plan; the team around the family plan; effectiveness of universal health services; the voices of the children and their lived experience; disguised compliance; assessment and management of the father’s risks to the children; and elective home education (EHE).
Recommendations include: GP practices should be fully compliant with all relevant safeguarding procedures, including information sharing, knowledge of a child’s safeguarding status and when to refer to children’s social care; the EHE service should provide guidance, including an integrated decision and action pathway, that enables professionals to assess that children are receiving a suitable education, that also meets any safeguarding needs and which is subject to the prevailing statutory provisions; the Department for Education should produce practitioner guidance that seeks to integrate EHE and safeguarding policy and practice, including a decision-making flowchart; National Probation Services and the local constabulary should take steps to ensure that offender manager practice of sex offenders is informed by a more holistic approach to assessment and risk management planning; and the College of Policing should review the active risk management system tool and consider including wider family dynamics and additional corroborative evidence beyond offender self-reporting.
Keywords: child abuse images, disguised compliance, fathers, home education, probation service, sex offenders
> Read the overview report

2022 - Blackburn with Darwen, Blackpool and Lancashire – Child C, D and E

Deaths of Child D aged 24-days-old and Child C aged 21-months-old seven months apart in 2013 following breathing difficulties at home. Several years later Child E was admitted to hospital with breathing difficulties. In 2018 Child C and D’s father was arrested and found guilty of murder and attempted murder.
Learning themes include: perplexing presentations (PP)/fabricated or induced illness (FII) and physical abuse in children; medically unexplained deaths in children including sudden unexpected death of children (SUDC) arrangements, child death overview panel (CDOP) arrangements and criminal investigation; and coercive control and domestic abuse.
Recommendations include: review the implementation plan developed in support of the new local arrangements for perplexing presentations or fabricated or induced illness in children and consider the inclusion of the proposals for learning identified in this review; request paediatricians consider a review of using an assessment tool such as the Brief Resolved Unexplained Event (BRUE) model to support their clinical practice and to improve the risk assessment of children attending with brief resolved unexplained events; conduct a partnership wide audit with their acute hospital trusts to review the effectiveness of the arrangements for facilitating strategy discussions/meetings in the hospital setting; request that the integrated care systems across the partnership review their child death arrangements and provide assurance that the proposals for learning have been addressed; consider how the local in-school programme on coercive control and healthy relationships can be expanded and delivered to young people not in education.
Keywords: child deaths, fabricated or induced Illness (FII), sudden infant death, family violence, abusive fathers, risk assessment
> Read the overview report

2022 - Blackburn with Darwen, Blackpool and Lancashire - Child LS (Thomas)

Significant head injuries to a 2-week-old boy in Autumn 2018. The injuries were suspected to be non-accidental. Thomas was alone in a room with his brother when the injury occurred.
Learning themes include: early help; supporting adults with experience of adverse childhood experiences (ACES) and trauma; the impact of domestic abuse on children; abusive head trauma; safer sleep for infants; and identifying and supporting learning difficulties of parents and carers.
Recommendations include: the safeguarding children partnership should require all partners to evidence their organisational focus and response in relation to the Domestic Abuse Act 2021's requirement to recognise children who see, hear or experience the effects of domestic abuse as victims in their own right; the partnership should re-promote the local area's pre-birth protocol across all partners including the examples of pre-birth strengths and concerns to ensure all practitioners have a sound awareness of when and how to consider its use; the partnership should consider how professionals across the partnership are supporting parents and carers with learning disabilities and learning difficulties, what resources are available and whether further awareness raising and promotion regarding responding well to people with learning disabilities and difficulties is required; and the partnership should request assurance from members and subgroups that housing related challenges for families remain a focus across the partnership, including all professionals becoming more aware of the cumulative risks to children which housing issues can bring.
Keywords: family violence, early intervention, homeless families, non-accidental head injuries, adverse childhood experiences, adults with learning difficulties
> Read the overview report

2022 - Blackburn with Darwen, Blackpool and Lancashire – Child LZ

Death of a 15-year-old girl in January 2020. Michelle was found unresponsive in circumstances that suggested she had ended her life. Statutory agencies had been involved with Michelle due to concerns around drug and alcohol use, exploitation and missing from home episodes.
Learning: N/A
Recommendations include: issue a reminder to safeguarding partners of the value of working together, adopting a single, whole system approach; issue a reminder to all agencies regarding the effectiveness and use of child abduction warning notices as a pro-active intervention and disruptive option to better safeguard children; issue a reminder to statutory agencies to review policy and procedure around information sharing, ensuring that staff have sufficient awareness, training and are confident in what information to share and who they need to share the information with across statutory and non-statutory agencies; issue a reminder to statutory agencies regarding the definition of domestic abuse, ensuring that staff have received sufficient awareness, training and are confident around the Domestic Abuse Act 2021; commission a review of children in need procedures and processes to ensure all agencies have an effective focus on engaging with a child when an initial contact has been unsuccessful to ensure better outcomes through improved assessment, planning and review; and develop processes to ensure a more robust and tenacious partnership response from all agencies when children known to children's social care go missing to reduce the number and frequency of such episodes.
Keywords: child deaths, suicide, adolescent girls, runaway adolescents, drug misuse
> Read the overview report

2022 – Blackburn with Darwen, Blackpool and Lancashire – Millie

Suicide of an 11-year-old-girl in March 2019.
Learning includes: be less risk adverse and more risk sensible around working together; demonstrate professional curiosity around the effect an absent parent or role model may have on the well-being of a child; think about the bigger picture and adopt a single, whole system approach to needs and risk of a child; be alert to the impact that an increase in the number of underlying risk indicators can have on a child and to be able to spot them, and then respond to them collectively, as early as possible, even in the absence of any obvious high risk factors; have clear management intervention and involvement at critical moments.
Recommendations include: staff should be professionally curious when a pupil has not attended a drop-in session and record the reason for the non-attendance; staff training around the importance of when to share information, what information to share and who they need to share the information with; schools that have a manual paper-based safeguarding system should be encouraged to move to an online system; all designated safeguarding leads in schools should be aware of the importance of the accurate recording, cataloguing, and storing of safeguarding material; safeguarding practitioners should escalate and de-escalate cases up and down the continuum of need scale to ensure that children are receiving the proper level of safeguarding support.
Keywords: suicide, schools, professional curiosity, children at risk
> Read the overview report

2022 – Blackburn with Darwen, Blackpool, Lancashire – Sarah

Death of an 8-day-old baby in Summer 2017 following head trauma caused by shaking.
Learning includes: maternity services should ensure written records reflect the needs of the mother and baby; support plans should be clearly documented to ensure links with early help teams; when significant support is in place for a family it is good practice to hold a professionals' meeting before that support network is closed; maternity services must ensure that there is a full transfer of information in cases where a pregnant mother moves from one area to another; where appointments are missed there should be an effective follow up mechanism; health visitors should follow standard operating procedures when a patient is transferred from one area to another; when a pregnant patient fails to attend appointments, it is critical that these failures are correctly recorded and that a follow up is carried out according to procedures; the need for professionals to have a robust discharge plan for mothers to provide protection and support, including who is responsible; professionals in health and social care need to better understand structures and processes to improve information sharing and joint working.
Recommends that the local children's safeguarding assurance partnership should ensure that the learning points raised are subject to a SMART action plan.
Keywords: infant deaths, shaking, maternal health services, antenatal care
> Read the overview report

2022 – Bolton - Strengthening practice thematic review

Thematic review exploring local practice in relation to three key learning themes (see below). Follows a rapid review in March 2020 in relation to a young infant who suffered serious non-accidental injuries, and further rapid reviews in the same year from which these themes emerged.
Learning themes include: effective child protection practice, including exploring practitioners knowledge, understanding and confidence in applying local child protection systems and processes; understanding family and parental individual needs and how practitioners assess and respond to these needs; and understanding the child’s lived experience.
Recommendations include: the partnership develop practitioner guidance and pathways to support effective information sharing across the multi-agency system, clarifying the legal gateways for sharing information and the expected practice principles across the safeguarding children system; use research generated from the review to inform the redevelopment of local child protection processes led by the local children’s services; the safeguarding children partners use research from the review to create ‘best practice principles’ for the three themes addressed; the partnership develop and host bi-monthly sessions for the multi-agency workforce to increase awareness of services and interventions available in the local area, prioritising areas such as supporting parents with a learning difficulty or disability, money issues, or mental health difficulties; and the partnership develop multi-agency standards to support effective safeguarding supervision and core safeguarding induction standards across the system. Also suggests that support to parents following the removal of a child from their care should be considered in future service and practice development.
Keywords: infants, injuries, information sharing, child protection, adults with a learning disability, voice of the child
> Read the overview report

2022 – Bradford – Harry

Hospitalisation of 12-year-old boy with a complex range of physical and learning needs admitted with severe weight loss and numerous severe pressure sores in May 2021.
Learning includes: a shared digital system is not always a guarantee of effective communication; exercise professional curiosity when there are a high number of absences from school; when domestic violence is known to occur, there should be an assessment of the impact this might have had on the children; there should be robust attempts to engage fathers when they are involved in the child's life.
Recommendations include: heads of service/senior managers of education, health and care services working with disabled children with complex needs should ensure that the recommendations in NICE NG213 relevant to their service are implemented; safeguarding training for all professionals who work directly with children with disabilities and complex needs takes into account the research and learning from safeguarding reviews on how and why disabled children are more vulnerable to abuse; promote the importance of 'thinking family' via a campaign aimed at all professionals involved in assessments and/or with designated safeguarding responsibilities in their setting; agencies should review their existing training programmes to ensure that it is clear to practitioners that all children should have a voice, including those who are pre- or non-verbal; review the CSPR arrangements to ensure all relevant services are included in scope even if they were not initially involved in the rapid review; undertake a systems review to ensure a robust approach to child in need arrangements.
Keywords: cerebral palsy, disguised compliance, medical care neglect, professional curiosity, voice of the child
> Read the overview report

2022 – Brighton and Hove - Child Delta

Death of a 20-month-old girl in December 2019, caused by a combination of starvation and influenza, after being left alone for six days.
Learning themes include: decisions about assessment of risk and safety planning; the child’s lived experience; the impact of housing need within assessments; the impact of a young parent being not in education, employment or training (NEET); significance of family history and the impact of trauma and exploitation on an adolescent parent; adultification of an adolescent parent; and issues around facilitating a child focused service for children of parents who are looked after children or care leavers.
Recommendations include: review assessment guidance so that holistic multi-agency assessments take place prior to making significant changes to a child’s plan, except when emergency action is required, and include an explicit section to address risks and any necessary risk management plan; assessments of adolescent parents should always include a specific focus on the child’s vulnerable child, especially if they do not have their own social worker; assessments should include all family members who will be involved with child-care; ensure staff are aware of the allocations policy enabling senior managers within children’s social care to nominate a family for housing transfers when there is a need to keep a family together; consider practitioners training needs on the long-term impacts of trauma for children; clarify which social worker is the lead professional when there are different social workers in a family; consider what systems need to be in place to meet the needs of children NEET; and the local authority should address the range of potential accommodation needs for young parents to be able to provide a range of support provision.
Keywords: adolescent mothers, child deaths, child sexual exploitation, child neglect, children in care, housing
> Read the overview report

2022 - Buckinghamshire - Child AA

Death of a child in 2019. At the time of death Child AA was known to several agencies.
Learning: concludes that the death could not have been predicted prior to or at the point of the mother’s mental health assessment during the critical period.
Recommendations include: work with the local safeguarding adults board to oversee the review of approaches to the assessment and interventions with whole families where the criteria for a referral to adult services is met; promote the learning from this review across relevant partner agencies, and hold a multi-agency workshop in order to increase working relationships and practitioner awareness; work with the local safeguarding adults board to maximise practitioners’ skills in the assessment of parental mental health and the impact on children including an audit of single and joint training with a view to strengthening arrangements across agencies; oversee the review of multi-agency policies, procedures and protocols relating to parenting capacity and mental illness; work with the local safeguarding adults board to review and update its information sharing code of practice, including the value of working closely with and seeking information from extended family members.
Keywords: child deaths, financial support, housing, homicide, parents with a mental health problem, psychiatric care
> Read the overview report

2022 – Buckinghamshire – Family T

Significant non-accidental physical injuries sustained by female twin siblings aged 14-weeks-old.
Learning includes: a need for risks and vulnerabilities to be effectively identified; the importance of stronger decision making procedures for unborn babies when parents have known vulnerabilities; a need to understand the impact of pregnancy on a looked after child and provide the necessary support; a need for improved information sharing; better understanding around the different roles and responsibilities of various professionals; where relationship coercion concerns are present, clarity is needed around the nature of the concerns and any support or intervention required; a clear understanding of escalation policies to ensure concerns are acted upon; the importance of following the correct policy and procedure when non-mobile infants require a child protection medical for suspected non-accidental injuries; and a robust multi-agency plan to safeguard vulnerable infants should be established during meetings prior to them being discharged from hospital.
Recommendations include: timely communication with the parents if there are concerns for the infant; identification of parental support needs; clear communication between social workers for the parent and social workers for the infant; opportunity for parents to contribute to care plans for the infants; improved process and procedures for multi-agency assessments, particularly regarding the involvement of fathers and the use of historical information to inform analysis; and early identification of actions required to safeguard infants when a looked after child becomes pregnant.
Keywords: infants, injuries, siblings, twins, pregnancy, risk assessment
> Read the overview report

2022 – Calderdale - Baby Q

Referral of a 5-month-old baby to the multi-agency screening team after they were observed to be very pale and underweight.
Learning themes include: policies and procedures for monitoring of babies' growth and development; information sharing and effective working between professionals; relationships between parents and professionals; and identification and escalation of safeguarding concerns.
Recommendations include: multi-disciplinary professionals meetings should be used to discuss how the needs, wellbeing or safety of children are being met when experiencing difficulties, or plans are not meeting expected progress; there must be a clear handover between professionals who are making or receiving referrals and the management plan should be clearly documented in the child’s records; accurate recordings of a child’s clinical observations and growth parameters are essential; differences of opinion and varying perspectives about events and professionals' and families' views should be recorded as such, and not translated into 'fact'; an entry must be made in the child health record after a child is discussed at a GP safeguarding meeting to reflect the discussion and any agreed actions; make sure key professionals are involved in safeguarding discussions; growth/centile charts should be used to give a consistent overview of trends in weight, length and head circumference; when there are disparities in measurements there should be a joint approach to clarifying the issues; children with a faltering weight pattern should be kept under review to ensure progress against targets set; and individual health professionals should seek advice from their safeguarding leads when safeguarding concerns continue to escalate.
Keywords: birthweight, bodyweight, feeding behaviour, health visitors, midwives, parent-professional relationships
> Read the overview report

2022 - Cambridgeshire and Peterborough - Child D

Spans the period from March 2018, when concerns relating to physical abuse by Child D’s father and indicators of sexual abuse were raised, until August 2020 when Child D’s brother admitted sexually abusing his sister.
Learning themes include: signs and indicators of child sexual abuse, especially the possibility of sibling perpetrated sexual abuse; cultural considerations; language barriers; the role of family members within a household; and no recourse to public funds.
Recommendations include: seek assurance from partner agencies that work relating to child sexual abuse that has been undertaken in the past 12 months has been embedded; make information available to practitioners within their agencies for them to gain a better understanding of cultural considerations such as attitudes towards relationships, family life, child development and abuse; all agencies should ensure that the needs of children and families who have a limited understanding of English are met via the use of face-to-face interpreters, translated written material and additional time allowances for meetings; consider whether resources available to parents and families relating to safeguarding such as leaflets should be made available in additional language formats; seek assurance that existing tools such as genograms are utilised for the purpose of considering a family’s composition and the roles that all family members play within a unit especially male family members; and make information available to practitioners within their agencies to improve their knowledge and skills in relation to the financial pressures and impact of having no recourse to public funds.
Keywords: child sexual abuse identification, children with learning difficulties, interpreters, language, sibling abuse, no recourse to public funds
> Read the overview report 

2022 - Cambridgeshire and Peterborough - Nadia

Suicide of a 16-year-old girl in 2021 at a low secure (inpatient) unit. Nadia had experienced sexual assault, difficult family relationships, and suffered from anxiety and depression. She had been living in inpatient psychiatric units for 12 months.
Learning includes: understanding the impact of parental conflict on children; providing the right support at the right time for children with mental health concerns; seeing a child as a whole with regards to multi-agency and multi-familial working; breaking the silence with regards to sexual violence; risks of inpatient stays; and lack of alternative placements to home.
Recommendations include: further work to raise awareness about the impact of parental conflict on children and consider whether zero suicide multi-agency approaches/strategies/guidance adequately take account of the recent findings from the National Child Mortality Database (NCMD); to learn from examples of good practice and consider what more may be needed to embed a culture of muti–agency working across the system; ensure a review of multi-agency work includes mapping and engaging immediate and extended family, engaging fathers and building provision in the community to avoid inpatient admission, wherever possible; review service developments in relation to identifying and responding to child sexual abuse, including extra familial sexual assault; and explore how multi-agency partners are working across the organisational hierarchies to find bespoke solutions for children in challenging circumstances.
Keywords: suicide, children with a mental health problem, psychiatric hospitals, family conflict, child sexual abuse, voice of the child
> Read the overview report

2022 – Cardiff and Vale of Glamorgan – C&VSB 022019

Explores the historic sexual abuse of at least five females committed during the 1980's, 1990's, and 2000's. The majority of disclosures were made when the victims became adults, and the case was investigated fully as a result of these historic disclosures.
Learning includes: progress has been made in understanding, recognising and responding to child sexual abuse and exploitation (CSAE) and that this has been helped by dedicated teams, able to contribute to the development of knowledge and expertise; confidence and understanding can be developed through discussions with peers; attention needs to be paid to staff welfare; a major issue for professionals is how to move on from being reactive, i.e. waiting for a disclosure of CSAE to being proactive and actively looking for and recognising signs of abuse; how and who can bridge this divide between communities and professional systems so that the sharing of information and concerns can be facilitated; the importance of holding the 'bigger picture' and the risk that a label can lead to a too narrow focus; professionals must move away from labelling children as challenging or difficult and consider instead why they are behaving as they are; the importance of seeing and understanding children and young people through a child development lens; a shift in the tolerance of sexually abusive and aggressive behaviour and exploitation in schools is required; and the impact on victims can be profound, long lasting, and affect future generations.
Recommendations are embedded in the learning.
Keywords: child sexual abuse, grooming, disclosure, child sexual exploitation, unknown men
> Read the overview report

2022 – Cardiff and Vale of Glamorgan – C&VSB 042019

Death of a 16-year-old young person from suicide, who had difficulty in managing emotional regulation from a young age. The young person was receiving professional support due to adverse childhood experiences and developmental trauma experienced within the family unit.
Learning is embedded in the recommendations.
Recommendations include: a child or young person who is being considered as a child looked after and where placements are being sourced, should have a shared multi-agency chronology, the chronology should detail the risks and triggers for the child or young person and should be shared with agencies who will have direct involvement, to ensure they can plan and respond effectively; review the multi-agency arrangements for information sharing and planning for an effective transition of a child or young person into an out of county therapeutic placement, to ensure it is fit for purpose; agencies to be accountable for the transfer of services and care arrangements; no service should discharge their involvement until the receiving area has engaged and there is a continuous service between local authority areas; ensure that a child, young person and their families are listened to and are able to fully engage in the care planning process; ensure the voice is captured at all stages of working with a family; and all agencies to receive training and fully understand the relevance of attachment theory, trauma, and adverse childhood experiences and for this to be evidenced as embedded into practice.
Keywords: suicide, self harm, voice of the child, family conflict, adverse childhood experiences
> Read the overview report

2022 – Cheshire East – Children H and I

Serious sexual offences committed by the mother and a former partner, against Child I. These offences came to light in 2021 but took place in 2013. Concerns for the subject children and/or their siblings are recorded from 2000. There have been many changes in professional practice in all agencies over the course of time considered in the review.
Learning themes include: escalation of practitioners’ concerns; inter-generational abuse; management of sex offenders and risk assessments; the voice of the child in assessment and planning; timeliness of forensic testing where children are at risk of abuse.
Recommendations include: ensure planned review of the escalation policy is completed; increase awareness and confidence in using the escalation policy and monitor its effectiveness; ensure practitioners have access to training in respect of the impact of inter-generational abuse and tools to support risk assessments; ensure that, where convicted sex offenders are in contact with children appropriate and effective risk management mechanisms are in place; consider the arrangement for risk assessments and safety planning where the allegation is regarding an alleged offender rather than one with convictions; agencies should work together to ensure that potential risk from sex offenders in the family network are assessed in respect of other children with whom they have contact; ensure policies and procedures reenforce the importance of specific risk assessments, such as the ‘Persons who Pose a Risk of Harm’ tool, being completed pending the outcome of forensics.
Keywords: abusive fathers, abusive mothers, child abuse images, child sexual abuse, child sexual abuse identification, voice of the child
> Read the overview report

2022 - Cheshire East Cheshire West and Chester - Contextual Safeguarding Thematic Review

Incident in October 2020, involving five adolescent boys, in which three adults were stabbed and one ultimately died.
Learning themes include: the child criminal exploitation (CCE) ‘system’; mental health and young people known to the CCE system; prevention, early identification and early help; definition of risk and vulnerability; transition for young people in the CCE system to adult services; school exclusions; empowering communities; and workforce development in relation to CCE.
Recommendations include: create a multi-agency vision statement regarding contextual safeguarding that informs and directs future practice; enhance existing multi-agency universal and targeted training and support to professionals in relation to CCE; share the learning from this review with the local All-Age Contextual Safeguarding Task Group so that it informs and directs developments in relation to policy and practice (including managing demand on the system); be assured that the local early help offer focuses and responds to known vulnerability indicators associated with CCE and that there is a shared and widely understood definition of vulnerability to CCE; ensure there is sufficient focus on the physical and mental health needs of young people at risk of or involved in CCE and that pathways, such as the ADHD and CAMHS, are appropriately linked so that non-engagement is assessed in the context of potential increased vulnerability; work on communicating prevention messages to local communities and services to recognise indicators of CCE; and ensure young people transitioning to adult services are offered a transition plan and appropriate ongoing support.
Keywords: adolescent boys, adverse childhood experiences, child criminal exploitation, contextual safeguarding, county lines, exclusion from school
> Read the overview report

2022 – City and Hackney – Child Q

Child Q, a girl of secondary school age, was strip searched by female police officers from the Metropolitan Police Service in 2020. The search, which involved the exposure of Child Q's intimate body parts, took place on school premises without an appropriate adult present and with the knowledge that Child Q was menstruating.
Learning includes: the decision to strip search Child Q was insufficiently attuned to her best interests or right to privacy; all practitioners need to be mindful of their duties to uphold the best interests of children; school staff had an insufficient focus on the safeguarding needs of Child Q when responding to concerns about suspected drug use; the application of the law and policy governing the strip searching of children can be variable and open to interpretation; the absence of any specific requirement to seek parental consent when strip searching children undermines the principles of parental responsibility and partnership working with parents to safeguard children; adultification bias is believed to have a significance to the experience of Child Q; racism (whether deliberate or not) was likely to have been an influencing factor in the decision to undertake a strip search.
Makes 14 recommendations to improve practice, including: the Department for Education should review and revise its guidance on Searching, screening and confiscation (2018) to include more explicit reference to safeguarding and to amend its use of inappropriate language; police guidance governing the policy on strip searching children should clearly define the need to focus on the safeguarding needs of children; where any suspicion of harm arises by way of concerns for potential or actual substance misuse, practitioners should contact children's social care to make a referral or seek further advice.
Keywords: children’s rights, racism, schools, police, supervision, adolescents
> Read the overview report

2022 – Coventry - Stephen Wilson

Concerns a 16-year-old boy’s experiences as an inpatient in various mental health units since early adolescence. In November 2020, Stephen was admitted to an acute hospital, where significant concerns were identified with the care he received.
Learning themes include: early intervention in transition to secondary school, CAMHS and children’s services; meeting the needs of children with autism spectrum disorder (ASD); Education, Health and Care Plans (EHCPs) and the importance of school life; responding to complexity; availability and suitability of care in general hospital wards and inpatient units; governance and assurance after a significant safeguarding incident has occurred; collaboration across the multi-agency system; voice of the child; and advocacy.
Recommendations include: the partnership to seek assurance that primary schools routinely identify children who may struggle with transition, with a focus on children with ASD; the partnership to strengthen multi-agency working with children who have mental ill health; the partnership to maintain an active overview of the waiting times for ASD assessment; local education services to review the EHCP strategy to reflect the urgent need for an EHCP assessment to be expedited for children at the point of admission to an inpatient unit; for partner agencies to review their approach to children with severe complex needs arising from ASD and/or mental health needs in the community; to ensure that support provided to staff on general paediatric wards enables the best possible care to children suffering from a mental health crisis; to review referral pathways for notifying the partnership of serious incidents, including incidents involving children placed out of area; to include the importance of trusted adults in the multi-agency framework; and to ensure children in inpatient mental health units are offered an independent advocate.
Keywords: autism, child neglect, psychiatric hospitals, child mental health services, children with a mental health problem, provision of services
> Read the overview report

2022 – Coventry – Child T

Physical and sexual abuse of a 2-year-old boy. Child T was presented to hospital by his mother on 21st July 2020. Extensive bruising was noted on examination, including to genital area. There was a lack of recognition of the potential sexual abuse in this case, and physical abuse was the initial focus.
Learning includes: the importance of recognition or consideration of the potential of sexual abuse; the importance of a robust, appropriately attended and informed strategy discussion to provide opportunities to gather information to protect a child; need for the Sexual Assault Referral Centre (SARC) to attend the strategy meeting in child sexual abuse cases; the importance of awareness, policy and guidance for practitioners regarding the accessing and coordination of medicals for child sexual abuse.
Recommendations include: consider what the barriers are to professionals considering the potential of sexual abuse in the family environment; agencies involved in referring children to the SARC for examination should ensure that full relevant records of previous examinations (including body maps) are made available to the SARC to fully inform the examination and that they are available for retention; where a child is examined at the SARC, on each occasion, consideration should be given to examine the child for any signs or indications of sexual abuse where clinically and evidentially appropriate and with appropriate consent, accompanied by easy to follow staff guidance; consider what information is available to practitioners to effectively seek and record the voice of the child, in particular in young pre-verbal children.
Keywords: abused boys, bruises, child sexual abuse, child sexual abuse identification, medical assessment, voice of the child
> Read the overview report

2022 – Coventry – Matt

Death of 2-and-a-half-month-old boy in June 2019. Cause of death has not been formally determined.
Learning includes: need for all agencies to ensure practitioners are aware of the lived experience of the child and understand the cumulative effects of continued neglect; where there is concern regarding safe sleeping, despite advice, there is a need for escalation and differentiated response; clear procedure required once disguised compliance is identified; suspected drug use by parents should be effectively considered in social work assessments, to allow this is be ruled in or ruled out; there should be a clearer pathway between children’s social care and early help; exploration required of how well children leaving care are prepared for parenthood; pre-birth assessment should be considered when there are concerns around neglect or other vulnerabilities; where a referral is made to the MASH and a strategy meeting takes place, the professional making the referral should attend, and any assessment by children’s services should seek the views of other involved professionals.
Recommendations for the local safeguarding partnership include: review of the neglect strategy, including implementation and embedding of the Graded Care Profile 2 (GCP2); review the approach to safe sleeping, with particular focus on parents that are suspected or are known to use substances and/or alcohol; review the support, training and advice for professionals dealing with families demonstrating disguised compliance or who are avoidant and/or resistant.
Keywords: adults in care as children, infant deaths, neglect identification, parenting capacity, preparation for parenthood, sleeping behaviour
> Read the overview report

2022 – Croydon - Jake

Suicide of a 17-year-old boy. Jake was subject to a care order, living in supported accommodation and awaiting an alcohol rehabilitation placement at the time.
Learning themes include: early help; the help seeking nature of challenging behaviour; drug awareness; responding to risk in adolescence, especially for high-risk children who are not engaging in services; identity and belonging and youth culture; engaging family members; and models of care for children with a complex and high-risk presentation.
Recommendations include: consider how multi-agency reflective forums will be built into multi-agency meetings or panels and other current established processes; develop and promote the directory of statutory and voluntary services so that services and referral pathways are visible and known to all agencies; promote substance misuse training; raise awareness of intersectionality and the use of an appropriate framework or tools to consider a child’s presenting needs; assess the number of services involved with a child, their engagement and impact; consider how current training and awareness raising forums can be used to facilitate an understanding of youth culture; review, with services, support offered to families; oversee the development of multi-agency plans for children where contextual risks exist and when risks do not fit into the usual categories of gang affiliation and sexual exploitation; and agree across agencies the main principles for in-patient admission, welfare secure or other response including clarification about who is the lead agency in the child’s care to ensure multi-agency ownership of care for children who are known to be at high risk.
Keywords: suicide, adolescent boys, substance misuse, exclusion from school, child mental health, youth justice
> Read the overview report

2022 – Cumbria – Leiland-James Michael Corkill

Murder of a one-year-old male child in 2021. At the time of his death, the child was in the care of the local authority and was placed with prospective adopters. The female prospective adopter was found guilty of his murder and child cruelty.
Learning includes: medical assessments of potential adopters require a thorough consideration of their medical records and include information from specialists and providers of mental health support; the system would be more robust if these assessments were updated at the point of matching and before an adoption order is made; improvements are required regarding seeking, sharing, and considering any adult vulnerabilities that could be a risk to children; adoption systems and practice must ensure that there is improved consideration of the lived experience of other children in an adoptive household; when it is apparent that there are issues with prospective adopters bonding with a child placed with them, a robust and timely professional response is required that recognises the emotional impact on the child and the pressure on carers.
Recommendations include: the Child Safeguarding Practice Review Panel to ask the Department for Education to review adoption guidance considering the learning from this review.
Keywords: child deaths, murder, adoption
> Read the overview report

2022 – Cwm - Child M

Death of a 16-year-old boy in 2019. Child M was in and out of care throughout his life and experienced multiple placements. There were significant concerns each time M returned to the care of his mother, linked to neglect and emotional harm.
Learning themes include: the importance of placement permanency planning; the importance of escalation and professional challenge; and the importance of record keeping, decision making and accountability.
Recommendations include: the child’s wellbeing should be central to decision making in identifying permanency options; updated plans to support placement should be informed by the child’s multi-agency chronology, specialist reports, assessments, and research relevant to the child’s specific circumstances; the evolving view of the child should be obtained, recorded and considered as a critical element to permanency planning; clear handover arrangements should be in place when cases are transferred between teams or reallocated to a newly appointed worker; where a care and support protection plan is not keeping the child safe all involved professionals have a responsibility to challenge using existing processes; independent reviewing officer (IRO) resolution processes should be used and followed by IROs; proper consideration of S5 of the Wales Safeguarding Procedures (Concerns about practitioners and those in positions of trust) and S3(1) (Responding to a report of a child at risk of harm, abuse and/or neglect) must be followed; and agencies should provide the safeguarding board with assurances that record-keeping is robust and provides clarity of context, incorporates the voice of the child and includes records of decision-making.
Keywords: permanency planning, placement breakdown, emotional abuse, child deaths, decision-making, accountability
> Read the overview report

2022 – Cwm Taf – Child T

Death of a 5-year-old boy in July 2021. Child T's mother, mother's partner and the stepchild of mother's partner were subsequently convicted of Child T's murder.
Learning includes: the impact of COVID-19 restrictions on the ability of agencies to implement optimum child protection processes; the complexities of adult relationships overshadowed understanding of Child T's lived experience; a lack of understanding from professionals of their duty to inform any person who holds parental responsibility of child protection concerns; professionals did not fully explore the context of Child T's race and ethnicity on his lived experience; information sharing systems not supporting multi-agency information sharing and being a barrier to systemic decision making; and an inconsistent approach within children's services to quality assurance of assessments and planning across several areas of case management.
Recommendations include: the Wales Safeguarding Procedures Project Board includes guidance for child protection practitioners on their duty to include all persons with parental responsibility in child protection assessments and processes; a pan-Wales review of approaches to undertaking child protection conferences to identify effective chairing/facilitation methods and ways of ensuring full multi-agency attendance and participation; the Welsh Government considers commissioning an annual national awareness campaign to raise public awareness on how to report safeguarding concerns; the Welsh Government considers commissioning a full review of health, social care, education and police recording, information gathering and sharing systems; and the President of the Family Division considers the imposition of a12-week minimum for any social work assessment within public law proceedings.
Keywords: child deaths, injuries, murder
> Read the overview report

2022 - Cwm Taf Morgannwg - CTMB 5/2020 (Child O)

Key themes include: understanding the relevance and importance of chronologies; explore if there were any missed opportunities for important intervention by agencies; the relevance of good communication and handover of care/information between professionals/agencies; routine enquiry and the opportunity to explore any concerns; and the impact of COVID restrictions and challenges for all agencies.
Learnings include: midwifery and health visiting services need to develop a regular, consistent information sharing process; review and update their guidance in relation to public protection notices and the assessment of the impact/risks posed to children from domestic abuse; health visiting and midwifery services to complete an audit of routine enquiries to establish compliance; use of chronologies to help identify risks, patterns, and issues in a child’s life; referrals to agencies were treated in isolation, and did not fully consider previous contacts, as individual referrals these were not sufficient to meet thresholds for child protection; be alert to patterns of coercive or controlling behaviour, as well as incidents of abuse; remain professionally curious when working with individuals and families; assist professionals to recognise when individuals are resisting engagement with services and how this can manifest itself; and ensure that information relating to anti-social behaviour is submitted to relevant agencies in line with South Wales Police anti-social behaviour process and without unreasonable delay.
Recommendations: N/A
Keywords: child neglect, sudden infant death, sleeping behaviour, adolescent parents, family violence
> Read the overview report

2022 – Derby and Derbyshire - Baby RD

Death of an infant in 2020 while in a mother and baby unit of a psychiatric hospital. The mother admitted she had caused Baby RD’s injuries and was subsequently charged, convicted, and sentenced.
Learning themes include: the potential impact of a parent’s significant mental ill-health on their children and in particular the challenge of assessing risk when the illness is of a cyclical nature; the role of early help for vulnerable parents, making a referral and planning an intervention; the benefits of the ‘think family’ message; the response to emergency situations, for example suicidal behaviour or attempts to harm a child when the adult concerned is a parent.
Recommendations include: consider how best to promote and embed the ‘think family’ agenda and seek information from each agency about how they evaluate the effectiveness of the initiative; seek assurance that all agencies, including adult services, are fully engaged with the use of early help assessment; engage in discussion with commissioners of service about developing and strengthening the team working on the mother and baby unit in order to ensure a multi-disciplinary approach to risk assessment and that the voice of the child is not lost in the midst of a parent’s mental health crisis and medical treatment; seek assurance from the local Healthcare Trust that an effective protocol is in place which addresses the response to a medical emergency and that all staff are familiar with the content and its application within their working environment.
Keywords: bipolar disorder, infanticide, maternal depression, parents with a mental health problem, psychiatric hospitals, psychoses
> Read the overview report

2022 – Derby and Derbyshire – Child QDS 20

Death of 10-year-old girl in April 2020, found in bed with a ligature around her neck. Her father was in prison following a violent assault on the mother.
Learning themes include: the lived experience of domestic abuse for a child; vulnerable children remaining the focus of agency concern when they move areas; parental alcohol abuse; cultural and language considerations; signs and triggers of emotional distress in children; and online safety and the dangers of children viewing age-inappropriate content.
Recommendations include: all guidance should emphasise the importance of understanding the lived experience of the child; re-emphasise the message that domestic abuse is always harmful to children; proactively offer support to those families who are transitioning from refuge into independent living; review training needs to ensure professionals have a better understanding of the complexity of parental alcohol misuse and include training on interpretation and understanding of hair strand samples; continue to emphasise the dangers of children viewing age-inappropriate content; ensure processes are in place so that when children on a Child Protection Plan move areas, they are not removed from systems automatically and their information is reviewed; ensure schools display the appropriate level of professional curiosity and proactively seek information for new pupils transferred in; ensure that third sector organisations such as refuges share information so that partner agencies have clarity about their role in safeguarding existing and previous residents; ask the ‘Victim Care’ service to consider reviewing the current arrangements governing the sharing of information regarding the prison release of perpetrators within the family.
Keywords: child deaths, family violence, alcohol misuse, culture, online safety, prison and prisoners
> Read the overview report

2022 – Derby and Derbyshire - LDS 19 / OD 20

Joint review considering the experience of two infants from two separate families. Death of a 6-month-old infant from oxygen deprivation as the result of unsafe sleeping with the mother, and serious injury suffered by an infant with significant medical needs. Neglect was a feature of both cases. The review also refers to the case of a third infant who suffered serious non-accidental injury.
Learning themes include: intrinsic risk to infants due to their immature anatomy, physiology and rapid development; the introduction of any infant into a household resulting in some level of stress; the need to quickly identify and assess any additional risks an infant will face, such as additional needs, challenges in the home environment, carer response to stress, and current/history of carer mental health problems or substance misuse; the importance of good multiagency communication and relationships built on understanding, valuing, and trusting each other's roles; and the importance of recognising and having ways of addressing hidden risk when carers are not accessible to assessment or there is a lack of openness by carers about potentially harmful behaviours.
Recommendations include: the development of a universal risk assessment tool to guide professional practice in safeguarding infants; recognising the importance of supervision in supporting implementation of all actions aimed at keeping infants safe; child safeguarding learning programmes across all agencies to address the need for practitioners to be knowledgeable about the roles of all professionals involved in child safeguarding; and a review of current practice for partnership working at all levels in cases involving infants, including clarity about multiagency plans, and due attention given to stress points within a family.
Keywords: infant deaths, children with disabilities, stress, non-attendance, parental involvement, interagency cooperation
> Read the overview report

2022 – Derbyshire – Child G

Death of a 2-month-old child in June 2019 following admission to hospital with severe breathing difficulties. Child G was found to have died from non-accidental injuries; their father was charged with manslaughter.
Learning includes: a need for 'hidden men' training to be reinforced on a regular basis, in order to keep this issue current to practitioners; interventions could be strengthened by a more professionally curious approach around parental history, relationships and dynamics; concerns and subsequent actions need to be clear in the GP record, and information placed on health IT systems; need for better cross border communication to help safeguarding between community midwives and hospitals.
Recommendations include: the safeguarding partnership ensures their 'pre-birth protocol' is operating effectively; all assessments and interactions with families to consider the role, presence and the history of fathers to the children and male partners living in or associating closely within a household; the local parent education programme on 'shaking the baby’ is delivered by community midwives to both parents if the programme is not delivered in hospital.
Keywords: infant deaths, neglect, non-accidental head injuries, parenting capacity, shaking, unknown men
> Read the overview report

2022 - Dorset - The Siblings

Sexual abuse of a 13-year-old child by adults not known to them. Over three years there were concerns for this child and their siblings in relation to extra-familial child sexual abuse, intra-familial child sexual abuse and child neglect. The siblings were aged between 9-18-years-old at the start of this review.
Learning themes include: working to identify, assess and address intra-familial child sexual abuse; addressing extra-familial harm; recognition, identification and addressing the neglect of children; supporting disabled parents and ensuring their participation; and cultural literacy.
Recommendations include: the child sexual abuse toolkit highlights the importance of understanding a parent’s capacity, as the non-abusing parent within assessments, particularly where that parent may have additional needs such as a disability; review the local ‘keep safe’ work to respond to actual or likely child sexual abuse and child sexual exploitation in line with the emerging evidence base about this work; review the local child sexual exploitation toolkit and multi-agency child exploitation (MACE) paperwork to ensure this explicitly references the harm caused to children, has a focus on the impact of that harm, what action is to be taken, and how this will be communicated to the child in a trauma informed way; align the child sexual abuse toolkit and child sexual exploitation toolkit more closely, and provide consistent practice messages; work is undertaken to understand how child neglect tools are working in practice, considering any barriers to professionals in using these; update the ‘engaging families’ toolkit to include information on culturally literate practice.
Keywords: child sexual abuse, child sexual exploitation, intra-familial child sexual abuse, child neglect, siblings
> Read the overview report

2022 – Dudley – Child Y

Significant developmental delay in a 7-year-old boy due to neglect. Developmental delay issues were identified when Child Y started school in October 2020.
Learning includes: when a young child is missing from education, while it is a priority to ensure that the child starts or returns to school, the possibility of parental neglect should also be considered; systems need to support information sharing between health professionals to ensure that a child's needs are met if there are indications of developmental issues or if appointments are missed; when professionals have concerns that a child is not in education, there needs to be timely information sharing and consideration of the child's lived experience, which includes the child being seen; COVID-19 restrictions have allowed parents who are hard to engage with to avoid professional contact, which indicates that professional rigour and persistence are required to meet the needs of children during a pandemic.
Recommendations include: review procedures in relation to children missing from education to ensure that reference is made to younger children, and to links with neglect; seek assurance on the effectiveness of the local authority education service when a child missing education meets the criteria for a school attendance order; ensure partner agencies hold Working Together compliant strategy meetings to plan investigations and visits, and that there is consideration of a child protection medical in neglect cases.
Keywords: child neglect, school attendance, coronavirus, information sharing
> Read the overview report

2022 – Dudley - Child Z

Child Z was brought into emergency department by ambulance in March 2021 in moderate diabetic ketoacidosis following attendance at a general practitioner surgery. There were concerns in relation to neglect and the impact of chronic neglect on the management of Child Z's diabetes as well as mother's cognitive ability to understand the impact of diabetes for a child.
Learning includes: further training for children’s social care practitioners to recognise chronic and cumulative neglect for a child, to understand what is happening in their life, how neglect impacts their life chances and how services can provide support; professionals to collectively look at historic safeguarding concerns and risks, in the form of a chronology, rather than identify them as isolated incidents; health professionals to develop a programme around supporting parents with learning disabilities where they are struggling to understand the complexities of calculating and administering medication to their children; and the importance in understanding the child’s voice, adverse childhood experiences and lived experience.
Recommendations include: front facing practitioners working with children and young people to revisit the partnership’s neglect strategy to recognise chronic and cumulative neglect for a child and the impact on their life chances; health and children’s social care professionals to develop a clear pathway and timeliness of intervention for parents with learning needs in order they understand the complexities of calculating and administering medication to their children; and children’s social care to complete piece of work around parents with learning disabilities to support them with their parenting.
Keywords: children with a chronic illness, child neglect, child health, parenting capacity, home environment, adults with a learning disability
> Read the overview report

2022 – Doncaster - Cameron

Death of an infant in 2020. Cameron was attacked in the family home by a dog owned by the father.
Learning themes include: parental neglect; analysing risk in relation to ‘Signs of Safety’ guidance; parental mental health; responding to indications of domestic abuse; assessing the risks which dogs may present to children; the GP practice response to an earlier dog bite; GP practice involvement in child protection planning; and the impact of Covid-19 restrictions.
Recommendations include: monitor progress against the strategic priority of neglect and associated workstreams; seek assurance the 'Signs of Safety' approach ensures that all risks to a child receive appropriate attention and that the cumulative impact of multiple risks is not obscured by a requirement to focus on a small number of risks; consider both maternal and paternal mental health and their potential impact on parenting capacity; learning from the case informs Doncaster’s domestic abuse training programme; share the concerns about the system for combining reports of the same domestic violence incident reported to different agencies by the victim and perpetrator; revise referral criteria in the partnership's 'Dangerous dogs practice guidance' to include injuries to children by a dog who are subject to child protection or child in need planning; introduce the mandatory use of the partnership's 'Assessing dogs who may pose a risk to children' alongside all pre-birth assessments where there is a dog in the family home; and seek assurance that all GP practices accurately code any involvement that children's social care has with every child.
Keywords: infant deaths, pets, partner violence, child neglect, general practitioners, risk assessment
> Read the overview report

2022 - Ealing - Young Person H and others

Review of three cases involving adolescent self-harm, including a young person who attempted suicide in 2021.
Learning includes: professional fears around challenging conversations with young people on self-harm being rooted in a fear of making situations worse; if foster carers are equipped and supported when taking on a young person who self-harms; issues around risk management plans and working collaboratively to find the best support for a young person; issues of working across boundaries, including young people being registered for services in a different borough and in relation to child and adolescent mental health service (CAMHS) provision; if therapeutic interventions are focused enough on the impact of adverse childhood experiences; lack of knowledge or experience in discussing gender identity with young people.
Recommendations include: review working practices to improve the confidence and ability of practitioners to have difficult conversations that focus on mental health; adolescents are able to have agency over their own risk management plans; training on gender identity and what this means for young people; support parents struggling with self-harming behaviour; support the training of foster carers in understanding self-harm and risk management; the young person and their parent/carer have continued access to a CAMHS clinician regardless of where they are living; agree a mechanism for managing risk across agencies; ensure gender identity is a key strand of equality action planning across all agencies.
Keywords: adolescents, self harm, child mental health, child sexual abuse, gender identity, children in care
> Read the overview report

2022 – East Sussex – Child AA

Stabbing of a 17-year-old in April 2021, resulting in life threatening injuries, and a need for long term medication.
Learning themes include: robustness of multi-agency activity to disrupt criminal exploitation and county lines; impact of missing education for vulnerable children and young people; transfer of safeguarding information between schools; transition between educational establishments for children who are excluded from school; and family engagement and environmental factors.
Recommendations include: the Multi-Agency Child Exploitation (MACE) Silver Group should review measures of effectiveness of disruption tactics currently used in plans and what legal orders, if any, would be most effective in supporting disruption plans; the police force should strengthen communication between themselves and MACE partners to ensure effective involvement of partner agencies; the local safeguarding children’s partnership (LSCP) and safeguarding adult board should develop a strategy to ensure there is adequate transition provision to support criminally exploited children as they move to adulthood; embed the referral process to MACE with schools and facilitate improved information sharing of safeguarding records between schools and colleges; develop a robust register of children who are permanently excluded which is monitored and reviewed to ensure support and a full-time education offer; the local authority should establish a clear pathway for how alternative provision is accessed and the role of the pupil referral unit for permanently excluded children; embed a protocol to follow for the transfer of records between schools; and the LSCP should encourage the use of therapeutic thinking across all secondary schools so that suspensions and permanent exclusions are used as a last resort.
Keywords: child criminal exploitation, children missing education, county lines, exclusion from school, pupil referral units, young offenders
> Read the overview report

2022 – East Sussex – Thematic review

Thematic review focusing on two families where adults had significant vulnerabilities, including a history of abuse and neglect in their own childhoods, previous relationships where domestic abuse featured, mental health issues and substance misuse.
Learning includes: systems must enable the impact of a parent’s vulnerabilities and associated risks to be understood by all professionals working with the family; professionals require support when trying to work with resistant and hard to engage families who do not acknowledge professional concerns and refuse to ‘own’ a child protection plan; when the concerns or allegations do not meet the threshold for criminal charges, formal multi-agency consideration should be given to why this is and to the potential need to safeguard the child and/or their siblings; professionals need to understand the ongoing and reoccurring nature of domestic abuse and parental mental health issues to fully appreciate the impact on children; there is cumulative risk of harm to a child when parental and environmental risk factors are present in combination or over periods of time; as children approach adulthood, those who are known to be vulnerable, particularly those that are on a child protection or child in need plan, require on-going and focused multi-agency support with a clear plan; and COVID-19 had an impact on the families and the professional response.
Recommendations are embedded in the learning.
Keywords: adverse childhood experiences, substance missuse, family violence, transition to adulthood, mental health
> Read the overview report

2022 – Essex - Child P

Death of a 13-year-old girl in September 2019 from suicide five days before her 14th birthday.
Learning is embedded in the recommendations.
Recommendations include: be able to articulate what the barriers might be to hearing the voice of the child at a system and practice level; make clear the expectation that all working with vulnerable children are alert to the depth and breadth of knowledge that they hold about the child’s history and current networks and ensure that this is incorporated into ongoing assessments and plans; where there is a significant change in a child’s circumstances a swift meeting should take place with relevant practitioners and family members in order to agree a multi-agency response and any adaptations to the Child in Need plan; work with partner agencies to clarify the expected steps to take when young people engage in sexually harmful behaviour; ensure that staff have the knowledge and skills to work confidently with young people and support families, where there are risks associated with their engagement in the digital world; ensure that strategy meetings/discussions are child focused and separately identify the vulnerabilities of the young person alongside risks to others; promote a balanced approach to discussions about whether a child should become looked after; clarify the process for the provision of financial support for family and friend carers and make sure that this is used creatively to prevent children becoming looked after; and review the training and development opportunities for staff who are expected to chair Child in Need meetings to ensure that all staff are adequately supported to undertake this task.
Keywords: bereavement, foster care, sexting, children with a mental health problem, adolescent girls
> Read the overview report

2022 - Gloucester – Laura and Ella

Joint domestic homicide review and serious case review. Murder of an 11-year-old girl by her stepfather in May 2018. Ella's mother was also murdered.
Learning includes: the important role of family and friends as source of support; the need to consider the voice of the child; consider the impact of a new step-parent and their background on a child's life; health professionals need to know and document who has parental responsibility for a child as well as the other adults in a child's life; the need for all services to ensure they have  policy, training and record-keeping procedures to adequately address domestic abuse, and for services to benchmark themselves against best practice or national guidance; all frontline professionals need to confidently speak to survivors of domestic abuse about their situation despite any denial or minimisation, to understand where barriers come from, and to address domestic abuse beyond basic inquiry; the need for strategic boards for domestic abuse, safeguarding and health and wellbeing to work together to adequately resource and support multi-agency and best practice in relation to domestic abuse.
Recommendations include: all agencies should provide domestic abuse training, including economic abuse and the homicide timeline; local safety partnership agencies to ensure stronger links with the domestic abuse board; local safety and children's safeguarding partnerships to ensure that national mapping data on domestic abuse, child fatalities and child safeguarding is applied countywide.
Keywords: child death, murder, family violence, voice of the child, interagency cooperation
> Read the overview report

2022 – Gwent - Elena

Death of an 8-month-old girl in August 2020. She was born with a serious heart condition identified antenatally and fitted with a naso-gastric tube for the feeding and medication routine.
Learnings include: agency arrangements for responding to vulnerable families during the pandemic could have been better promoted across partners; a discharge planning meeting or multi-agency disciplinary meeting could have improved better information sharing and coordination of community and hospital-based services; health service records are fragmented with some not being recorded and stored electronically; a sleep environment assessment was not undertaken; when working with complex families, there can be misconception about the roles and responsibilities of statutory and non-statutory support, which includes, misconception about threshold criteria for access to each service.
Recommendations include: in the event of significant service disruption, individual agency service delivery plans for responding to vulnerable families, are shared with partner agencies; further training in relation to recognising and responding to concerns in respect of vulnerable individuals and families and on the quality of the information submitted; promote the utilisation of multi-disciplinary meetings in cases of children with complex needs requiring care in the community and where there has been cross health board involvement; improve the systems in which information is recorded, stored and shared; and ensure awareness regarding the duties, roles, and responsibilities of statutory and non-statutory services.
Keywords: infant deaths, health, sudden infant death, record keeping, home visiting
> Read the overview report

2022 - Halton - Child G

Non-accidental brain injuries to a 6-month-old boy in May 2021, thought to have been caused by shaking. A subsequent investigation made adverse findings in respect of his father.
Learning themes include: transfer in arrangements, and meeting the health and education needs of children; safeguarding and the importance of recognising the impact of domestic abuse on children including unborn babies; and consideration of cultural background.
Recommendations include: make sure that local health and education providers have effective arrangements in place to share information about children moving in and out of the area; seek assurance from all relevant agencies that when information is shared or received about an Acute Life-Threatening Event (ALTE), steps are taken to identify and safeguard any siblings; seek assurance from the local health trusts that health visitors and midwives exercise ‘respectful scepticism’ and curiosity when parents deny reported incidents of domestic abuse, especially if the mother has previously been subject to domestic abuse, and/or she is pregnant, and consider the potential impact on the unborn child and any siblings; support partner agencies to raise awareness about the dangers of shaking babies and how to reduce the risk, ensuring that fathers are also aware of the dangers and that this is also addressed in the roll out of the programme ‘Babies cry you can cope’; seek assurance from partner agencies that they have or will develop training and briefing materials for practitioners about working with BAME people, including how to find out about unfamiliar families’ cultural backgrounds.
Keywords: abusive fathers, crying, family violence, non-accidental head injuries, physically abused infants, shaking
> Read the overview report

2022 – Hampshire - Amelia

Multiple injuries to an infant girl in May 2019. Amelia's mother was later charged for child cruelty.
Learning includes: the local safeguarding children partnership to consider further promotion of its practitioner-based toolkits to support working with unidentified adults and adopting a family approach; children's services and the local NHS Trust to share the toolkits again with frontline staff, and ensure the toolkits are included in training; future audits of multi-agency practice to review agency record keeping, ensuring that records are clear regarding what information has been shared by service users, and what information has been passed to other agencies for further action; the need to develop information for partner agencies on the use of agreed escalation routes; seek assurance that the voice or perspective of the child is included in case files and safety plans.
Recommendations are embedded in the learning points.
Keywords: infants, physical abuse, information sharing, voice of the child
> Read the overview report

2022 – Hampshire – Child P

Death of a 5-week-old infant in 2019 due to severe, widespread and irreversible brain injury. Both parents were arrested and subject to criminal investigations. Mother was subsequently convicted of manslaughter.
Identifies learning for all agencies around the following themes: information sharing and assessment of risk; professional over optimism and professional curiosity; and substance misuse.
Recommendations include: request health partner agencies to review and develop guidance on the use of vulnerable families meetings to share information and assess risk; promote awareness and undertake training on the themes of professional over optimism and professional curiosity; request that health agencies review their missed appointments policies to ensure this is identified as a potential risk factor, alongside apparent compliance; consider developing best practice guidance and training for universal services on responding to potential risk issues of substance misuse by parents.
Keywords: infant deaths, risk assessment, optimistic behaviour, substance misuse
> Read the overview report

2022 – Hampshire – Emma

Death of a 16-year-old girl, Emma who was staying with a relative at the time of her death. The relative's partner was convicted of Emma's murder and sentenced to life imprisonment.
Learning includes: Emma's positive presentation may have resulted in professional over-optimism and disguised her ongoing vulnerability; when an adolescent is on a child in need plan the supporting professional network needs to consider the parent's ability to support the child; when children are linked to exploitation it should be established if the parent is able to understand the risk posed by contextual safeguarding issues; practitioners outside of children's social care do not always clearly record the voice of the child.
Recommendations include: encourage practitioners to operate a reflective mind-set with their case work, being aware of over-optimism and ensuring continuing practice of professional curiosity; practitioners understand expectations regarding recording standards, including how the child's voice is recorded; education settings should ensure that child protection records are transferred in a timely fashion at points of transition; practitioners questioning the language used to describe a child, their presentation and context in assessments and other recording; practitioners knowing how to respond when unreported domestic abuse is raised by a child service user; the local safeguarding partnership conducting a multi-agency audit of adolescents known to agencies due to risk of harm following neglect.
Keywords: adolescent girls, murder, contextual safeguarding, optimistic behaviour, professional curiosity, voice of the child
> Read the overview report

2022 – Hampshire – Liam

Professional concerns regarding an 11-year-old boy admitted to hospital in April 2020. Liam's presentation at hospital was due to an accidental injury, but his appearance and history of previous medical presentations raised concerns about his care and resulted in the instigation of care proceedings.
Learning includes: practitioners should take into account the impact of parental anxiety on a child's overall welfare; practitioners learn strategies for working with parents who are highly anxious; children cannot always easily articulate their day-to-day life experience, particularly when they have no ongoing relationship with an adult outside of the home; the need for practitioners to be professionally curious about information provided by parents and how that impacts upon the care provided; the challenges of working with families where there is partial engagement and disguised compliance.  
Makes no recommendations but notes that learning has been incorporated into the local safeguarding partnership's workstreams, including multi-agency training, planned audits and professional guides.
Keywords: injuries, disguised compliance, parents, anxiety, professional curiosity
> Read the overview report​

2022 – Hampshire - William

Serious neglect of a 12-year-old boy identified at admission to hospital in April 2020.
Learning includes: need to develop clear treatment pathways for specialist services; need for patient information for a family which details what the parental or carer expectations are to support the child's treatment; need for managerial oversight and supervision in complex cases, especially where there are concerns regarding parental engagement and compliance with advice and treatment; past information about a child and their parents or carers should inform the child's future health care; have honest and clear conversations with parents about their role in supporting health needs and what will happen if those needs are not met; be professionally curious about information provided by parents and how that impacts upon the care provided; professionals supplying referral information or agency reports for meetings need to be explicit when there are safeguarding concerns about a child; importance of seeking specialist support to ensure medical tests are completed in a timely manner; have robust conversations with other agencies to ensure they understand the significance of a child not having important medical tests completed.
This review makes no specific recommendations.
Keywords: child neglect, medical care, parent-professional relationship, supervision, professional curiosity
> Read the overview report

2022 - Haringey - Baby Mary

Death of a 10-week-old infant in February 2018 from significant non-accidental injuries whilst in the care of her parents. Mary was born prematurely and spent several weeks in a special care baby unit prior to discharge home.
Learning themes include: information seeking, sharing and usage to inform assessments, decision making and intervention; over-optimism in parenting capacity; professional challenge and escalation; cross border working arrangements; parents’ engagement with the professional network; transient lifestyle and housing difficulties; and practitioners and managers’ knowledge and confidence in understanding risk of harm, abuse and neglect.
Recommendations include: to seek assurance that professionals across the partnership have knowledge about how to respond to professional challenge, professional disagreements and the use of the escalation policy; to review arrangements for discharge planning from hospital when there are concerns about a child’s safety and welfare, and where there are multiple statutory agencies involved; to seek an update about the progress made regarding efforts to unify and promote consistency of practice for children and families moving across London boroughs; to promote a dialogue with relevant partner agencies about how to consistently interpret, apply and evidence threshold decisions when making referrals, with the use of scaling being one tool for achieving this; and to seek assurance that the local housing service is fulfilling its statutory obligations under the Housing Act 1996 regarding notifications to other housing authorities when placing families, or pregnant women, outside of their borough, and their responsibilities under the Children Act 2004 in relation to sharing information with other professionals.
Keywords: infant deaths, premature infants, injuries, housing, optimistic behaviour, parenting capacity
> Read the overview report

2022 - Hartlepool - Alex

Serious injury to a 3-month-old baby in April 2019; baby was taken to hospital twice in one day, firstly following a reported choking episode and secondly with seizures. The baby was later diagnosed with a subdural haematoma and a healing rib fracture, which were determined to be non-accidental.
Learning includes: information regarding parental history and any information on the children known by all agencies should be sought, shared and considered; there needs to be clarity across agencies when a case is closed to Social Care regarding what should happen if any concerns emerge or if the family do not continue to cooperate with any agreement made at closure; impact of parental risks and vulnerabilities should be considered in assessments and when working with a family; when none of the injuries in themselves are likely to meet the threshold for a child protection intervention, consideration of the wider picture may be helpful; if the case is not yet allocated to a midwife, information should be shared with the safeguarding nurse for the midwifery service if a pregnancy is known or suspected; at the point of closure information should be shared with those continuing to work with the family; GP information should be considered as part of a strategy discussion and additional information sought as part of the assessment; strategy discussions should include consideration of whether siblings require a Child Protection Medical; and professionals should be alert to whether assumptions are being made about a family and whether any professional disagreements need resolving formally.
Recommendations are embedded in the learning.
Keywords: premature infants, non-accidental head injuries, information sharing, parenting capacity, professional curiosity
> Read the overview report

2022 – Herefordshire – Louise

Serious, life changing injuries, sustained by 18-month-old girl in June 2019 while in the care of her mother's partner.
Learning includes: training on the cycle of change and motivational interviewing; escalation and professional disagreement; and recognition and prevention of abusive head injury in infants.
Recommendations include: ensure that there is a joint understanding and agreement in the application of thresholds of all levels of need and that referral pathways are clear and understood; ensure that both child in need and child protection plans and processes are robust, outcome focused and clearly understood and owned by all agencies; to develop a one multi-agency safeguarding access point, that there is robust and consistent management oversight; to ensure that information is effectively shared to make effective and safe decisions including in domestic abuse cases; ensure multi-agency responsibility to identify and respond to all aspects of neglect, including educational and emotional neglect and the effects of non-dependent alcohol use by parents and the impact of these on children; to ensure the impact of domestic abuse on children is understood and prioritised.
Keywords: child neglect, partner violence, non-accidental head injuries, information sharing, professional curiosity
> Read the overview report

2022 – Herefordshire - Thematic learning following allegations of peer-on-peer abuse

Disclosure of peer-on-peer abuse experienced by a young person. YP1 made two disclosures to a school nurse, who referred the case to the multi-agency safeguarding hub (MASH) and the police.
Learning includes: MASH decision-making should be collaborative and multi-agency, and there should be a clear process to record referrals, decisions and actions to ensure that information is not lost when more than one agency makes a referral; family history of relevance to safeguarding should be included in the social care records of all children to facilitate holistic consideration of issues which may impact on children; when there are concerns about peer-on-peer abuse, child and family assessments should be considered for both the child who shared experiences of harm and the child reported to have caused harm; when there are concerns that a child has suffered significant harm as a result of peer-on-peer abuse, it is important that a coordinated multi-agency plan is agreed to focus on the needs and vulnerabilities of both the victim and young person alleged to have caused harm; when speaking with young people about their sexual health, it is important that professionals provide an opportunity for young people to be seen alone without a parent or carer.
Recommendations include: implement action plans to improve the multi-agency response to peer-on-peer abuse; ensure that the views and experiences of young people involved in peer-on-peer abuse and their parents and carers inform practice improvements.
Keywords: adolescents, harmful sexual behaviour, referral procedures, decision-making
> Read the overview report

2022 – Hertfordshire – Child N

Death of a 13-week-old child due to injuries consistent with trauma. There were 41 separate injuries including fractures to her ribs and spine. Child N's mother and her partner were convicted of offences relating to her death and are serving prison sentences.
Learning includes: the importance of accessing and analysing historical information about families; the potential risks from the mother's new partner were not understood; the need for practitioners to comprehend fully the significance of bruising to non-mobile infants; transfers of case responsibility between teams, individuals and services were problematic and would have benefitted from a more collaborative child centred approach; inconsistent understanding of the significance of faltering weight and growth measurements in babies; the over reliance on members of the extended family as a protective factor; and the failure to reassess when different information emerges.
Recommendations are made in the following areas: antenatal identification of need and risk; background family information; bruising policy; case transfer; poor weight gain, neglect and faltering growth; and assessment of extended family.
Keywords: infants, physical abuse, fractures, bruises, feeding behaviour
> Read the overview report

2022 - Hounslow - Child A

Long-standing chronic neglect suffered by a child whilst in the care of her mother. She was removed from her home under police protection and admitted to hospital due to the impact of severe physical and emotional neglect in August 2020.
Learning includes: the need for professionals to collate and consider information which raises concerns about the safety of a child being home educated; when a child has a history of non-school attendance professionals need to recognise this as a serious safeguarding issue; the necessity for professional challenge when there is indecisiveness and or inappropriate decisions being made during the course of child protection conferences; use of resources available to assess neglect is vital if professional practice is to be improved and children protected.
Recommendations include: the Department for Education (DfE) consider amending statutory guidance so that when a parent gives notice of their intention to electively home educate their child, information should be collated from safeguarding partner agencies prior to the child being removed from mainstream education; the DfE consider amending statutory guidance so that local authorities have authorisation to seek assurance that the parent has the intellectual capability and appropriate resources to provide suitable home education to the child, and decide whether it is in the child's best interest; the Safeguarding Review Panel consider including a section on children who are electively home educated in any future revision of Working Together to Safeguard Children.
Keywords: child neglect, home education, parents with a mental health problem
> Read the executive summary

2022 – Hull – Child C

Death of a child who was found unresponsive at home. The cause of death was recorded as 'sudden unexpected death in childhood' (SUDIC). Several months later information was shared by family members about a non-accidental injury to another child in the family, along with allegations of domestic abuse to mother by her partner. Following a criminal investigation Child C's cause of death was concluded as 'unascertained'.
Learning themes include: identifying, assessing, managing, communicating, and working with risk in relation to safeguarding children, supporting young parents, domestic abuse, and child neglect; the child's voice, and the need for continual focus on and consideration of the child's lived experience; and collaborative safeguarding, with practitioners understanding their own and others' roles and responsibilities as set out within legislation and multi-agency policy and procedure.
Recommendations: N/A
Keywords: child deaths, risk assessment, family violence, child neglect
> Read the executive summary

2022 - Isle of Man - Child J

15-year-old Child J experienced a high number of adverse childhood experiences (ACEs) in their life. Child J’s long involvement with social workers revealed a childhood of domestic abuse.
Learning themes include: Child J’s ACEs; multi-agency working and information sharing; and contextual safeguarding.
Recommendations include: establish with partners a multi-agency strategy and procedural framework for contextualised safeguarding and exploitation, this should ensure it includes an information sharing protocol and consider adopting a vulnerable adolescent service strategy; seek assurance from partners that an early help strategy is being considered and developed to intervene early in the lives of children similar to Child J, this should include a professional framework to improve professional’s knowledge and understanding of the impact of ACEs, implement that understanding in response to children and young people, and for professionals to provide a trauma informed response; ensure that learning is provided that highlights to professionals the importance of identifying and acting on a ‘reachable moment’ for a child at risk of child criminal exploitation; seek assurance from the safeguarding strategic partners that they have systems and structures in place through them working as a multi-agency team with joint responsibility to be able to capitalise on this moment; and support the implementation of the proposed standard operating procedure for a ‘Child presenting to emergency department with a Mental Health Crisis Out of Hours’ as this would help to ensure there is in place actions to deal with similar situations in the future.
Keywords: adverse childhood experiences, child criminal exploitation, family violence, mental health, trauma informed practices
> Read the overview report

2022 - Isle of Man - Family K

Homicide of Mrs K and serious assault of Mr K by their son. Mark was mentally ill at the time of the incident. He was convicted for the manslaughter of his mother and remains in secure care. In the weeks leading up to the homicide, Mrs K and a friend of Mark’s had contacted mental health services on five occasions with concerns about his behaviour.
Learning themes include: the context of adult family violence; mental health issues; substance misuse issues; caring relationships; instability, dependence, and social isolation; the lack of a clearly defined ‘primary’ victim; absence of ‘visible’ high risk and lack of engagement; the role of GPs in safeguarding adults and children; and responding to domestic abuse in the Isle of Man.
Recommendations include: the Isle of Man Safeguarding Board should ensure that there are robust measures in place for responding to incidents of domestic abuse, which consider the risks and vulnerabilities of all people within the household, particularly children and young people; Manx Care Social Care should lead an awareness raising campaign about being a young carer which provides information on the impact of being a young carer and tools and aids to help agencies generate support plans and signpost to support services; DHSC and Manx Care should assure there are robust processes in place to correctly identify the adult/child’s registered GP; assurance should be sought that GP’s are involved as key multi-agency partners in responses to safeguarding and domestic abuse concerns and that information is shared in line with policies and professional guidance.
Keywords: abusive adolescents, children as carers, children in violent families, children with a mental health problem, substance misuse, domestic abuse
> Read the overview report

2022 – Islington - Child R

Sexual abuse, including rape of a child by their foster carer from March to July 2020.
Learning themes include: children looked after (CLA) who are placed ‘out of borough’; decision making following placement breakdown; exploration of local authority designated officer (LADO) concerns; use of ‘safer care’ agreements; issues of relationships, sexual health, and contraception; and the influence of the COVID-19 pandemic on hearing the voice of the child
Recommendations to the partnership include: review and update procedures in relation to sourcing fostering placements for CLA so that, regardless of their status they are subject to the same rigour as occurs for all other fostering placements; the senior leadership team should oversee a review of policy and application of safer care agreements; requests for CLA to take part in activities that involve risk should be agreed in line with the current care plan and only by heads of service; safer care agreements need to be updated in light of changing information; when children are out of borough all the professionals providing the local services should be linked into the team around the child; provide reminders and training to GPs to ensure that they understand their responsibilities in assessing risk when prescribing contraception to young people who are looked after.
Recommendations to the corporate parenting board include: review care planning decisions about contraception for CLA who are victims of sexual abuse are or at risk of CSE; oversee a multi-agency task and finish group to review how sexual health is incorporated into CLA care and pathway planning.
Keywords: child sexual abuse, children in care, disclosure, foster parents, placement breakdown, rape
> Read the overview report

2022 – Kensington and Chelsea and Westminster - Holland Park School

Allegations of staff bullying, poor safeguarding practice, discrimination, and intimidation of students, as well as health and safety issues at a secondary school in summer 2021.
Learning themes include: understanding and learning from complaints; school policies; recruitment and training; and school culture.
Recommendations to the school include: revise and update the complaints policy and implement a system to review complaints on a regular basis in order to identify areas of strength and areas for development; school policies should be reviewed (annually) and approved by the governing body and shared with school staff; devise systems for maintaining staff training records centrally in line with statutory guidance and managing staff exit interviews; ensure that the staff and governors have sufficient knowledge, safeguarding training and skills to undertake their roles effectively, in order to adopt a whole-school approach to safeguarding; review the use of safeguarding recording systems in line with statutory guidance, including where there are low-level concerns about an adult; review and update its line management systems to ensure that all staff, including senior leaders, are held effectively to account; ensure school governors receive refresher training on how to manage allegations about staff, including senior leaders; review the range and purpose of sanctions in line with DfE guidance including the use of the isolation room to ensure that this is consistent with good practice; the Local Authority Designated Officer (LADO) service should review how low-level concerns about children’s settings are recorded and tracked in order to help identify patterns and trends that may indicate further concern.
Keywords: complaints, secondary schools, school records, staff welfare, teachers, leadership
> Read the overview report

2022 – Kent – Children O and P

Death of two 23-month-old toddlers in December 2018.
Learning includes: a need for information sharing between the general practitioners (GP) and the health visitor; a need to draw on the wider healthcare team to obtain as full a picture as possible of a child’s life in order to recognise those in need; a need for insight into the impact of the breakdown in the parents’ marriage on the children; a need for information sharing with regards to updating the NHS spine when people move address; professionals need to recognise the relationship between adult mental health and safeguarding children; a need for further focus on the impact of a parent’s deteriorating mental health on their capacity to care for their children; and recognition that there is less likelihood of determining a patient’s true condition when contact with a service is over the telephone.
Recommendations include: review the effectiveness of the ‘health visitor/GP link meetings’ in relation to parental mental health issues; consider how to enable patient’s addresses on local records and the NHS spine to reflect their current whereabouts; review the effectiveness of telephone and email contact and its impact on mental health assessments and practitioners’ capacity to assess risk; and ensure all professionals are aware of the risks around parental mental health, including the potential for children being harmed, and that children should not be viewed solely as a protective factor.
Keywords: parents with a mental health problem, filicide, official inquiries, injuries, information sharing, health
> Read the overview report

2022 – Kent – Child S

Death of a 7-week-old infant boy in August 2020. The cause of death was ruled as sudden unexpected death in infancy (SUDI).
Learning focuses on: risk assessment and decision making; child neglect; substance misuse; and safe sleeping.
Recommendations include: undertake an audit of the processes of convening child protection conferences to review the attendance of key agencies and the quality of reports submitted by agencies; consider learning from the Child Safeguarding Practice Review Panel's report "The myth of invisible men" to ensure the overt engagement of men in risk assessments across the partnership; raise awareness and understanding of the Public Law Outline (PLO) process so that practitioners are clear of the processes and aware of opportunities to influence risk assessment and decision making; children's services review the arrangements for risk assessment and decision making in the PLO process and the interface between the legal advice received and the decisions taken to ensure this is a constructive process with sufficient challenge; review the neglect strategy to develop a clear shared understanding of "good enough" home conditions that provide practitioners with an agreed baseline; develop a substance misuse strategy, with a specific focus on cannabis use, to support a shared understanding of risks, appropriate interventions and decisions on the threshold for escalation; and to promote and raise awareness of the need to deliver safe sleeping advice, particularly when there is substance misuse by parents.
Keywords: sudden infant death, substance misuse, sleeping behaviour, child neglect
> Read the overview report

2022 – Kent – Harm to Under 2s in Kent

Explores the death or serious injury to 17 under 2-year-olds in Kent to identify key themes that help us understand when and why harm occurs, and what practice can safeguard young children from harm.
Learning is embedded in the recommendations.
Recommendations include: seek clarification on current Health Visiting operating standards around face-to-face visits; Early Help assessments and plans to be shared with involved multi-agency partners (with family consent); the positive practice audit to be published and shared as a standalone report, as a reminder that familiar, expected, basic practice works, and avoid a sense of needing to wait for learning from individual LCSPRs to be published before seeking to change or improve practice; the need for universal services to be more inquisitive and alert to less obvious risks has been clearly identified, particularly when considering the inherent physical vulnerabilities of children under 2-years-old; that practitioners, against human instinct, must be prepared to think the worst – even where there are not clear ‘red flags’; and professionals need to understand that significant harm occurs to children in families where risk is not obvious, where universal services may be the only ones engaged, and to consider whether there is one more question which might help identify an obscured risk.
Keywords: early intervention, home visiting, infant deaths, parenting capacity, safety measures
> Read the overview report

2022 – Kent – Lost in plain sight

Death of a pre-school aged child in 2019. The child sustained head injuries when in the care of the mother’s partner and died some days later in hospital.
Learning includes: adequate consideration must be given to the practical implications of significant changes to a child’s lived experience when planning for their ongoing care and support needs; when a child with a disability is presenting with injuries reported to be self-inflicted, there is a need for further consideration and enquiry; and a need to remain mindful that there may be factors impacting a caregiver’s ability or willingness to give an accurate explanation for a child’s injuries.
Recommendations include: each agency to be aware of the challenges some staff may face in keeping abreast of safeguarding policies; update forms used in Minor Injury Units to include consent to share information and referral to onward services; and seek assurance that safeguarding concerns within Accident and Emergency and Minor Injury Units are raised to professionals of appropriate seniority and expertise, and that parental explanation is explored and challenged where necessary to consider all likely causes.
Keywords: infant deaths, head injuries, professional curiosity, hospitals, children with disabilities, siblings
> Read the overview report

2022 – Kent - Oliver Steeper

Death of a 9-month-old boy. Oliver choked on food at nursery school, and following admittance to hospital died six days later. It was concluded that Oliver had choked due to being fed food which was not age appropriate.
Learning includes: early years settings should clearly and regularly discuss, and record, appropriate foods and progression of the introduction of solids for young children with parents; empower parents to ask questions about provisions in settings; and it should be clear and documented within settings who is responsible for ensuring food is suitable for children.
Recommendations include: encourage early years settings to have a food policy which considers the individual needs of each child, and resources for practitioners documenting the individual needs of a child regarding appropriate foods; resources for parents to build confidence in pro-actively seeking reassurance from early years settings on feeding in non-familial settings; engage with early years qualification providers to include safer eating materials into foundation training for early years staff; include safer eating in the broader sense (as opposed to solely regarding allergies or healthy eating) into the early years foundation stage (EYFS) requirements; review the position of pre-2016 qualified nursery staff being included in staff ratios without current paediatric first aid; and include a 'thinking about nursery' section in the personal child health record ('red book'). N.B. This report includes a photo of the child.
Keywords: infant deaths, nurseries, feeding behaviour
> Read the overview report

2022 - Kirklees - Child A

Death of a 9-week-old girl in January 2018. Following the conclusion of the inquest it was confirmed that Child A died from unknown causes following unsafe sleeping environments at her home.
Learning includes: children's social care assessments should ensure historical concerns including home conditions and suitable sleeping arrangements for children are explored during re-assessment; risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services as this may indicate an ongoing, abusive relationship; retractions of statements regarding domestic abuse may be indicative of ongoing contact between the victim, the perpetrator and their children; social workers should speak directly to children being 'programmed' by their parents, without the presence of their parents, to explore their wishes and feelings; perpetrators of domestic abuse should be directly spoken to about the impact of their abusive behaviour on children and included in the assessment process or safety plan for children; consideration should be given to de-escalating to a team around the family plan if low level concerns still need to be addressed when child in need plan is closed; written agreements are not effective tools for managing risk and their use should be avoided; managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information.
Recommendations are embedded in the learning.
Keywords: family violence, infant deaths, parenting capacity, professional curiosity, sleeping behaviour
> Read the overview report

2022 – Kirklees - Child I

Significant injuries sustained by a 5-month-old girl while in the care of her grandmother in January 2019. A pre-birth assessment was undertaken due to the mother being pregnant at 15- years-old and her being assessed as vulnerable to exploitation.
Learning includes: the need for pre-birth assessments to be undertaken in a timely manner and professionals to take early action to minimise the impact of any known risks to the unborn baby; a need for professionals to establish and share a parent’s full history, to avoid missed opportunities to reassess a family situation; the importance of and need to support social workers to determine how long to spend on individual cases; and to ensure the quality of pre-birth assessments is sufficient to meet the needs of the parent(s) and unborn child.
Recommendations include: the Local Safeguarding Children Partnership should review compliance with procedures for pre-birth assessments, with the aim of ensuring pre-birth assessments are undertaken to a good standard within timescales; responses to young people should be fully informed and evidenced by an understanding of adverse childhood experiences; assessments must be outcome focused, the plan reviewed regularly, and evidence collected to determine that progress is being made; and multi-agency plans for young people at risk of, and vulnerable to exploitation should be coproduced with young people to fully capture their voice.
Keywords: head injuries, infants, teenage pregnancy, family conflict, adverse childhood experiences, parent-child relationships
> Read the overview report

2022 - Kirklees - Child K

Death of a 4-month-old child in October 2019. Child K was found dead in the family home, after having been asleep on the sofa.
Learning includes: need for greater focus on children's lived experiences and the emotional impact of substance misuse; need to develop practice of 'respectful uncertainty' as a means to combatting disguised compliance, particularly where substance misuse is a concern; risk to children was increased by parental drug misuse going undetected; need for consideration of reasons for grandparent's caring role as this can help professionals with their work with the family and the plans they develop; need for multi-agency approach to assessment of risk.
Recommendations include: safeguarding children partnership to ensure all agencies are using age appropriate tools in all assessments to understand children’s lived experience, and incorporating children's lived experiences into all plans; to ensure all partners incorporate disguised compliance into all safeguarding training, supervision and managerial sessions with frontline workers; seek assurance from children’s social care and local drug services that changes to service design, and ways of working have improved the reliability of testing, communication, information sharing and risk assessing of parents who are misusing substances; ensure that, where grandparents are playing a significant caring role, this is fully explored as part of assessments and contained within all action plans; explore ways of ensuring information about risk is provided by all relevant services and incorporated into safeguarding assessments and plans.
Keywords: infant deaths, substance misuse, sleeping behaviour, addicted parents, voice of the child
> Read the overview report

2022 – Lambeth – Angela

Sexual abuse of a girl by her mother’s partner. Angela disclosed multiple counts of rape and sexual assault to hospital staff in June 2020.
Learning includes: protection of children should not rely solely on disclosures from children; lack of grasp by professionals on the lived experience of the child; lack of awareness of the impact of domestic abuse in the safeguarding system; the need to support professional curiosity regarding recognition and response to sexual abuse; differing levels of confidence in the recognition of child sexual abuse, leading to professionals deferring to unspoken hierarchies; even for parents whose first language is not English who appear to have a good grasp of the English language, language used by professionals is more complex than conversational language.
Recommendations include: consider development of a multi-agency neglect strategy; any individuals or families living in property deemed unfit for human habitation are offered temporary accommodation without delay; consider a pan-London protocol about children missing education that move between boroughs; remind partner agencies of the function and purpose of a multi-agency risk assessment conference (MARAC) and the specialist domestic abuse services available; children services to consider a practice standard requiring a strategy meeting or management overview where there have been three or more referrals of children involved in domestic abuse incidents; ensure that practitioners and managers are aware of child sexual abuse expertise available in the borough; emphasise the importance of professional difference by developing the escalation process to create space for a multi-agency professionals meeting to explore perplexing cases; ensure availability and quality of interpreters used for children and parents whose first language is not English.
Keywords: abusive men, child sexual abuse identification, family violence, rape, sexually abused girls, unknown men
> Read the overview report

2022 – Lambeth - Dawit

Death of a 16-year-old boy by suicide in May 2021. Dawit had arrived in the UK from Africa in October 2020 to live with his sister after both his parents had died. His family had suffered religious persecution in their home country.
Learning themes include: developing a clear pathway and protocol for unaccompanied children who do not have anyone with parental responsibility in the UK to ensure their needs are met; supporting the integration of migrant children into schools and the wider community that takes cognisance of their cultural, religious, physical, or emotional needs; and the role of the partnership in safeguarding unaccompanied minors who do not have anyone with parental responsibility in the UK.
Reflections suggest: every child/family should be given the right advocate/support to navigate complex systems and bureaucratic processes, to ensure that they are not just matched up with universal services but are also supported to fully access them; there is a need to increase professionals’ knowledge and confidence in being curious about and exploring parental responsibility; all services must commit to using high quality translation services for all spoken and written information and in a school environment good quality English as an Additional Language (EAL) support is essential; and children’s social care should, once they have completed their child and family assessment, share the conclusions and outline plan with partners, including GPs, schools, and housing.
Keywords: African people, child deaths, suicide, unaccompanied asylum seeking children, language, parental responsibility
> Read the overview report

2022 - Leicestershire and Rutland - Child R

Significant harm to a 9-year-old boy over a number of years due to what was reported to be fabricated or induced illness (FII). These concerns became heightened when Child R was placed in foster care where he was seen to flourish, including being fully mobile and eating without medical intervention.
Learning includes: agencies, particularly health professionals, may benefit from systems that help recognise fabricated illness; when a child is under the care of multiple teams and the diagnosis is unclear, there is a need for a multi-disciplinary team meeting between health professionals; a need for continuing professional curiosity rather than relying on parental response; loss of focus on the harm to the child can occur when concentration on proving FII becomes a distraction; need for a move away from the inability to appropriately challenge parents because of concern about FII; multi-agency representation in strategy discussions is essential so that a full picture of the child’s life can be formulated.
Recommendations: N/A
Keywords: fabricated or induced illness (FII), feeding behaviour, information sharing, interagency cooperation, professional curiosity
> Read the overview report

2022 – Lewisham – Child FA

Death of a girl due to systemic inflammatory response syndrome during a COVID-19 pandemic lockdown in England.
Learning themes include: child experience of domestic abuse; child protection in complex families across households; cultural assumptions; parent-professional relationships; the impact of COVID-19 and access to healthcare; and the quality of working together to safeguard children.
Recommendations include: agencies should align adult and child risk management by case mapping to ensure there is a focus on the child where there is a parent or carer involved in historic domestic abuse; seek assurance that any potential risk to siblings is fully considered via assessment when a sibling or child living in the same household is being assessed under statutory safeguarding procedures; provide a development plan to ensure practitioners have relationship-based practice skills; agencies should ensure that there is a safeguarding supervision strategy that enables staff to reflect on how their own views and beliefs impact on their work; child protection procedures should ensure that there is continuity of child in need work when a family move; and the local authority should report on work done to learn from the pandemic in checking on children who are not attending school.
Keywords: family violence, coronavirus, parent-professional relationships, siblings, culture, health care
> Read the overview report

2022 – Luton – Luna

Serious harm of an 18-year-old girl through sexual and criminal child exploitation. Within the three previous years, Lena had been missing from care on over 60 occasions. On two of these missing episodes, Lena had provided statements about being raped and sexually assaulted. Lena was believed to be involved with local gangs and county lines drug trafficking groups.
Learning themes include: distant placements; the impact of the use of secure accommodation; relevant family history and dynamics; and record-keeping.
Recommendations include: conduct a multi-agency practitioner event to re-examine and debate the current potential (strengths and weaknesses) for collective local efforts to protect and support young persons in Lena’s situation. The LSCP should discuss the extent to which the required balance between medical confidentiality in GP practices and sexual health clinics and safeguarding of vulnerable individuals by children’s social care (CSC) and police is being maintained; GP practices should be reliably informed in a timely manner of terminations amongst under 16-year-olds; CSC should ensure expectations are clarified with respect to professional representation at strategy discussions; record completed ‘return home interviews’ and how the learning may effectively inform ongoing care planning for individuals; ensure the effectiveness of initial and review health assessments include expectations of further responses when faced by reluctance or refusal; and hospital staff should be reminded of the criteria for alerting the hospital’s safeguarding children and young persons’ service.
Keywords: child criminal exploitation, child sexual exploitation, children who go missing, secure accommodation, children in care, placement breakdown
> Read the overview report

2022 – Manchester – Child S

Murder of a 16-year-old boy who received fatal knife wounds during an incident in September 2021. No motive, rationale or explanation for the attack was identified during the criminal trial.
Learning themes include: managing behaviour and risks at school, exclusions and elective home education (EHE), the importance of multi-agency safety planning and intervention; engagement with parents and wider family members; ethnicity and gender; responses when a parent reports a threat to life in respect of their family; the importance of mapping young people involved in serious youth violence; contextual safeguarding; and the National Referral Mechanism (NRM).
Recommendations include: communicate any safeguarding concerns with regards to children receiving EHE to the safeguarding in education team and involve them in strategy meetings, section 47 enquiries and child and family assessments; housing providers should also be included in these meetings, especially when there has been information to suggest that threats to people or property have been made; review procedures and training to ensure that the learning highlighted in this review is embedded in practice; distribute it across the children’s workforce and seek reassurance from agencies that practitioners are provided with continuing professional development in trauma informed, relational practice, which address the rule of optimism, over reliance on self-reporting and the importance of holistic assessment; ensure through its training programme that staff in all agencies are aware of what constitutes a threat to life and what responsibility individual agencies have.
Keywords: child deaths, contextual safeguarding, exclusion from school, home education, murder, youth justice
> Read the overview report

2022 – Manchester – Jacob

Injuries indicative of physical and possible sexual abuse of a 7-year-old boy in May 2019.
Learning includes: practitioner knowledge and beliefs about children and families from different ethnic groups or migrant backgrounds can influence their ability to address children’s needs; when a school records safeguarding concerns in the CPOMS electronic system, used by many schools, to report, record and track safeguarding concerns, they should notify key professionals and record any discussions and plans made between agencies; the need for clear terms of reference for safeguarding teams in schools; seek out information about significant people in a child’s life in order to recognise risks posed by some men; information about commissioned services proposed by schools should be provided to parents; designated safeguarding leads should have access to opportunities to develop their practice; well-kept records in schools are vital to keep children safe; professionals need to be supported to remain curious about children’s lives.
Recommendations include: assurance sought through the local workforce safeguarding strategy, that agencies provide briefings and access to training supporting culturally competent practice; seek assurance that all professionals, including safeguarding leads in schools, are well equipped to work with diversity, culture and ethnicity in safeguarding work; explore how supervision, team learning, training and programmes can help professionals improve their skills as professionally curious practitioners in relation to relation to ‘significant males’; ensure a robust system for quality assuring safeguarding audits and action plans in schools and partner agencies.
Keywords: abused boys, abusive men, child abuse identification, injuries, professional curiosity, unknown men
> Read the overview report

2022 – Merton – Eddie

Overdose by an adolescent boy, Eddie, in May 2019, following an argument with a friend on the phone and following negative comments from his father. There had been four incidents of intentional self-harm since 2016.
Learning themes include: taking a ‘think family’ approach that recognises successful change within the family requires working with all members as a whole; the importance of agencies constructively challenging each other; contextual safeguarding/harm; the importance of trauma informed practice; self-harm and suicide risk and prevention; continued support when making a decision to end social care involvement.
Recommendations include: agencies to agree what a ‘think family’ way of working means, supported by a practical approach and the tools to deliver this; request all partner agencies refresh their escalation procedures with a reminder of professional responsibility to escalate if they consider a child is in need or remains at risk; training to be provided for awareness of the social and professional tolerance of cannabis use and associated harms, including use for self-medication to manage trauma and contextual harms; request all providers of training incorporate trauma informed practice, ‘think family’ and ACE’s in course materials and delivery; review the provision of trauma based services for boys experiencing domestic abuse, neglect, poverty and risk of exclusion; in conjunction with a ‘think family’ approach, implement a universal family friendly template for a single plan designed with users of services; support a trusted adult approach in working with young people by considering adaptive mentalisation based integrative treatment training.
Keywords: adolescent boys, adverse childhood experiences, children in violent families, children with a mental health problem, family functioning, self harm
> Read the overview report

2022 – Merton – SUDI review

Two cases of sudden unexpected death in infancy (SUDI). It was concluded that neither of the SUDI cases met the criteria for a serious incident notification, but a joint agency response (JAR) meeting identified that there could be learning for multi-agency partners.
Learning includes: the importance of children’s services pursuing the need for housing support for families experiencing homelessness; the socioeconomic impact of poor housing on families, especially mothers and babies; agency checks should be completed and obtained in a timely manner to establish past concerns about a family and current intervention; more professional curiosity from health visitors and midwives regarding the home environment of a family.
Recommendations include: safeguarding partnership to commission training or briefings on the impact of poor housing and homelessness on safeguarding children and families; undertake a review of the effectiveness of early help in dealing with issues of homelessness; provide and promote information and training around the risk factors relating to SUDI identified nationally, including signposting partners to the national SUDI review and considering the availability of safe sleeping advice in a range of languages.
Keywords: home environment, homelessness, infant deaths, professional curiosity, sleeping behaviour, sudden infant death
> Read the overview report

2022 – Mid and West Wales – Cysur 4/2019

Intra-familial sexual abuse of two generations of children and adults which came to light in 2018.
Learning is embedded in the recommendations.
Recommendations include: children’s services to reinforce the need to ensure staff are well trained on both the indicators and best practice multi-agency response to sexual abuse and exploitation; further work is needed to support practitioners to work with confidence, particularly in ‘grey’ areas of professional uncertainty where concerns exist, but where the threshold for statutory intervention is not met; the need to make improvements to their recording systems that did not always demonstrate good practice, and have introduced electronic recording for safeguarding in schools; the importance of the role of the School Safeguarding and Attendance Team who played an important role in monitoring and supporting the family outside of formal statutory intervention in safeguarding; legal challenges and professional frustration associated with obtaining consent and its link to establishing paternity raised some dilemmas for all professionals and agencies; share the learning from this case in internal safeguarding training; the GP surgery conducts regular multi-disciplinary meetings, and has introduced a flagging mechanism to alert all staff of any safeguarding concerns; and adult safeguarding recognise the need to further develop joint working opportunities with children services.
Keywords: child sexual abuse, grooming, adverse childhood experiences, trauma, paternity, sexually abusive parents
> Read the overview report

2022 – Milton Keynes – Child K

Reported rape of a 16-year-old boy in May 2020. Child K disclosed that he had been assaulted by another looked after child whilst in semi-independent accommodation.
Learning includes: decision-making when identifying placements for young people with autism and additional vulnerabilities should be needs led; key partners should have confidence that placements for young people with complex needs have the capacity and expertise to meet assessed needs, and that specialist services are spot purchased if necessary; effective collaboration, as directed by the Transforming Care Programme, will prevent inappropriate hospital admissions; a multi-agency discharge plan for young people admitted to a mental health in-patient unit is essential in preventing further hospital admission; professionals require appropriate knowledge, skills, and competence, to effectively support young people with autism and for a clear understanding of needs and vulnerabilities; professionals should have a shared understanding of the impact of autism on the behaviour, wellbeing and mental health of young people and work collaboratively to understand what the young person may be attempting to communicate by their behaviour; multi-agency assessments of young people with autism should inform a consistent approach to care; when young people with autism are home-schooled, effective oversight is required to ensure that education and health care needs are met; when professionals are concerned about the provision of care, a formal escalation policy is important in highlighting unmet needs and practice shortcomings.
Recommendations: are embedded in the learning.
Keywords: autism, child behaviour problems, placement, rape, sexually abused children, voice of the child
> Read the overview report

2022 – Norfolk - AL

Death of a 17-year-old boy in January 2022 by apparent suicide. He had experienced several years of poor mental health and was in acute grief after the death of his mother.
Learning themes include: agency responses to mental health/safeguarding; family approach to multi-agency safeguarding and mental health; bereavement and trauma; older children and young people living with neglect; recognition of the needs of young carers; multi-agency arrangements for risk management, service provision and children and young people in specialist education.
Recommendations include: seek assurance from health commissioners and partners that protocols are in place to ensure the safe management of medication for young people known to have mental health problems, including monitoring use, and advice to carers on storage and administration; referral processes and forms should seek relevant information about family history, especially history of trauma and any concerns about current parental mental health or substance misuse, including appropriate checks to see if parents are known to adult mental health services, when children are being referred; review its guidance on thresholds in order to support practitioners’ understanding of neglect, the cumulative impact of neglect and how to identify non-cooperation of care givers, as possible evidence of neglect; produce and promote sector specific good practice guides on understanding the importance of fathers and father figures; seek assurance that there are processes in place to identify and note when vulnerable adults, including men, have parenting or caring roles; review how the Joint Agency Group Supervision process is working across services.
Keywords: anxiety, child deaths, children with a mental health problem, grief, parents with a mental health problem, suicide
> Read the overview report

2022 – Northamptonshire – Young Person BG

Fatal stabbing of a 16-year-old in August 2021 whilst in a local public space with a friend. BG and friend were accosted by young person A and an associate. Considers the context of six young people (including BG and A) drawn into exploitation and youth violence.
Learning themes include: extra-familial harm and professional understanding of gangs, including identification, risk assessment and multi-agency responses; consideration of ADHD in relation to access to education and risk assessment formulation; consideration of cannabis use in safeguarding risk thresholds; diagnosing neurodevelopmental disorders in children; the impact of adolescent neglect and prevalent key adverse childhood experiences such as domestic abuse; the practice context of Covid-19; and ethnicity, representation and adultification.
Recommendations include: the partnership develop and implement a multi-agency strategy and practice framework to support the identification, risk analysis, intervention and disruption of child exploitation; various agencies conduct a needs analysis to review domestic abuse services for young people aged 16-18-years-old who may be at risk of perpetrating domestic abuse; and the local NHS Trust in collaboration with key partners review their existing ADHD pathway, to ensure advice is given for non-medication options and to enhance safeguarding practitioner understanding of how to support young people with neuro-diverse conditions such as ADHD.
Keywords: gangs, criminal child exploitation, attention deficit disorder, drug misuse, violence, child neglect
> Read the overview report

2022 – Nottinghamshire – SN20

Death of a 19-month-old infant girl in March 2020. The mother was convicted of her murder.
Learning includes: the importance of recording information accurately and the need to be precise in the language used, to avoid formulaic language and better support understanding of risk; the importance of implementing a holistic assessment of the adult and child which considers predisposing vulnerabilities, risks for the adult and child and the potential impact on and experience of the child in relation to those vulnerabilities and risk; ensure children's workers have access to expertise in adult factors such as mental health and substance misuse which may affect their care of a child; address any gaps in understanding between children's services practitioners and adult mental health services; and the need for empathetic curiosity and doubt about what parents say on topics which are inherently sensitive.
Recommendations include: review correspondence sent out to patients when they are offered an intervention specifically in relation to waiting well whilst on the list; and explore models of integration between adult and children's health and social care services so that the services can undertake joint assessments of adults with parental responsibilities who have issues including mental health problems and substance misuse.
Keywords: parents with a mental health problem, drug misuse, parenting capacity, risk assessment, mental health services, infant deaths
> Read the overview report

2022 – Nottinghamshire – Tom

Death of a two-week-old boy from positional asphyxia on a sofa where his father was sleeping.
Learning includes: safe sleeping is an issue for services broader than health visiting and midwifery; the importance of parents having an effective relationship with key health and social care professionals; a need for sufficient curiosity about evidence of indicators of domestic abuse; reasons for parents not wanting family support when it was offered or help from substance misuse services could have been clarified with more purposeful curiosity; there was a need for a good chronology of contacts with the family to help detect patterns and cumulative indicators; and a need for services to use tools and practice frameworks that are available to assist professionals to make a more informed judgment when dealing with complex and complicated family circumstances.
Recommendations include: recognising the danger of co-sleeping has implications for any services visiting homes with infants under 12-months-old; a safe sleep assessment should result in a record being left with the family and be included in any other risk-based discussions or actions including child protection plans; and intervention is likely to be more effective through a service that can allocate a dedicated worker offering consistent relationship-based and practical help informed by a well-informed assessment.
Keywords: infant deaths, professional curiosity, health visitors, substance misuse, alcohol, mental health problems
> Read the overview report

2022 - North Lanarkshire - Anne

Death of a girl from an acute medical condition in 2018. Concerns were expressed that neglect of Anne's medical needs had been a factor in her death.
Learning includes: issues around mechanisms for bringing the right people together to share information and make joint decisions, resulting in some children not receiving the right service at the right time; issues across children's services in relation to the use of assessment tools and frameworks, running the risk of failing to identify the point at which older children are in need of protection; and the need for opportunities for formal critical reflection within and across agencies at all levels, as not having these opportunities makes it more difficult to develop and revise shared understanding of the needs of children in complex circumstances, and exacerbates the risk that assessments may rest on untested assumptions.
Recommendations: N/A
Keywords: child deaths, adolescent girls, child health, medical care neglect
> Read the overview report

2022 - Oldham - Child J

Serious non-accidental injuries to a 7-month-old child in July 2015. Both of Child J's parents were charged with causing grievous bodily harm. Child J had been placed in foster care from birth and was returned to the care of the parents aged six months.
Learning points include: responding robustly to domestic abuse within a safeguarding plan requires an approach that works with both victims and perpetrators to support robust analysis of risk and change; comprehensive assessment of risk and planning for children is best supported through adopting a common model of assessing motivation and capacity for change; management oversight at critical points of assessment needs to support practitioners to utilise critical thinking techniques to draw confident conclusions and develop plans that appropriately address risk; for children reviewed within looked after children arrangements, systems to support multi-agency working should remain a priority where more than two agencies continue to be involved with the child and family; and the local authority must carefully and robustly exercise its parental responsibility for children placed with parents.
Recommendations include: the local safeguarding children board (LSCB) should promote the use of a model of change within partnership agencies to assist single and multi-agency assessment of parenting capacity; the LSCB should require children's social care (CSC) to ensure that every child for whom they share parental responsibility and is placed with parents is subject to ‘placement with parents’ regulations reviewed alongside the child's care plan; and CSC should review and report to the LSCB how multi-agency work is promoted through systems that support children subject to care orders.
Keywords: family violence, injuries, drug and alcohol services, parental responsibility, risk assessment, child protection registers
> Read the overview report

2022 – Oldham - Thematic review of harmful sexual behaviour

Thematic review of harmful sexual behaviour (HSB). Focuses on cases of two 17-year-old boys. Both young people experienced significant adverse childhood experiences, including domestic abuse, and parental mental and emotional health issues. There were also communication difficulties in both cases due to learning disabilities, deafness and non-English speaking family members.
Learning themes include: identification of harmful sexual behaviour; evidence informed multi-agency approaches; recognition of vulnerabilities and complexities, including wider family functioning, and safeguarding concerns including domestic abuse; learning disabilities, mental health and communication; cultural competence; and basic statutory safeguarding processes.
Recommendations include: frameworks and pathways for HSB take into account responses to children and young people aligned to the Continuum of Need, as well as prevention, identification and early assessment; consider approaches to multi-agency working in the context of the lead professional role, including guidance for the workforce, as well as shared risk management, and multiagency supervision for complex cases; consider the communication strategy for children and families to ensure effective weight is given to barriers to communication, and that a plan is embedded across all levels of the safeguarding continuum; and seek reassurance from commissioning and provider organisations regarding the impact of interventions and services on HSB, including reviewing and identifying gaps in interventions, and reviewing the effectiveness of the complex needs panel in these two cases.
Keywords: harmful sexual behaviour, adolescent boys, children with a learning disability, deafness, culture, language
> Read the overview report

2022 – Perth and Kinross – Young Person A

Death of a 17-year-old by having completed suicide. Young Person A’s additional support needs became more pronounced following transition from primary school into secondary school, and aspects of their family circumstances were challenging and unsettling.
Learning includes: a need for multi-agency holistic understanding of what the young person is actually saying; a need for a holistic assessment of risk and need within child and adolescent mental health services (CAMHS); there could have been closer working relationships between children’s services and adult services, in terms of planning; information was not always being shared proportionately; and a need for greater awareness raising and training for professionals when working with young people with gender dysphoria.
Recommendations include: the voice of the child must be heard and reinvigorated and children and young people need to be given the opportunity to be involved in decisions impacting them and their families; the child protection committee (CPC) should seek reassurance that all existing and new CAMHS staff have received appropriate Getting it right for every child (GIRFEC) and child protection training; the CPC should request information from health and partner agencies about the level of unmet need for young people experiencing mental health difficulties and what crisis facilities are available; and the CPC should request information about what guidance and training is available to practitioners working with young people with gender dysphoria.
Keywords: suicide, child mental health, schools, gender identity, transgender, education
> Read the overview report

2022 - Redbridge - Baby A

Head injury to a 10-week-old girl in 2022. Baby A was on a child protection plan at the time of the incident due to risk of neglect.
Learning includes: a need for professionals to consider and apply the impact of cumulative harm and parental history to the current situation; a need at every meeting to consider fathers as a protective factor or potential risk to a child; professional responsibility to engage with fathers or question any apparent lack of engagement from other agencies; a need to balance supporting a vulnerable parent with clear child-focused challenge about the potential for a negative impact on the child; a need for professionals to be clear about the impact of substance misuse on children and unborn babies, including on the parent/carer’s ability to protect their child from harm; and strengths-based models of assessment and planning for children need to have a clear focus on risk and ensure that all available information is considered when deciding on the safety plan for a child.
Recommendations include: promote the involvement of fathers as a key focus; consider the timeliness of pre-birth assessments and assessing application and impact; review approaches to neglect and seek assurance that consistent trauma informed, strengths-based models of working are being implemented across agencies; and ensure agency policies that are applied when people “do not attend” or “do not engage” with services are reflective of safeguarding risk.
Keywords: head injuries, adults abused as children, infants, adverse childhood experiences, care proceedings, child protection registers
> Read the overview report

2022 – Rochdale - J1

The collapse of a boy in school in 2022 having ingested a bag of white powder, one of nine that he had brought into school in a kinder egg. He was transported to hospital where he was found to have cocaine in his system. He and sibling were removed from mother’s care.
Learning includes: the importance of understanding and using history to inform practice; there was an over reliance on self-report by mother; there was a lack of professional curiosity; child and family assessments lacked breadth and depth; fathers and the wider family were not included; information was not triangulated; practice standards were not adhered to, leading to flawed assessments of risk; managerial oversight was not sufficiently robust to identify and challenge frontline practice; child in need/child protection plans were not robust; the voice of mother overshadowed the voice of the child; opportunities to gain a greater understanding of the child and sibling’s lived experience were missed; processes and tools designed to assist practitioners to keep children safe were not used effectively; and agencies were not working in true partnership, leading to disagreements that allowed mother to deflect and deceive some practitioners.
Recommendations are embedded in the learning.
Keywords: child abuse, drug misuse, extended families, voice of the child, risk assessment
> Read the overview report

2022 - Salford - Nicholas 

Death of a 4-year-old boy in 2022 due to a serious incident whereby he was found face down in a bath. Nicholas had been subject to a pre-birth assessment in a different local authority.
Learning includes: consideration needs to be had of a national, uniformed, transfer information policy; and there is a need to develop professional curiosity.
Recommendations include: assure of a robust transfer of information policy to be used when a person presents safeguarding concerns from out of area, and when a person with safeguarding concerns moves to another area; assure the partnership around discharge processes and the flow of information from all maternity services; remind and encourage professionals to practice an open-minded awareness of the differences that cultural background can produce; and assure the partnership that professionals from all agencies know when and how to escalate any concerns.
Keywords: drowning, information sharing, professional curiosity, injuries, transient families, early intervention
> Read the overview report

2022 – Sandwell – Child LS

Death of a child in June 2018 due to significant non-accidental injuries. The stepfather was found guilty of the murder of Child LS, the mother was found guilty of causing/allowing their death, and both parents were found guilty of multiple counts of child cruelty.
Learning includes: that an early help intervention may have provided support to mother and her children, as there were indications that mother was struggling to cope; Child LS’s personal circumstances and developmental issues meant that there should not have been a gap in their nursery education; whether or not any professional intervention could have prevented the injuries to LS.
Recommendations include: review training provided to agencies regarding the thresholds for early help, and ensure that agencies are aware of their responsibilities to apply thresholds correctly; the local authority ensures that funded nursery provision is promoted and encouraged, particularly for families with vulnerable children; remind agencies of the need to include the voice of the child when recording information.
Keywords: child deaths, physical abuse, murder
> Read the overview report

2022 – Sandwell – Child RS

Serious and potentially life changing non-accidental injuries to a 4-month-old baby in June 2019. A police investigation and care proceedings were instigated.
Learning includes: bruising on non-mobile babies should always be treated seriously and advice immediately sought from the safeguarding lead; practitioners should guard against second guessing the response of the multi-agency safeguarding hub (MASH) to a referral of concern about a child; importance of early identification of vulnerability, assessment of risk and consideration of appropriate services; importance of gaining an understanding of who lives in a household and their role, not focusing solely on mothers but proactively engaging with fathers; information sharing alone does not safeguard children; be aware of the impact of professional desensitisation and cultural normalisation; importance of professional curiosity and respectful challenge; be aware that moving between areas, away from support systems, can increase a family's vulnerability.
Recommendations include: ensure that the learning from this review is disseminated widely and incorporated into updates, and the development of policies and procedures; ensure that the safe sleeping policy is shared with all relevant staff; ensure that guidance on bruising to non-mobile babies is widely disseminated and embedded in practice across all agencies.
Keywords: infants, bruises, physical abuse, professional curiosity, sleeping behaviour
> Read the overview report

2022 – Sandwell - Child RS

Serious injuries to an infant in June 2019. Child 2 was taken to hospital with multiple injuries believed to have been caused non-accidentally. There was a history of mental health issues, criminality and substance misuse in the family.
Learning includes: bruising to non-mobile babies should always be treated seriously and advice sought from a named nurse/safeguarding lead/MASH; safeguarding children and young people should be the priority for all agencies providing services to adults, with an embedded Think Family approach; the importance of practitioners engaging with fathers and not focussing solely on mothers; that practitioners should be aware that moving between areas can increase a family's vulnerability; the importance of the role of the GP and of early registration of a new baby with a GP practice; that key practitioners should have an understanding of the importance of safe sleeping; the value of multi-disciplinary meetings (MDTs) in GP practices where early concerns about the care and safety of children can be shared and a co-ordinated approach taken; the value of community health services using red flags/alerts in electronic medical records to indicate concerns regarding a child or family; and that severe staff shortages can create a 'start again approach', so that emerging patterns of concern are not identified.
Recommendations include: seek assurance from the local health forum that the safe sleeping policy for hospitals is shared with all relevant staff; and ensure that the West Midlands guidance in respect of bruising to non-mobile babies is disseminated and embedded in practice across agencies.
Keywords: infants, injuries, child health
> Read the overview report

2022 - Sandwell - Child SD

Serious injury resulting in a permanent disability to a 17-year-old male in 2022. No suspects were identified after a thorough police investigation. At the time SD was under a youth rehabilitation order for motoring offenses and had recently become a father.
Learning themes include: real-time information sharing; coordination of support among multiple agencies; the challenge of engaging with families involved in criminal activity; transitions between services as youth turn 18; and the role of education in early prevention by detecting reduced school attendance and behavioural changes.
Recommendations include: reinstating read-only access to children’s case files for adult social care; ensuring visibility of involvement and interventions across agencies through the Early Help system; clarifying the lead professional's role in co-ordinating support across multiple agencies; establishing a 'learning offer' to increase understanding of 'adultification'; provide briefings on the impact of exploitation; ensure that education practitioners are trained in the use of GCP2; and subgroups should work together to evaluate the effectiveness of information sharing for exploited young people, including their national referral mechanism status.
Keywords: adolescent boys, child criminal exploitation, early intervention, education, injuries, young offenders
> Read the overview report

2022 – Sandwell – Child VS

Death of an infant in 2020.
Learning includes: the need for a whole systems approach to safeguard unborn babies; where a child is subject to a child in need (CIN) plan due to neglect, and isolated incidents occur such as an injury, these should be managed with the same rigour as that for children not previously known to children’s services; history not always being drawn on to provide context for new assessments; all case discussion should include discussion about the legality of a child’s living arrangements; information sharing practice in CIN cases may not be robust; professionals were insufficiently curious, and they did not ask pertinent questions to better inform their plans.
Recommendations include: ensure frontline workers receive clear and consistent messaging on how to refer and work with pregnant women where there are concerns for unborn babies; professionals are encouraged to challenge and take an active role in progressing cases, escalating cases where insufficient progress has been made; agencies conduct holistic assessments inclusive of all individuals linked to the subject child; information is shared with all staff groups regarding how to recognise when a child is a looked after child versus a child living within a family arrangement; information sharing in cases where children are subject to a CIN plan is timely, recorded and shared.
Keywords: infant deaths, pregnancy
> Read the overview report

2022 – Sandwell – Child YS

Assault on a 7-month-old child by their father, resulting in life threatening injuries.
Learning includes: understand the impact of trauma and become more trauma-informed in practice; understand the way in which different faith communities perceive domestic abuse and the difficulty in speaking openly; the importance of professional curiosity and challenge; the importance of clear and factual record keeping and interagency cooperation; create a safe space for multi-agency reflection and supervision; the importance of cultural awareness and challenging assumptions recognising that different families from the same cultural or religious group may have different views and practices.
Recommendations include: ensure effective implementation of information sharing, 'think family' approach, using evidence-based tools, trauma informed practice, resolution and escalation policy; work with community groups to combat domestic violence; host training on effective safeguarding of Black, Asian and minoritised ethnic, cultural and faith groups.
Keywords: infants, physical abuse, family violence, ethnic groups, religion, trauma-informed practice
> Read the overview report

2022 – Sefton - Delilah

Death of a 12-week-old infant girl in October 2021 following co-sleeping with her mother and twin sibling. Delilah’s mother had consumed alcohol and cocaine the previous night and had experienced multiple incidents of domestic abuse.
Learning themes include: the effect of twin births on risks associated with co-sleeping; viewing substance use in the context of domestic abuse and depression; impact of alcohol use on parenting capacity; the presence of domestic abuse in current and past relationships; limitations in the child and family assessment; effectiveness of the child in need plan; understanding family composition and functioning, including older children living with family members in other local authority areas; and disguised compliance.
Recommendations include: remind partner agencies of the importance of an early referral for an assessment of risk to an unborn child; obtain assurance from partner agencies that consistent, unambiguous safe sleep advice is given to parents in respect of multiple births; develop a policy outlining action to be taken when parental consent to observe sleeping arrangements for new born children is declined; empower professionals with knowledge of alcohol risk identification; ensure the local Domestic Abuse Partnership Board address the training needs of non-specialist domestic abuse professionals, reflecting on the many ways domestic abuse may affect victims; ensure child and family assessments explore relevant issues in sufficient depth; ensure child in need plans are specific about what needs to happen and by when, and that plans are not ended prematurely; and commission a case study highlighting the challenges of professional engagement and the importance of exercising professional curiosity.
Keywords: sudden infant death, sleeping behaviour, substance misuse, family violence, parents with a mental health problem, professional curiosity
> Read the overview report

2022 – Southampton - Ted

Non-accidental injury to the leg of a 1-year-old boy who was identified with significant emerging health needs prior to the injury. He is developmentally delayed and was described as ‘non-mobile’.
Learning includes: the importance of knowing and understanding the impact of a parent’s vulnerabilities and history on their parenting; parental substance misuse, mental health, and prescribed pain medication; working with homeless families; exploring and understanding a disabled child’s likely and actual lived experience; considering absent parents, even when concerns have been shared about domestic abuse; considering what support is required to ensure a lone, non-birthing parent acquires ‘parental responsibility’; referring/ transferring a child in need plan across local authority borders; and the need to consider if the parent requires an assessment or support due to their own needs or as a care leaver.
Recommendations include: the partnership should request that agencies review their practice in respect of ensuring that the person caring for a child has parental responsibility and provide feedback on what recent progress has been made; the MASH to be asked to consider their expectations and processes regarding transfers from other local authorities in respect of children subject to a Child in Need plan; and the partnership to consider how it can promote the responsibilities of partner agencies to care leavers.
Keywords: children with disabilities, injuries, fathers, housing, substance misuse, adverse childhood experiences
> Read the overview report

2022 - South Ayrshire - Child B

Child protection concerns raised in September 2022 regarding the unhygienic and unsafe conditions in Child B’s home. Services were involved with Child B and their mother since 2016 due to concerns around Child B’s distressed behaviours, hygiene, welfare and secondary school attendance.
Learning points include: hearing the child’s voice to inform planning; the importance of meaningful actions and accountability within school attendance meetings; getting it right for every child (GIRFEC) processes; the importance of transitions and information sharing; continuation of supports and a whole family approach; practitioner knowledge of referral pathways and appropriate services; and the importance of relationship-based practice.
Recommendations include: local education services should review child missing in education (CME) guidance and create a training package for teachers, with a trauma-informed focus; the local council should consider actions from attendance meetings be recorded on the pupil’s pastoral notes on SEEMiS; when schools have concerns that a child is not in education, there should be timely information sharing and consideration of the child's lived experience, which includes the child being seen; local education services should review and update management guidance for transition from primary to secondary school; when identified risks don’t meet the threshold for child protection registration or referral to the children’s reporter, a ‘Team around the child’ discussion should consider the need for continued family support; and the ‘Team around the child’ should assist in supporting the ability to recognise when a child may be communicating via behaviours linked with trauma.
Keywords: child neglect, home environment, school attendance, voice of the child, child behaviour, secondary schools
> Read the overview report

2022 - South Ayrshire - Child P

Death of a 7-week-old boy in November 2017 following abusive head trauma. His father was convicted of his culpable homicide.
Learning themes explore: child health surveillance practice – relating to the examination of the baby and support for parents; short stay paediatric assessment unit standards; child protection training – relates to the assurance arrangements and coverage of training for particular groups of clinical staff; and effective multi-agency working around child deaths.
Recommendations include: need for audit of clinical standards to guide future training/supervision for child health surveillance; need for action to involve fathers by maternity and community child health services; instigation of programme of support for new parents of crying babies; discussion needed to consider amending online revalidation system to require GP refresher courses in child protection; learning needs analysis to clarify training coverage and guide future policy; need to ensure awareness/significance of multiple contacts with NHS by parents seeking help; and need to ensure Ministry of Defence understands importance of making veteran’s records available in terms of their experience in service and later possible mental health issues.
Keywords: crying, infant deaths, non-accidental head injuries, infant behaviour, fathers, hospitals
> Read the overview report

2022 - South East Wales - SEWSCB 2/2022

Suicide of 17-year-old girl in October 2021 while living in a supported accommodation.
Learnings is embedded in the recommendations.
Recommendations include: supported accommodation providers ensure there is a safeguarding training and development plan in place for all staff; the importance of acknowledging the age of the child when considering the presenting concerns, and the child’s lived experience; review internal recording tools to ensure the voice of the child is promoted and evidenced; ensure children are seen (and seen alone if appropriate) as part of an assessment; escalate concerns if parents refuse or challenge the need for a child to be seen (and seen alone if appropriate) and to record that decision; develop practice guidance on the lived experience of the child to assist practitioner insight, to ensure that the voice of the child is actively heard and to support effective action to safeguard children and young people; ensure that relevant staff are aware of the Southwark Judgement and how the key principles can be applied to assessments with homeless young people; review their assessment tools to ensure they are child focused, promote the voice of the child and record that the child has capacity to provide informed consent; ensure they have procedures in place to gather historical information from other areas where there has been known involvement with child or family and to have clear escalation policies in place if this information is not provided in a reasonable timescale; and have clear contingency plans in place for children and young people to ensure that they are seen face to face in the event of any future pandemics.
Keywords: suicide, homeless adolescents, adverse childhood experiences, child sexual exploitation, mental health
> Read the overview report

2022 - Staffordshire - J and K

Siblings J and K (aged 16-years-old and 12-years-old) reported missing in September 2021. The referrer expressed concerns about their safety, stating their father had taken the children from the UK and they might be entered into a forced marriage.
Learning includes: practitioners’ confidence and skills in recognising the warning signs for forced marriage and how to respond; understanding how Forced Marriage Protection Orders (FMPOs) should be used and which agency should take the lead in making an application; raising awareness of both the issue and the warning signs of forced marriage with young people in a school environment; raising awareness of the support that is available from the national Forced Marriage Unit; and ensuring widespread understanding of the ‘One Chance Rule’ - that practitioners may only have one chance to speak to a potential victim and therefore one chance to safeguard the child. Learning will be developed into formal recommendations.
Action taken includes: children’s social care to lead on FMPO applications related to children; training for the social care workforce to ensure all workers have an up-to-date understanding of the risks and indicators for forced marriage; a whole system transformation in the local authority to prevent multiple handovers; improved processes by police within the Force Control Centre to enhance safeguarding and ensure warning markers are accurate; education safeguarding leads to ensure warning signs of forced marriage are increased across education settings; and steps taken by the Intensive Prevention Service to disseminate national guidance on forced marriage and raise the profile of the Forced Marriage Unit.
Keywords: forced marriage, culture, siblings, abusive fathers, emergency protection orders
> Read the overview report

2022 – Stockport - Child A

Reported interfamilial sexual abuse of female Child A (9-years-old in 2017) by male sibling B (11-years-old in 2017) in May 2017 and April 2021. Family history includes domestic abuse perpetrated by the birth father against the birth mother, criminal activity, and the children living with their birth father and stepmother.
Learning includes: ensuring the voice of the child and understanding their experience is a focal point in education system record keeping; the importance of looking at family history within a social work assessment to avoid focusing on a single issue, and to include all adults with parental responsibility in the assessment; the need to risk assess parent safety plans to ensure sibling abuse does not re-occur; professionals understanding the complexity of the health information recording system; the impact of a criminal investigation on working with a family and delays to intervention; fully considering the role of the non-resident parent; practitioners acquiring the right skills to support young people who behave in a sexually harmful way so appropriate interventions take place; and making sure the knowledge, understanding and use of the processes and policy around sexually harmful behaviour are embedded in practice.
Recommendations include: makes no recommendations but documents system changes made since 2017.
Keywords: sibling abuse, harmful sexual behaviour, family violence, parental responsibility, assessment [social work], voice of the child
> Read the overview report

2022 – Stockport – Child F

Sexual assault of a 17-year-old girl in October 2020 by a male while missing from care. Child F has complex needs and required 2:1 staffing 24/7.
Learning includes: professional understanding of health pathways, what they mean and how to access them for children with complex needs; knowledge of processes and policy within various health systems to ensure greater co-ordination of the services working with children who are involved with several agencies; management of multiple and changing diagnoses in the context of what this means for the child and access to services or placement provision; the need to undertake risk assessments during placements when there are signs that a placement is not fulfilling its responsibilities; and professional understanding of the Dynamic Support Database (DSD) and the Care Education and Treatment Review (CETR) processes.
Formal recommendations are not included, but actions include: reviews to be undertaken of the transforming care hospital discharge and DSD information to ensure processes are working effectively for children with complex needs; children's social care to receive training in relation to the DSD, CETR and related processes for children with complex needs; challenges associated with commissioning specialist placements and availability of these will be raised with the National Panel; a universal information sharing system that would benefit agencies in ensuring robust information sharing will be shared with the National Panel; and arrangements will be reviewed to ensure that external placements will provide the best possible service for children with complex needs.
Keywords: runaway adolescents, children with multiple disabilities, placement breakdown, children in care, supervision orders
> Read the overview report

2022 – Suffolk – Andy and Arin

Joint serious case review following two cases of filicide and maternal suicides which occurred within a two-month period between March and April 2019.
Learning includes: professionals must consider the implications and risk for wider family members, especially children, when dealing with vulnerable people with mental ill-health; checks must be made by health professionals to establish if the patient or child are known to other agencies or teams in order to share relevant information; the use of information systems and good practice in sharing information must be part of any procedure and practice guidance within any health settings; practitioners should be proactive in sharing information as early as possible to help identify, assess and respond to risks or concerns about the safety and welfare of children; agencies must review their assessment processes to ensure they include mechanisms to support teenage fathers; health professionals need to be professionally curious as well as dealing with the clinical care of a patient; assessment process for health visitors and midwives must be reviewed to ensure they include professional curiosity around impact and cultural isolation; and health visitors need to consider the support needs of transient families, particularly when from communities who may be culturally isolated.
Recommendations include: review assessment processes to ensure they include consideration of the impact on individuals, the subject of the assessment, and to ensure they consider the support offered to young parents; and consider the effect of parental mental health or physical needs when planning service provision.
Keywords: filicide, information sharing, professional curiosity, social isolation, suicide
> Read the overview report

2022 – Suffolk – Child G

Injuries and hospitalisation of a 2-and-a-half-year-old boy in 2020. Child G was found to have a depressed skull fracture, resulting in a section 47 enquiry.
Learning is embedded in the recommendations.
Recommendations include: decisions stated in MASH outcomes as 'necessary' need to be actioned; MASH decisions which are not the outcome of strategy discussions and require adjustment to reflect local considerations and knowledge of the family must have a clear rationale recorded; workers and agencies who are key to the understanding and progress of a case should always be kept updated; the possibility of non-accidental injury should always be considered in the case of multiple injuries and bruises and when parents' explanations for these are inconsistent; professionals should always check the history, past referrals and the social worker/social work team to ensure all relevant and significant information is gathered; social care should routinely update all agencies involved in a case; all professionals involved in a case should ask questions and get clarity about the key adults in a child's life, and these questions should be standard practice for supervisors and managers to ask at supervision; all professionals should be guided to read the Child Safeguarding Practice Review Panel’s report 'The myth of invisible men' (2021); supervision in social care must always allow for reflection by the social worker.
Keywords: interagency cooperation, non-accidental head injuries, parenting capacity, supervision, unknown men
> Read the overview report

2022 – Suffolk – L, M and N

Thematic review based on the rapid reviews for three young infants who were born in Suffolk in 2021. Two infants died and one infant was injured whilst in the care of their parents.
Learning: N/A
Recommendations include: raise the profile of safer sleeping and associated risks across partner agencies including support to increase knowledge of this area for social workers; embed recognition that house moves and temporary living arrangements are seen as situational risks for babies which need proactive plans that recognise and addresses before babies are born; closer working together between social care and health services in pre-birth assessment and child in need processes; increase recognition of the importance of the health visitor's role; parents' own life experiences are explored in depth and understood; fathers are central and must be included whether they are living with the family or not; understanding and use of family network in pre-birth assessments, parents may highlight family as support; professionals need to explore and be respectfully challenging; supervision is used effectively to explore risk and hypothesis, ensuring that information has been verified or explored; pre-birth assessment to remain open until after the baby is born and there has been time for stress-testing of plans and support; hospital discharge planning meetings to be considered for child in need cases as part of the plan for younger parents, and parents with other vulnerabilities including where there are several addresses and uncertainties; recognition of the power imbalance between agencies and parents, relationship based case work that starts with this awareness is essential.
Keywords: sleeping behaviour, infant deaths, abused infants, home visiting, risk assessment
> Read the overview report

2022 – Suffolk – Young People F

The sexual abuse of an 11-year-old girl, and grooming of her 8-year-old sister, by their mother and her boyfriend over a 12 month period prior to April 2020.
Learning: N/A
Recommendations include: schools should consider how they monitor and review the concerns logged on their child protection online management system, there should be an automatic review built in when a certain number of concerns are logged within a specific period; safeguarding leads within schools should ensure that any referral to another agency is always followed up and that the nature of the response is recorded at the time; health services need to ensure that all transfers in families where children are at risk are accompanied by appropriate documentation, management review and a visit; when a concern is raised with health services by another agency, consideration should be given to a visit being undertaken by a health visitor rather than relying on what was seen at a visit some weeks or months earlier; children and young people services should ensure that at the point of referral, any extensive history is carefully considered within the multi-agency safeguarding hub as part of effective decision making on what action to take; and children and young people services should set any retracted compliance regarding a common assessment framework within the context of the family history and consider stepping up for a social work assessment rather than simply accepting that nothing can be done as parental co-operation is withdrawn.
Keywords: child sexual abuse, grooming, self harm, child abuse images, physical effects
> Read the overview report

2022 – Surrey – Child Acer

Death of a 5-month-old baby in January 2021. Acer was found unresponsive in a baby bouncer having suffered a cardiac arrest.
Learning themes include: assessing neglect and recognising its impact on outcomes for children; the importance of pre-birth assessments; 'start again syndrome' whereby family history was not sufficiently known or significant events in the children's lives were not considered holistically but as separate incidents; professional advice on safe sleeping; risk-factors identified in the out of routine report, which states that that the risk of SUDI should not be seen in isolation from other risks present in the home environment; the impact of the COVID-19 pandemic; and wider-systemic issues across the multi-agency system.
Recommendations include: continue to roll out the Neglect Tool/Graded Care Profile (GCP2) training programme to ensure that practitioners from partner agencies utilise it to recognise and assess neglect in children; practitioners must take account of known factors concerning the premature birth of twins when considering the timing of a pre-birth assessment, and this message requires constant reinforcement in learning and development; make sure that partner agencies use single/multi-agency chronologies to inform decision making concerning families where there is chronic neglect of children and complex family dynamics; and there should be continued development of a local multi-agency framework/protocol for practitioners working with families where infants are at risk because of unsafe sleeping arrangements.
Keywords: coronavirus, child neglect, assessment [social work], mental health, sleeping behaviour, sudden infant death
> Read the overview report

2022 – Sutton – Child X

Death of a 3-and-a-half-month-old girl in May 2021. Child X was in the care of foster parents when she was found unresponsive in an unsafe sleeping position.
Learning includes: joint working between midwives and social workers should be a core element of discharge planning for vulnerable new babies, even when they are going to foster carers; rigorous checks and assessments of foster carers taking on infants; gaps in supervision can occur when services use agency staff who might not have the appropriate knowledge and skills to undertake safe practice with vulnerable families; where there are concerns that a child has been harmed, there is a need for equivalent response when the child is in the care of foster carers as in the care of their birth parents.
Recommendations include: a campaign to raise awareness of safe sleeping arrangements for infants to include 'what if' questions; to seek assurance that independent fostering agencies comply with standard 10 of 'Fostering services national minimum standards' (2011), relating to suitable physical environments; to ensure managers and supervisors are aware of the importance of following up in supervision that safer sleeping arrangements have been checked by social workers and health professionals; all services ensure that their staff are aware of the neglect toolkit and bruising of non-mobile infants guidance.
Keywords: bruises, neglect identification, parents with a mental health problem, private foster care, sleeping behaviour, sudden infant death
> Read the overview report

2022 – Swindon – Babies with injuries

Reviews the assessment and safeguarding of infants prior to and following a non-accidental injury, focusing on three infants aged 7, 9 and 11-weeks-old.
Learning focuses on: the need to increase awareness of the unborn baby protocol; child protection processes and case management across perinatal mental health services; the response to anonymous referrals and the scope of the resulting health checks; the need to consider and involve fathers; improving the exercise of professional curiosity; the impact of COVID across agencies; use of targeted support in pregnancy in order to prevent escalation of concerns post-birth; improved awareness of the voice of the child; need for improved information sharing and recording; understanding that parents can be persuasive and that a parent may not be protecting their child; how caring for a new baby can lead to increases in parental mental health issues and domestic abuse; how professionals providing support to families with a new born baby need to be aware of fathers' mental health.
Recommendations include: ensure the attendance of the appropriate health professionals at strategy meetings, including when these take place out of hours; consider how to encourage and support all professionals to talk to each other and collaborate, so that that all information is known and considered; review systems and practice to ensure that fathers or male partners are equally considered by services.
Keywords: infants, physical abuse, injuries, pregnancy, fathers, men, voice of the child
> Read the overview report

2022 - Tameside - Ben and Alex

Harmful sexual behaviour and disclosure of rape by a female child in 2020, and neglect and non-accidental injuries to a young male child. Both Alex and Ben have been known to agencies since birth, with recurrent re-referrals for both children.
Learning includes: professionals' knowledge of strategy meetings and recognition of their positive effects upon case progression; professionals' understanding of how and when to complete the Graded Care Profile (GCP) effectively or when to seek the advice of a manager or supervisor; including the voice and lived experiences of young, non-verbal children in assessments; concerns regarding the success of the Signs of Safety model and its use in practice; some families consider child protection plans to be intrusive and not a source of support, this reduces their level of true engagement.
Recommendations include: ensure that the GCP training package is completed and evaluate whether professionals are understanding the tool and embedding it into their practice effectively; consult with general practitioners (GPs) to gain a better understanding of their roles and responsibilities, and to understand what can realistically be expected of GPs in terms of safeguarding; remind staff in partner agencies to fully explore the lived experience of a child and to include their findings in all records including assessments, alongside the voice of the child; consider developing a parent advocate scheme to support families coming to case conferences.
Keywords: harmful sexual behaviour, child sexual abuse, injuries
> Read the overview report

2022 – Tameside - Craig

Allegations of rape and sexual abuse of a boy in care by another child living at the children’s home in 2019.
Learning includes: the importance of having specially trained interviewers in police and social work services available to undertake forensic interviewing with a good enough understanding about helping children disclose information and being sufficiently well informed about current guidelines for interviewing; there was a belief that the risk assessment measures put in place in the care home were impenetrable which excluded the possibility of abuse taking place; a need for strategic leaders to create a context in which practitioners and front-line staff are better equipped and supported to make effective and timely responses to children in care with the most complex needs; a need to ensure that therapeutic reports and updated risk assessments are received and considered as part of on-going, overall risk assessment; and a need for professional curiosity about allegations being made and a need for a neutral and enquiring position to support further exploration of allegations.
Recommendations include: provider impact assessments should have clear mitigations in place for children who exhibit harmful behaviour and are a risk to other children; ensure reviews of looked after children include a full account of any therapeutic input and how it integrates with the care plan; and ensure information sharing protocols reflect the national information sharing protocol issued by the Government and take into account immediate risk and assessed risk either identified through reports or assessment processes.
Keywords: harmful sexual behaviour, residential child care, risk assessment, abuse allegations, disclosure
> Read the overview report

2022 – Tameside – Dominik

Non-accidental injury to an infant boy in 2019 including eye injury, cracked ribs, and a fractured leg.
Learning includes: a need to assess the impact of parental mental health on parenting capacity; a need to identify potential safeguarding concerns to a new-born baby following a family dispute; a need for information held on early help systems to be held on children's social care systems; a need for a pre-birth assessment by children's social care which could have informed part of the court proceedings; and a need to ensure GDPR guidelines are correctly applied by children's social care.
Recommendations include: information sharing policy, between the multi-agency safeguarding hub (MASH) and partners, should not allow GDPR to act as a barrier to sharing information when there are safeguarding concerns; the quality of recording and decision making based on effective triage in the MASH needs to continue to be improved and monitored for consistency so that information, risks and vulnerabilities can be connected; the sharing of information between early help and children social care systems needs to be strengthened so that there is a stronger interface between them; there needs to be assurance, from children's services and midwifery, that the threshold for initiating the pre-birth protocol is being applied appropriately; and any agency that identifies that parental mental health needs are impacting on parenting capacity needs to share that with other partner agencies working with the family so that information can be triangulated and an appropriate response agreed.
Keywords: injuries, infants, mental health problems, record keeping, grandparents, pregnancy
> Read the overview report

2022 - Tameside - Ellie

Death of a girl in 2021. Ellie's brother, a young adult, was found guilty of manslaughter.
Learning focuses on: the assessment of children and young people as young carers; procedures to address domestic abuse in families where a child is a perpetrator of abuse; how capacity to parent a child is assessed when mental ill health has been identified in a parent; how the impact of parental mental ill health on a child is assessed; recognition and response to vulnerability in an adult who has parenting capacity; availability of help and support for a person who has a diagnosis of autism.
Recommendations include: adult and children's multi-agency services should address transitional care between adult and children's services; children's social care to provide evidence of robust procedures when closings cases, ensuring there is clear identification of the services continuing to support the child and family; social work assessments should include an effective consideration of history and parenting capacity that informs thorough analysis of risk; commissioners should provide assurance on improving waiting lists for neurodevelopmental pathways timescales, so that children don’t wait too long for support and diagnosis; review the availability of services and support for families who are waiting for an autism spectrum disorder (ASD) diagnosis and post diagnostic support; the safeguarding children partnership to seek assurance on the effectiveness of interventions available for children with complex and challenging behaviours.
Keywords: child deaths, sibling abuse, autism, children as carers
> Read the overview report

2022 – Thurrock - Serious Youth Violence

Local learning review conducted following a serious incident of youth violence.
Learning includes: agencies would like clearly defined thresholds in relation to contextual safeguarding; agencies do not always feel confident on what information they should be sharing, with who, and how to escalate concerns of poor information sharing; it is difficult to evidence change where there appears to be positive engagement and possible disguised compliance; the benefits of extensive mapping, including the collection of data on gang related violence, hotspots, presentations at local hospitals, and local police intelligence data; the value of child criminal exploitation leads in agencies including children's social care.
Recommendations include: the completion of a review into information sharing between local police, children's social care and youth offending services; ensure information relating to the transfer of care of vulnerable children and their families from 'out of area' is shared with relevant local health agencies; information about hospital attendances by young people related to serious youth violence, especially in hospitals outside the young person's local area, is shared with relevant agencies; ensure the inclusion of health representatives in multi-agency forums related to children who are at high risk of youth violence; develop a clear threshold and pathways document on contextual safeguarding; consider the development of a transitional safeguarding approach with the Safeguarding Adult Board.
Keywords: adolescents, violence, contextual safeguarding
> Read the overview report

2022 – Torbay – C92 and C93

Stabbing of a boy by his mother in December 2021 when she suffered from an acute and transient psychotic episode.
Learning includes: the importance that professionals working with children have the skills and knowledge to identify parental alcohol misuse and neglect and intervene for children who are not able to voice their experiences; there tends to be an over optimism about parent’s self-reporting and that quite often substance misuse is known about but not seen as excessive; in instances where an individual smells of alcohol but there is no evidence of intoxication this may reflect that they have a tolerance for alcohol at harmful or dependent levels.
Recommendations include: assurance that practitioners have sufficient training and development to enable professionals that work with children to understand the impact of parental alcohol misuse and recognise and respond to children exposed to parental alcohol misuse; assurance that local education settings have an effective policy and systems in place to ensure that information is available to inform decision making by the MASH during school holidays; and ensure that children are put on school roll immediately that a place is accepted and that this is not a systemic problem in their area.
Keywords: alcohol misuse, child neglect, children missing education, professional curiosity, referral procedures
> Read the overview report

2022 - Tower Hamlets - Julie

Head injuries to an infant girl, on two separate occasions due to falling off a bed, both of which required hospitalisation.
Learnings is embedded in the recommendations.
Recommendations include: promote learning as a public health message about the importance of avoiding co-sleeping and unsafe sleeping arrangements; explore if translated versions can be made available for online pre-birth packs; neglect tool kit to be promoted within multi agency forums and used as a tool where all agencies involved contribute; review practices to capture the voice of the infant; support for practitioners regarding professional curiosity, such as tool kit, bitesize videos or training; review how to support practitioners around the non-engagement of parents and carers to ensure cases are appropriately stepped down; review how to strengthen continuity of care when vulnerable families move to other parts of the borough; review if GP deregistration should be discussed at a multi-disciplinary team meeting for vulnerable families; review what percentage of MASH referrals are received from GPs; review the effect of the pandemic on multi-agency practice and families; investigate how agencies ensure interpretation services are used, and how the level of need of interpretation is addressed and recorded and ensure the interpretation services are easily accessed by practitioners; communications/awareness raising to be sent out to practitioners on consistent use of interpretation and cultural competence; ensure there is a multi-agency agreement and approach to a Think Family/ Think Community strategy, and this is replicated in practice; and ensure there is a trauma-informed model of support across all safeguarding agencies.
Keywords: child neglect, head injuries, health visitors, home environment, infants
> Read the overview report

2022 – Trafford - Michael

Death of a 17-year-old boy by suicide in July 2021. A social work assessment had identified concerns around neglect, mental health and Michael’s education. Michael had a history of contact with agencies including child and adolescent mental health services (CAMHS) and the police.
Learning focuses on: response to long-term neglect and specifically neglect in adolescence; information sharing; disguised compliance and non-engagement; application of the ‘Think Family’ approach; effectiveness of interventions; safeguarding young people perpetrating crimes; lived experience of the child; and the impacts of COVID-19.
Recommendations include: re-launch the ‘neglect strategy’ and ensure specific reference to adolescent neglect continues to be an area of focus; improvements to multi-agency involvement in the development and delivery of education, health and care plans (EHCPs); seek assurance that cases below the child protection or child in need level of need facilitate good multi-agency planning and working and lead to targeted interventions, and that ‘Think Family’ and the Graded Care Profile are embedded in practice; seek assurance from commissioners that mental health support for children includes arrangements for joint working and shared records; seek assurance from children’s social care that there is careful consideration of cases where there are repeated referrals; and that health practitioners are reminded of the importance of guidelines which require a review to be undertaken where there is a pattern of repeat prescription requests, and that safe storage is understood by the patient.
Keywords: child deaths, suicide, adolescent boys, child mental health, child neglect
> Read the overview report

2022 – Trafford - Teddy, Wilbur and Peter

Suicide of a 17-year-old and attempted suicides of a 16-year-old and 17-year-old, all cases occurred separately, in England.
Learning includes: a need for local authorities to find suitable alternative placements and health and social care to commission appropriate placements for 16 and 17-year-olds; the impact of chronic underfunding of mental health services nationally on young people’s timely access to appropriate mental health services; the need to consider each individual in the context of their age, maturity and mental capacity at each contact; a need for professionals to maintain high levels of engagement and support throughout a young person’s admission into hospital; a need for resources to support 16-17-year-olds who do not meet the threshold to be detained under the Mental Health Act, but are deemed to require a level of care that cannot be fully met within the home or by community services; and a need for triggers for harmful behaviours to be sufficiently considered when formulating plans of care.
Recommendations include: ensure appropriate services are being commissioned that can meet the needs of young people aged 16-17-years-old within the community; ensure that there is a clear record of parental responsibility that is amended if a child is placed on an interim/full care order or adopted; review discharge planning processes and ensure a multi-agency response to discharge planning that commences on admission; and strengthen trauma informed practice and safety plan intervention.
Keywords: suicide, child mental health, adolescents, transgender, LGBTQ, child mental health services
> Read the overview report

2022 - Wandsworth - Alsami

Death of a 14-year-old boy by suicide in June 2021.
Learning includes: the importance of taking time and assertive commitment to understand the lived experience of a child; ensure that professionals are proactive in understanding and working with the religious, cultural background of children they are in contact with; the impact of adverse childhood experiences (ACEs) and childhood trauma on children whether they verbalise their concerns or not; take particular care and attention towards 'sensitive and quiet' children in a large family group, ensuring that their views, worries, concerns and lived experience are sought and assertively included in plans and any work with them; purposeful parental engagement which takes account of the parental vulnerabilities, ACEs, and childhood trauma on their parenting; have an informed view about the impact of sexual abuse on all children in the family and in particular male children where the perpetrator is a male and the victims are female children; take account of research into the impact on male self-image, masculinity, and self-esteem of male abuse in families; recognition of the impact of contextual safeguarding to adolescents, especially young men who may be subject of exploitation and fear in communities.
Keywords: suicide, adolescent boys, adverse childhood experiences
> Read the overview report

2022 – Wandsworth - Alvah

Presentation of a 3-month-old boy at a hospital in August 2020. Alvah was brought to the hospital by his mother, due to swelling in his left leg. Examination revealed facial bruising and fractures to the tibia and foot. Professionals concluded that the injuries were possibly caused by non-accidental injury. Alvah, and his 20-month-old brother Rafa, were immediately subject to child protection procedures and placed in foster care.
Learning includes: safeguarding professionals struggle to hold babies in mind when identifying vulnerabilities and risks, particularly those who are non-mobile and too young to speak for themselves; there is no standardised approach to information sharing between urgent care and primary/community services, and to primary care triage of the information as it comes in; and the history of the family can be lost when situations change, particularly when a family is mobile between boroughs.
Recommendations include: seek assurance that practitioners know what to do in response to a pre-mobile baby with injuries; primary and urgent health care processes for identifying children who may have been abused; is there the need for a standardised liaison process from hospitals to GP and HV services?; is there is a robust process for triaging information coming into GP practices that will identify and flag injuries in non-mobiles babies?; do health information systems and processes support robust information sharing when vulnerability is identified in pregnancy, and settings or situations change?; and the impact and implication for new ways of working implemented during the Covid-19 pandemic.
Keywords: accident and emergency departments, infants, injuries, maternal health services, parents with a mental health problem, transient families
> Read the overview report

2022 – Wandsworth - ‘Rachel, Andy and Dean’

Removal of three children, Rachel (7), Andy (10), and Dean (3), from their mother’s care in April 2020, following concerns that they were at risk of sexual abuse. At the time of their removal the children had suffered significant neglect.
Learning includes: despite professional concerns, there was limited understanding of the children’s day-to-day lived experiences, and an apparent lack of curiosity from professionals to understand what the children’s presentation and behaviour may be communicating; professionals in universal services commonly do not know how they should engage with either the parents/carers or the children when concerns arise; the emotional harm of mixed heritage children is often unaddressed because of an unconscious bias of professionals that limits recognition of racist treatment of mixed-heritage children by family members; and there is no consistent training to enable professionals to recognise and address the impact of unresolved multi-generational trauma on parents and children.
Considerations for the partnership include: ensure that practice across the children’s workforce identifies multi-generational child abuse and neglect; ensure first line management provide supervision, supporting and encouraging curiosity by asking the right questions which seek to identify historical concerns; ensure professionals are confident in having respectful, robust conversation with families, colleagues, and partners when they are concerned about neglect and abuse and discover what prevents them from talking directly to a child or parents; ensure that safeguarding practice proactively identifies, assesses, challenges, and responds to racism within the family in the context of harm and abuse; set priorities around anti-discriminatory practice; and embed a trauma informed approach across the system.
Keywords: child neglect, child sexual abuse, intergenerational transmission of abuse, racism, mixed ethnic group, professional curiosity
> Read the overview report

2022 – Warwickshire - Grace

Significant and intentional overdose in January 2021 by a 13-year-old girl.
Learnings include: in order to understand what a child might be communicating by their behaviour, professionals need to build a relationship with a child; ensure that they consider the cumulative impact of neglect and emotional harm on children who are struggling with their own mental health when assessing and deciding on the need for support or a plan; and the COVID-19 pandemic has had an impact on families and on the ability of professionals to respond to children and families requiring support.
Recommendations include: assurance that the waiting times for autistic spectrum disorder (ASD) assessments are addressed; all relevant partner agencies to be asked to provide evidence regarding how they are ensuring that the siblings of children with complex issues receive an assessment and early help/preventative support, and that assessments and plans give due consideration to all the children who spend time in a family home; assurance from the Integrated Care Board that GPs are briefed and trained to think beyond pregnancy prevention including considering the risk of abuse when prescribing contraception to children; consider the cumulative impact of neglect and emotional harm on older children when reviewing and launching their revised neglect strategy, using this case as an example; and review the current systems and practice regarding seeking consent for information sharing, including about parental health, considering what further support is required to ensure that information is appropriately sought, provided, considered, and recorded.
Keywords: suicide, drug misuse, autism, bereavement, adverse childhood experiences
> Read the overview report

2022 - West Glamorgan - A

In April 2019, a 14-year-old girl went missing for five days from her foster home. She was found by police in a caravan in during which time she reported that she had been subject of both sexual and criminal exploitation. She was known to the local authority children’s services team since 2006.
Learning is embedded in the recommendations.
Recommendations include: all agencies are reminded to be child centred in their approach which includes the use of language to accurately reflect the voice of the child; all agencies are reminded of the benefit from formalising the frequency in which it undertakes holistic assessments; the profile of child information form (CIF) to be raised across the partnership to ensure practitioners, partners, children, carers and parents are clear as to the part they play in the completion of the CIF; consider adopting an approach to serve as the cornerstone of all practice – a common language - such as, trauma-informed practice; review the current arrangements for interviewing child witnesses in partnership with social services and agree best practice and compliance for interviewing children; consider extending the current use of the Child Witness Booklets to Strategy Discussions, Strategy Meetings and Section 47 Enquiries; consider children and adults within their practice in relation to proactive information sharing; send out a reminder of practice across the partnership in respect of Section 5 of the Wales Safeguarding Procedures (2019); and develop and publish guidelines for practitioners and partners on how to work the technological era and the impact social media has on safeguarding children and young people.
Keywords: child criminal exploitation, child sexual exploitation, children in care, placements, voice of the child
> Read the overview report

2022 – West Glamorgan – S58

Death of a three-year-old during the autumn of 2019. It was established that Child D had died of natural causes relating to their complex underlying health needs. There had been historic concerns around the four siblings and in Summer 2019 the children were placed on the child protection register under the category of neglect.
Learning includes: the optimistic view of some professionals appeared to allow disguised compliance by the parents; parents used complaints and conflict to achieve changes in services they received; the importance of hearing the voice of the child; professional ability to analyse information from differing perspectives; and understanding multi agency working and the benefits of sharing information.
Recommendations include: the need to be aware of disguised compliance and have strategies and methods for working with families where this is a factor; support for practitioners in dealing with conflict and complaints from families that has potential to impact on the safeguarding of children; listening to children; and multi-agency working and sharing of information.
Keywords: child health, childhood illness, child neglect, siblings, disguised compliance, parent-professional relationships
> Read the overview report

2022 – West Lothian – Learning Review

Presents findings from two significant case reviews involving two children from different families between 2018-2021. Child C was removed from their mother’s care after attending hospital with a fractured skull. The details of Child D are not shared.
Learning includes: the interaction of child protection with adult services when parents experience mental health problems or learning difficulties; formal assessments of parents’ capacity balanced against the safety of the child; recognising adolescents as vulnerable from neglect or other harm, and not solely focussing on their presenting behaviour; male carers living in the family home; careful consideration of historical information; engaging with families and over optimism; multi-agency planning and the role of lead professional; and multiple referrals to screening groups or other services for support.
Recommendations: there are no formal recommendations. Provides reflections from a survey of 128 respondents (incorporating all agencies working with children and families) and three discussion groups to obtain views of how learning is embedded into practice.
Keywords: child neglect, family violence, parents with a mental health problem, parenting capacity, unknown men
> Read the overview report

2022 – Wigan - George

Multiple injuries including significant subcutaneous swelling to the head of a 23-month-old boy in March 2022. George was brought to nursery by his mother and shortly after his arrival staff noticed several bruises and abrasions to his face. George’s mother was arrested on suspicion of assault.
Learning themes include: supporting the transition to adulthood, especially for those approaching parenthood; considering the meaning behind missed appointments, late cancellations and rearranged appointments; the impact on young carers when their siblings are placed in care; ensuring the child’s voice and lived experience leads decision making; critical thinking, professional curiosity and over optimism; threshold application at point of closure of cases; unseen men and their relationships with vulnerable women / those with experience of abuse; development of practice approaches for those working with individuals who have experienced trauma.
Recommendations include: consider whether transitional planning is aligned with the Care Act 2014 and whether the correct trigger points are in place to start that planning (in order to help support adolescents who have multiple areas of vulnerability as they transition into receiving an adult service offer); review the data infrastructure cross-agency to identify whether improvements can be made within current systems, for example, automatic chronological entry to be implemented, a possible positive outcome being the ability for practitioners to see real-time updates across agencies outside of set review timings.
Keywords: abused boys, bruises, child abuse, child neglect, cycle of abuse, transition to adulthood
> Read the overview report

2022 – Wiltshire - Baby Eva

Death of a 3-month-old baby girl in 2021 from injuries that suggest she had been shaken.
Learning is embedded in the recommendations.
Recommendations include: explore work to engage fathers in ante and post-natal care and look at ways of embedding and mainstreaming the improvements; services for young people should include awareness raising about the harmful effects of street cannabis, with an especial focus on those entering parenthood; services for adults should be constructed such that a greater focus is placed on those service users who are parents and, within that group, an even sharper focus on those who are parents of babies; ensure that there is a clear message driven that the real or suspected presence of cannabis in a family home where children are present should be regarded as a potential risk factor; commission training for front-line staff aimed particularly at exploring the impacts and effects of cannabis use; produce either practice guidance and/or an assessment template to help guide front-line staff in assessing the impact of cannabis use; review of arrangements between the police and MASH about the reviewing and sharing of untested intelligence reports; police should share information with acute hospitals in relation to substance misuse and mental health issues; and ensure a similar response to women and men who might be parents and are taken into custody.
Keywords: infant deaths, drug misuse, home visiting, information sharing, mental health services
> Read the overview report

2022 – Wiltshire – the long-term sexual abuse of children in care

Long-term sexual abuse of three siblings in foster care. The abuse was perpetrated by the male foster parent.
Learning includes: professionals should not assume that when a child has had therapeutic interventions this will be protective in the longer term; as children with disabilities are more vulnerable to sexual abuse, professionals need to ensure that this is considered when their behaviour is being assessed; professionals need knowledge and confidence about adult behaviours that might indicate a sexual risk to children; professionals need to be able to consider the 'unthinkable' about carers they may know well and be alert to the possibility of sexual abuse; when professionals predominantly work with one carer, they need to ensure that equal professional scrutiny applies to the second carer; opportunities should always be taken by trusted professionals to have age and ability appropriate discussions about sexual abuse with children in care; schools are key in providing an environment where children know who they can talk to about sexual abuse and what will happen if they tell someone; children in care in long term placements need significant relationships with professionals and/or their carers if they are to disclose sexual abuse.
Recommendations include: ensure professionals are thinking and talking about the risk of sexual abuse of children in care; learning from the review is shared with the local corporate parenting panel; training foster carers about intra-familial sexual abuse; and assurance of the local plan to include direct information from respite carers in child in care reviews.
Keywords: child sexual abuse, foster care, children with learning difficulties, siblings, abusive men
> Read the overview report

2022 – Wirral – Emily and Lily

Sexual abuse of two sisters by their grandmother and her partner which came to light in January 2021.
Learning includes: over-optimism in family carers with an over reliance on self-reports and a lack of true understanding on the lived experience of the child in visits and assessments; the lack of a detailed re-assessment rather relying on copying forward a lot of the information already there; impact of covid on contacts and lack of school attendance meaning less visibility at a particularly vulnerable time; and dismissal of concerns raised by other family members as being malicious.
Recommendations include: support the implementation of systemic practice, training and guidance about the importance of professional curiosity, especially to help with understanding the strength or weaknesses and dynamics of family and wider support networks; review findings from audits and recent reviews to identify the impact of lockdowns and reduced face-to-face contact with families, and to use the findings to inform future strategy; children's social care to review its assessment process for connected carers to assure that decisions are appropriately informed by up to date assessments; and review guidance and training about gathering the daily lived experience of children and adults and to update in light of the introduction of systemic practice.
Keywords: child sexual abuse, adverse childhood experiences, foster care, sex offenders, sign language
> Read the overview report

2022 – Wirral - Taylor Children

Concerns the welfare of three siblings aged 3, 5 and 7-years-old whilst living with their mother and her new partner in the family home. In December 2021, multiple bruises were found on two of the children following an anonymous referral reporting that the 5-year-old boy was being physically and verbally abused by the mother’s new partner.
Learning themes include: introducing a new partner to the family; professional curiosity and disguised compliance; the impact of adverse childhood experiences (ACEs); and the impact of COVID-19.
Recommendations for the partnership include: to undertake a wider review of the impact of COVID-19 on safeguarding families; for learning from this rapid review to be shared with partner agencies; to ensure that there continues to be a focus on understanding the daily lived experiences of children in its review of the local model for working with children, young people and families; to ensure guidance and training about professional curiosity, and responses to new partners are available to all professionals; and to continue to support ongoing work locally to raise awareness and response to ACEs.
Keywords: physical abuse, unknown men, professional curiosity, adverse childhood experiences, coronavirus, siblings
> Read the overview report

2022 – Wokingham – Aisha and Ciara

Sexual abuse of two siblings under 6-years-old by an acquaintance of their mother. Both children were also subject to neglect by their mother.
Learning includes: the importance of understanding the circumstances of parents or family members who are identified as having unmet and unassessed learning needs or learning difficulties; the need for a structured approach to identify and address child neglect; ensuring professionals are equipped when working in the area of child sexual abuse and improved awareness of the importance of clarity regarding risk; professionals balance intuitive reasoning with analytical reasoning; and a need for discussion in a multi-agency context about how to facilitate communication with a child and ensure their needs and voice are brought into focus, considering issues of disability, age and language.
Recommendations include: build a stronger, structured approach to neglect; and remind practitioners that verbal or written communication is adapted to ensure accessibility during contact with families where there are potential learning needs.
Keywords: child sexual abuse, child neglect, family conflict, professional curiosity, children’s services, language development
> Read the overview report

2022 – Wokingham - Young Person Harry

Arrest and conviction of a 13-year-old boy for a serious violent crime.
Learning includes: children and young people with special educational needs and disabilities (SEND) need to be understood, and local capacity improved, so that these specialist needs can be met; the quality of information sharing when a child or young person with an education health and care plan (EHCP) changes schools is crucial; new pathways are required for young people with complex needs if exclusions from school are to be reduced; there is a need to develop a culture of safeguarding within front line staff to improve the service offered to young people by Thames Valley Police.
Recommendations include: develop new procedures for the early review of EHCPs when a child or young person moves local authority area at the same time as transitioning from primary to secondary school; develop new information sharing procedures when students with an EHCP change schools, including professional meetings attended by the relevant schools, the agencies working with the young person, and the parents/ guardians; Thames Valley Police should produce new policy and guidance in relation to children and young people who are identified as suspects in a criminal investigation and develop a culture of safeguarding and partnership working, with training delivered to all police officers and police community support officers; update policy and guidance for the review of referrals and contacts that involve children and young people with SEND.
Keywords: children with a learning disability, county lines, criminal child exploitation, exclusion from school, police
> Read the overview report

2022 – Wolverhampton – Child R

Suspected non-accidental head injury to an 8-day-old baby. At the time of Child R’s birth all of the children in the household were the subject of child protection plans.
Learning themes include: knowing and considering the parent’s history and vulnerabilities when working with a family; understanding a child’s lived experience and what they may be communicating by their behaviour; the likelihood of child neglect coexisting with other forms of abuse; the impact of ‘growing families and growing children’ on the ability of parents’ to cope; the cumulative impact of long-term neglect; awareness among professionals of control and coercion and non-violent domestic abuse; need for professionals involved with adults to be aware of plans for the children in the household; the effect of COVID-19 on families and services received; considering making older siblings aware of safe handling and careful behaviour around a new born baby; child protection procedures regarding parental contact following an injury.
Recommendations include: ensuring improvement actions are taken, including seeking assurance that the learning from this review is considered by those responsible for ICON training, and that ICON recognises the need for bespoke plans about safe handling for parents with learning difficulties and where there are older children in the family; ensure that services are aware of the need to follow child protection procedures when a non-mobile child has injuries; and ensuring that when children are the subject of a plan, this is recorded on the GP record of any adults in the household.
Keywords: abusive men, family violence, neglected children, non-accidental head injuries, parenting capacity, siblings
> Read the overview report

2022 – Worcestershire – Baby D

Death of a 6-week-old boy in October 2020 who was found unconscious and unresponsive by his father in the early hours of the morning. Reports identified fractures to his posterior ribs that were believed to have occurred 5-10 days before the baby’s death and were unexplained.
Learning includes: where new information becomes available that gives rise to safeguarding concerns, such information should be shared with all appropriate agencies in a timely manner to ensure any other children or individuals are safeguarded; a need for early consideration of the circumstances of a case to understand if abuse or neglect is suspected or whether significant concerns arise regarding potential child protection issues; and if information is received during an investigation which raises a new or additional safeguarding concern, a clear decision should be made whether this will be managed within the sudden unexpected death in childhood (SUDIC) process or whether this requires referral or strategy discussion.
Recommendations include: all appropriate agencies are being invited to, attending and contributing to information sharing meetings; where abuse and/or neglect is suspected within a SUDIC joint agency response, then a decision must be made and recorded, using the levels of need guidance, as to whether there are specific risks for other children; and the partnership should seek assurance that the local and regional multi-agency procedures provide sufficient guidance on dealing with risks to children who have moved with their parents to another country.
Keywords: sudden infant death, transient families, risk management, referral procedures, police, hospitals
> Read the overview report

Case reviews published in 2021

A list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2021. To find all published case reviews search the national collection.

Case reviews describe babies', children's and young people's experiences of abuse and neglect. If you have any concerns about children or need support, please contact the NSPCC Helpline on 0808 800 5000 or emailing help@nspcc.org.uk.

2021 – Anonymous – Anonymous Family

Chronic neglect, physical and sexual abuse of eight siblings and three older half siblings perpetrated by their parents and one sibling. Both parents and the eldest child of their relationship were convicted and sentenced for sexual offences and neglect.
Learning includes: the impact of securing evidence in criminal proceedings and safeguarding children; mothers as sexual abusers of their children and the impact of disguised compliance by parents; the level of knowledge, skills and training available to practitioners on child sexual abuse within the family; the continuing need for escalation and professional challenge by practitioners; the historical and current issues around the retention of records; the central role of the Independent Reviewing Officer (IRO) needs to be recognised when there are a number of children within a family in different placements; and children “not brought” to medical appointments.
Recommendations provided around the following themes: child sexual abuse investigation processes and management oversight; professional escalation and challenge; training and professional development for frontline practitioners; and information sharing.
Keywords: child neglect, child sexual abuse, physical abuse, non-attendance, disguised compliance
> Read the overview report

2021 – Anonymous – Anonymous victims of FC1

Sexual abuse of several children by their foster carer between 2007 and 2019. The foster carer and his wife were registered with a private fostering agency and had fostered 40 children from five different local authorities between 2007 and 2020, usually as mother and baby placements.
Learning includes: while there were no obvious physical injuries to the young children victimised by the foster carer there will be potential long-term impacts on their health and wellbeing; training about the “invisible male” should also be used to consider situations where foster carers and other professionals are providing care and support in their own homes; the identification of child sexual abuse in particular with regard to children who are pre-language or have significant language or communication difficulties.
Makes no recommendations but sets out actions including: regional event to be developed to share learning on: understanding and avoiding the impact of professional bias; ensuring neither foster carer is an “invisible party”; understanding perpetrator profiles; and sexual abuse of babies and pre-verbal infants.
Model: Rapid review.
Keywords: child sexual abuse, foster care, infants, child abuse identification, unknown men
> Read the overview report

2021 – Anonymous – Baby D

Injuries to a 4-month-old baby boy in 2019 inflicted by his mother who was mentally unwell.
Learning includes: inconsistent understanding regarding statutory guidance in the child protection procedures about undertaking pre-birth assessments related to mental health risk factors; coordinated work, robust information sharing and effective strategic oversight will better ensure all children are safeguarded; children are best protected when the local system of management oversight in supervision and meetings is strong, resulting in well-coordinated risk assessments, interventions, and planning; professional curiosity is best supported if there is a local culture of collaboration and professional challenge; confident and open practitioners work better with families if their professional views are challenged and practitioners at times struggle to communicate with some families; families do well when they have a good understanding of their rights and responsibilities and can make informed choices.
Recommendations include: ensure that all local multi-agency pre-birth risk assessment tools and protocols and information sharing comply with child protection procedures and local guidance, and that staff are aware of, and trained, in using these; seek assurance of the quality of individual agency supervision and management oversight; consider how empowering staff and supervisors in exhibiting professional curiosity can be encouraged in training and supervision, so that staff feel confident to have challenging conversations.
Keywords: physical abuse, mothers, parents with a mental health problem, mental illness, professional curiosity
> Read the overview report

2021 – Anonymous – Child E

Death of a 6-year-old girl in June 2019. Cause of death is unknown.
Learning: there was a need for more focus on the quality of Child E's lived experience and on her parents' refusal to consent to potentially lifesaving treatment; there was insufficient professional curiosity and response about understanding and investigating the children's experiences of living in overcrowded accommodation.
Recommendations: review the process and procedure for identifying risks and harm to children when parents or carers are not complying with medical advice; professionals need to establish whether fathers have parental responsibility for children; consider the options for improving the coordination of services and information sharing to address the needs of children with disabilities.
Keywords: child deaths, children with disabilities, medical care, parental responsibility, professional curiosity, voice of the child
> Read the overview report

2021 – Anonymous – Child P1

Injuries to a 6-week-old child in July 2017, including a fractured skull and injuries characteristic of a shaking injury.
Learning includes: there were specific areas in which awareness of honour based violence may not have sufficiently informed practice; limited use of psychological assessments to inform subsequent assessments and decision making raises the possibility that practitioners may not pay sufficient attention to historic reports when carrying out assessments; the rule of optimism appeared to be influential; the role of GP practices in safeguarding children was weakened by the father being registered at a different practice to the mother and their children, and the father's practice being unaware of his children and the prior safeguarding measures; identifies good practice including, effective multi-agency working and psychological assessments of the mother and father which proved to be insightful.
Recommendations include: guidance on how the honour based violence apparent in the early years covered by this case review should be responded to; consider whether court ordered reports should be shared during and after court proceedings; request partner agencies to include the extent to which practitioners make appropriate use of historic reports and assessments in the quality assurance of case files; ensure that professional challenge becomes an integral element of safeguarding practice; ensure that pre-birth assessments are carried out in accordance with the agreed multi-agency policy; seek assurance from health providers regarding decision making on the level of service provided to families where there are safeguarding children concerns.
Keywords: infants, shaking, culture, optimistic behaviour, violence, general practitioners
> Read the overview report

2021 – Anonymous – Child X1

Sexual abuse and sexual exploitation of a girl whilst she was looked after by the local authority. Child X1 was one of several victims and the evidence from the disclosures resulted in the successful convictions of the perpetrators.  
Learning includes: the completion of full family histories by professionals is not always given sufficient priority and that this has the potential to undermine the quality of risk assessments and associated planning for children who are looked after; a safe system in terms of placing children who cannot live with their parents will necessitate decision-making which has a clear understanding of children's needs; although resources are a challenge for all local partnerships, if these are balanced by a strong focus on the needs of a child this has the best likelihood of allowing and supporting a child to grow up with consistent carers, and helping them to reach their potential; an approach that is based on contextual safeguarding and includes proactive investigation and evidence gathering as a means of tackling child sexual exploitation is core; when children request contraception, good principles of critical thinking need to be applied to ensure that indicators of risk are clearly articulated and responded to within the multi-agency safety plan; good practice indicates that information sharing, risk assessment and transparency are key in planning for the young person within a multi-agency context.
Recommendations: makes no recommendations but poses several questions to the safeguarding partnership.
Keywords: child sexual abuse, child sexual exploitation, children in care, contraception
> Read the overview report

2021 – Anonymous – Family H

Sexual and physical abuse of siblings over a two-and-a-half-year period by their father.
Learning relates to: the home education of children and young people; identification of home educated children; ensuring a stable education; safeguarding home educated children; social, pastoral and leisure needs as the foundation of child development; and bereavement support.
Recommendations: raise awareness of the importance of the identification of elected home educated children and the need for them to be registered across all agencies; make a recommendation to the National Panel to complete a thematic review of serious case reviews, rapid reviews and child safeguarding practice reviews that relate to home educated children; consider the existing pathways to bereavement support for the children of terminally ill parents.
Keywords: child sexual abuse, physical abuse, siblings, abusive fathers, single parent families, bereavement
> Read the overview report

2021 – Anonymous – Hatty and Jen

Sexual abuse of two sisters aged 14-years-old and 13-years-old by their father over a period of six years. Both children were placed with a foster family, and a police investigation was initiated.
Learning focuses on: home education of children; working effectively to identify and address sexual abuse and exploitation; understanding adult sexual offending behaviour and evaluating the risks of likely and future harm; supporting children to seek help from professionals; children communicating that something is wrong through their behaviour; interviews with children which do not follow guidance are likely to undermine effective safeguarding, decision-making in the family courts and criminal processes; recognising and addressing the impact of domestic abuse; safeguarding children from being physically harmed, characterised as "physical chastisement or physical punishment"; delivering culturally competent practice; the importance of a structured approach to children's experience of parental neglect over time.
Recommendations include: make a recommendation to the National Panel to complete a thematic review of serious case reviews, rapid reviews and child safeguarding practice reviews that relate to home educated children; scrutinise how partner agencies are equipping their staff to understand and support children's help-seeking behaviour; issue a child-centred position statement about the appropriateness of physical chastisement and provide guidance about what safeguarding responses are required; understand and scrutinise how supervision arrangements promote professional curiosity, are child-centred, and address fixed thinking across partner agencies.
Keywords: child sexual abuse, home education, help-seeking behaviour, family violence
> Read the overview report

2021 – Anonymous – PS

Serious assault of a child in care by an adult in 2019, resulting in life-changing injuries. The perpetrator was the son of a member of the residential unit staff where PS lived.
Learning includes: it’s critical that families involved in Special Guardianship Order placements receive information, advice and training on adverse childhood experiences and the strategies they need to adopt to maintain the placement; agencies should have acted as responsible adults and asked for a previous assault of PS to be investigated; victims of crime often are fearful of retribution.
Recommendations include: ensure that the ‘voice of the child’ is routinely captured during assessments; ensure that measures used to determine suitability of residential settings for placing children are fit for purpose; ensure that newly-qualified social workers and practitioners working directly with children and families receive formal monthly supervision; staff working with children such as PS should be trained to spot and respond to early signs of exploitation, such as cash in hand work; staff and managers should know and be able to apply the principles of trauma-informed practice.
Keywords: children in care, child criminal exploitation, trauma-informed practice, adverse childhood experiences, violence
> Read the overview report

2021 – Bexley – Baby R

Death of a 4-week-old boy in July 2020 due to non-accidental head injuries.
Learning: the family should have continued to receive the right level of support when they were transferred to another local authority; disagreements between local authorities over the transfer and status of the family caused delays in the family receiving the appropriate level of service; housing services not being aware of the neurodiversity and safeguarding needs of the family; lack of communication between mental health services and children’s services; bruises or marks observed on a non-mobile baby should have triggered a robust multi-agency response.
Recommendations: current approaches to risk assessment through child protection enquiries or child in need processes should obtain and take into account family background and previous experiences such as trauma, neurodiversity, and parental mental health difficulties; strengthening education and training on the ‘think family’ approach, as well as neurodevelopment disorders and what such difficulties mean for parents’ understanding and interpretation of information and advice; raise the role of housing services in statutory child protection processes as an issue of concern with the Child Safeguarding Practice Review Panel; ensure that practitioners understand the significance of bruising in infants and the need to act.
Keywords: infant deaths, non-accidental head injuries, parenting capacity, developmental disorders
> Read the overview report

2021 – Bexley – Child O

Serious and potentially life-threatening incident to a 4-year-old boy in July 2019. Child O was taken to hospital after accidentally swallowing Gamma-ButryoLactone (GBL), a Class C drug commonly known as ‘liquid ecstasy’, he found in his mother’s handbag.
Learning looks at: the support offered to the family under the Special Guardianship Order (SGO) and the quality of the support plan; robustness of the communication between local authorities (LAs) including how safeguarding referrals were raised; adult mental health; domestic abuse and Multi-Agency Risk Assessment Conference (MARAC) involvement; issues arising from management oversight and supervision information.
Recommendations include: review training programmes about the legislations, governing and meaning of different types of placements such as SGOs, Children Looked After (CLA) and adoptive placements that are open to LAs when considering the future of children who are unable to live with their birth parents; oversee a multi-agency review of current arrangements for children in need that are also subject to SGOs.
Keywords: accidents, drug misuse, kinship foster care, placement, special guardianship orders, child neglect
> Read the overview report

2021 – Birmingham – BSCB 2017-18/02

Death of a 21-month-old girl in November 2017 as a result of brain injuries following physical abuse by the partner of the child's special guardian. The perpetrator was found guilty of murder and sentenced to a minimum term of 20 years in prison.
Learning includes: the importance of a close family relationship for the child with the special guardian; the importance of wider family support for the arrangement; management of contact; the importance of understanding a special guardianship order (SGO) as at the adoption end of permanence.
Makes no recommendations but identifies learning points with actions: enough time should be given to assess the integration of a child placed within a family, the care of that child and the impact on all members of the family before a final SGO is made; organisations need to reflect on how the impact of a change of social worker and team in the middle of proceedings and planning can be mitigated to keep the needs of the child at the centre; there is an absence of guidance on what action to take when a child is presented with concerning bruising for frontline professionals; an absence of appropriate challenge and professional curiosity, particularly around apparently open reporting.
Keywords: physical abuse, bruises, special guardianship orders, professional curiosity
> Read the overview report

2021 – Birmingham – Child A

Death of an adolescent boy due to a fatal stabbing in January 2020.
Learning includes: professionals tackling child criminal exploitation need to know and understand the serious youth violence strategy, engage with families, have a comprehensive knowledge of the National Referral Mechanism and be alert to a 'reachable moment' for a child; professionals need to understand the impact of adverse childhood experiences on children and how to use a trauma informed approach; professionals need to understand what 'place' means to a child and how that influences their lives; preventing school exclusion is a good preventative move because being in education is a safe place for children to be; educate children as to the dangers of knives and being involved in gangs and serious youth violence because this can prevent future exploitation; consider using a 'think family' approach; health agencies have limited occasions to intervene and so should capitalise on them where possible; children who go missing should have a return home interview.
Recommendations are embedded in the learning.
> Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Ava, Lucas, Harper and Chloe

Chronic neglect of four siblings over several years. In 2019, two of the siblings aged 1.5-years-old and 2.5-years-old were reported to have been injected with heroin, which was confirmed by a child protection medical examination.
Learning focuses on the following themes: understanding the lived experiences of each child and impact of the parents’ and carers' behaviour and lifestyle; responding to neglect; processes around child protection, public law outline and placements; adult services' work with parents and incorporating a Think Family approach; multi-agency working and communication; and de-sensitisation and professional culture.
Recommendations include: examine the current position relating to neglect in the local area; ensure that public law outline (PLO) processes are being conducted in a timely way and any delays and risks are addressed immediately; ensure a partnership approach in supporting families involved in PLO proceedings and related matters; provide training to the multi-agency workforce on working with families significantly affected by substance misuse; promote the use of the resolving professional disagreements protocol and the role of the child protection conference chair as a point of reference for any professional who is concerned about the progress of a child protection plan; provide opportunities within training for professionals to focus on desensitisation and the impact this may have on the children and families receiving support.
Keywords: child neglect, substance misuse, poverty, voice of the child
> Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Child CD

Death of a 13-month-old child in February 2019. Ambulance services were called but Child CD did not show signs of life and resuscitation was not attempted. The ambulance crew expressed concerns about the home environment and circumstances in which Child CD was found.
Learning includes: maternity services should provide assurance that routine domestic abuse enquiry is effective, and not a widespread issue; Early Help may be indicated when families move frequently; there should be a robust assessment of family needs when women with a significant history of mental health or emotional instability are pregnant and in the post-natal period so that they can be supported in caring for their baby and other children.
Recommendations include: safer sleep and the risks to mobile infants or toddlers should remain a focus of local multi-agency activity; a focused response and co-ordinated multi-agency working with adolescents with complex health and social needs on the edge of statutory intervention; assessing and working with young fathers who have or assume childcare responsibilities is crucial.
Keywords: child deaths, sleeping behaviour, housing, mental health, parental involvement, prescription drugs
> Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Child LO

Death of a 16-month-old child in December 2017. Child LO died due to an airway obstruction whilst sleeping unsupervised in an unsafe environment.
Learning includes: seeing where babies and young children sleep (day and night) can improve assessment of safe sleeping environments and provide an opportunity for professional advice; local authorities should be aware of local holiday parks and ensure that the winter rules are adhered to; professionals need to be curious about why a mother and child is living in a holiday caravan and provide relevant advice and support to address any accommodation issues; the courts should share safeguarding concerns with front line staff; the midwifery electronic record and health visitor child health record should include full details of previous children by a mother or father, and new family members; parents are more likely to disclose their vulnerabilities if they know and trust the professional involved; multi-agency safeguarding hubs should share concerns with health professionals; better links between health visiting and nursery provision would promote better assessment and support through early help; recognising and addressing domestic abuse early has a beneficial impact on children and family life.
Recommendations include: improved arrangements for: multi-agency working and information sharing, standards of domestic abuse processes, ensuring safe sleeping arrangements for babies and young children; reduce the risk of children and families living in holiday park accommodation during the cold winter months.
Keywords: child death, sleeping behaviour, housing, professional curiosity, health visitors
> Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Child LT

Injuries to a 3-month-old infant in June 2018 consistent with having been severely shaken and from impact with a hard surface. The father was arrested and made subject to a criminal investigation.
Learning focuses on: the extent to which practitioners considered the impact of the father's mental health issues on his parenting capacity; the mother's disclosure of domestic violence and abuse and the professional response to this; the effectiveness of interpreter services; the lived experiences of the children.
Recommendations include: ensure that risk assessments address the impact of parental mental ill health on children; promote awareness of the ways in which parental mental ill health can result in abuse or neglect of children and the key issues for practitioners to consider when assessing the risks to children; ensure that hospital staff fully explore a patient's presentation after suspected self-harm, make referrals for hospital mental health assessments and consider any safeguarding issues; promote the Think Family approach; consider advising the National Child Safeguarding Practice Review Panel of the interpretation challenges highlighted by this case; promote the need for practitioners to provide advice on coping with crying babies to parents for whom English is not their first language when using interpreters.
Keywords: infants, shaking, parents with a mental health problem, language, communication
> Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Holly

Death of an 8-month-old girl in 2016. Holly was found unconscious and not breathing in the family home and was pronounced dead at hospital.
Learning: includes: professionals should encourage parents to elaborate when conversations reveal stress factors that could affect their capacity to care for their children; family members being registered with different GP surgeries could be a weakness from a safeguarding perspective; pathways for support staff in managing the risk of not being able to see children at home would enable staff to persist in their follow-up with families where increased risk factors are identified; professionals ensure that vulnerabilities identified at an early stage in work with families reduce rather than increase over time; the safeguarding risk factors associated with babies and very young children.
Recommendations: ask agencies to provide evidence they have completed proposed actions and to summarise their impact.
Keywords: infant deaths, adolescent parents, teenage pregnancy, siblings, child health, non-attendance
> Read the overview report

2021 – Blackburn, Darwen, Blackpool and Lancashire – Mia

Death of an 8-month-old girl in July 2020 after becoming submerged in the bath whilst unsupervised by her parents. Mia was treated in a hospital intensive care until her death three weeks later.
Learning: considering the risks for a blended family of several households; identifying and responding to neglect; sex offenders spending time within a family home; whether COVID-19 restrictions affected the single or multi-agency response.
Recommendations: emphasise the importance of documenting how a child is presenting and the interaction between the child and parent or carer to better understand the child’s lived experience; the importance of understanding the lived experience of children in blended families, particularly when they are visiting or staying in different households within the blended family; ensure that situational risks such as house moves and temporary housing are highlighted in the local response to learning about sudden unexpected deaths in infancy; a robust process for information sharing between partner agencies when sex offenders are suspected of presenting a risk of sexual harm to children; work to support women who have been exploited by sex offenders should consider a range of scenarios in which women may become vulnerable to exploitation in the future.
Keywords: infant deaths, drowning, child neglect, step-families, siblings
> Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Ryan, Nathan and Amelia

Serious persistent neglect of three siblings over a number of years by their mother.
Learning: lack of access to the family home can prevent agencies from fully responding to child neglect.
Recommendations: resolve professional differences; child protection proceedings should not preclude pre-birth assessments; staff working with children with complex and additional needs should be trained and skilled; tools such as the Graded Care Profile 2 and local strategies and procedures should be followed; health, education and care plans should be robust; parenting assessments should be repeated or updated when necessary; consider filling gaps in service provision.
Keywords: child neglect, children with chronic conditions, inter-agency cooperation, children with disabilities, autism, depression
> Read the overview report

2021 – Bradford – child sexual exploitation: thematic review

Review of five children, three now adults, two of whom were abused during the 2000s. Considers the impact of learning from two other case reviews carried out locally in 2015 and 2016. Most of the children in the review experienced domestic abuse, physical abuse, emotional abuse and neglect for most of their lives.
Learning: the two audits of recent cases recognised that the Ofsted improvement activity resulted in more regular formalised supervision by children’s social care; the complexity of the cases and the scale of the challenges involved in the work, risks that the cases ‘run the worker’ rather than the other way around.
Recommendations: recognise that drugs and alcohol are used as part of the grooming coercion and control of victims by perpetrators and that responses need to be developed to reflect this; recognise the additional vulnerability of disabled children and respond appropriately; that the outcome for children (and their children) who become pregnant as a result of sexual exploitation or abuse is better understood and responded to.
Keywords: child sexual exploitation, pregnancy, family violence, emotional abuse, child neglect, children with learning difficulties
> Read the overview report

2021 – Bradford – Emily

Potentially life-threatening non-accidental head injuries to a 6-week-old girl in August 2019.
Learning includes: inconsistencies around attendance at meetings meant that there was never a clear, shared understanding of the children’s lived experiences; key people were missing from child in need meetings, child protection conferences and core group meetings; and possible indications of neglect were missed.
Recommendations include: child in need plans should clearly describe areas of concern, actions to be taken and measures of success; changes in the composition of a household where there is a child in need or child protection plan should lead to an updated social work assessment; schools should put arrangements in place so they can contribute to conferences and meetings during school holidays.
Keywords: child neglect, family violence, non-accidental head injuries, parenting capacity, physical abuse, siblings
> Read the overview report

2021 - Brent - Child K

Death of 16-year-old boy in 2019 in an attack which is believed to be connected with rival criminal groups.
Learning: is embedded in the recommendations.
Recommendations include: ask the Safeguarding Review Panel for guidance of serious youth violence incidents; review of practices on the provision of parenting support, where there is a perceived risk of involvement in youth offending; improve information sharing with schools and colleges in relation to children who are at risk as a result of serious youth violence or child criminal exploitation; ensure that youth offending service assessments consistently seek to identify and take full account of the child's background and relevant contextual factors and take full account of information from other localities when a young person is known to have links with services in other boroughs; consider making decisions to support or enable the relocation of family the responsibility of a manager at director level who should be reassured that all alternatives and risks present in the proposed area of relocation have been considered.
Keywords: child criminal exploitation, child mental health services, gangs, homicide, interagency cooperation, information sharing
> Read the overview report

2021 - Buckinghamshire - Baby N

Death of a 13-week-old girl in January 2019.
Learning includes: the importance of understanding the family history; assessing the holistic needs of children; understanding the cross-border issues and how it impacted on the children's needs; assessing risks to staff whilst meeting the needs of those living in disadvantaged areas; and responding to urgent and emergency housing needs of children living in neglectful circumstances.
Recommendations include: strengthen the provision of supervision for health visitors to ensure that good quality, regular supervision is offered, in line with the supervision protocol; development of a common cross-border understanding regarding the placement of vulnerable families in temporary accommodation; consider the use and effectiveness of existing tools, to support professionals in the wider children's workforce, to understand the impact of neglect on the lived experience of children; and implementing planned unconscious bias and professional curiosity training.
Keywords: early intervention, family support services, neglected children, interagency cooperation, information sharing, referral procedures
> Read the overview report

2021 - Camden - Child E

Death of a newborn infant in September 2020. Child E was born with no brain activity after a breeched labour and delay in the parents accessing medical care, with their life support being switched off the day after birth.
Learning includes: professionals should understand that some parents with a long history of intervention may be resistant to professional involvement; there are limitations to child protection information sharing arrangements when it comes to missing people; information sharing on missing people requires joint data to be made available on risk factors to predict the likelihood of specific harmful outcomes.
Recommendations include: safeguarding practitioners use joint supervision to reflect on progress made against intervention plans when there is limited engagement and risks remains unresolved; joint agreement and understanding of a missing person incident enables action to be taken, including the most appropriate use of police powers; practice should be led by continuous assessment of need for children and families, with assessment including therapeutic input and, when appropriate, joint intervention by children and adult's services; parents who have a history of repeated removals of babies, and a history of adverse childhood experiences (ACEs), require support and joint intervention from adult and children’s services; local partnerships should explore how they can engage with providers of private baby scans to raise safeguarding standards.
Keywords: infant deaths, newborn babies, adults with learning difficulties
> Read the overview report

2021 – City and Hackney – Child A

Child A was born by emergency caesarean section at 27- weeks-old and was diagnosed with a condition found in premature babies.  There were concerns about suspected fabricated or induced illness, including the prescription of opioids for pain management, covering the period from birth to the age of 11-years-old.
Learning: practitioners did not listen to the voice of the child; acceptance of what mother said and responding without any objective assessment led to unnecessary and inappropriate medical intervention; lack of professional challenge and curiosity culminated in ongoing medicalisation; there was an insufficient response in meeting educational needs. 
Recommendations: embed the voice of the child in procedures and training and ensure that children are involved at each stage of their care; review practice guidance on fabricated and induced illness to ensure it takes account of children who are coming to harm through excessive medical intervention; training should include the potential safeguarding impact on children not being brought to health appointments; ensure escalation policy incorporates supporting professionals being able to challenge colleagues. 
Keywords: fabricated or induced illness (FII), children’s rights, abusive parents, non-attendance, professional curiosity, voice of the child
> Read the overview report

2021 – City and Hackney – Child B

Neglect of a 10-year-old child over a number of years. Child B was born with a disability and needed significant support from health specialists.
Learning includes: children not being brought to appointments is an indicator of potential neglect; effective and child focused safeguarding practice with disabled children ensures they are seen, heard and helped; the focus on engaging parents and carers to support disabled children is key, but should not dilute professional challenge; the need for professionals to think about family and fathers.
Recommendations include: ensure that all services have access to and use a ‘Was Not Brought” policy across the local health system; the Disabled Children’s Service should ensure that meetings include an analysis of a child’s attendance at appointments; ensure that recording systems are sufficient to identify repeating patterns of children not being brought to appointments; ensure that guidance for safeguarding children with disabilities sets out the importance of communication and hearing the voice of the child.
Keywords: child neglect, children with a disability, non-attendance, voice of the child
> Read the overview report

2021 – City and Hackney – Child I

Death of a 16-year-old child from natural causes whilst in custody at a Young Offender Institution. Review does not consider the circumstances of Child I’s death.
Learning: practitioners need to recognise ‘subtle moments’ that might present clear opportunities to help and protect a child; where children are identified as needing early help, it is important that parents and carers fully understand what this involves in respect of a coordinated, multi-agency approach to help and protection.
Recommendations: ensure that policy, procedure and practice relating to critical moments (both well established and those less obvious) is sufficiently robust to ensure effective safety planning; work with schools to ensure that they are able to identify children who show persistent behavioural difficulties; ensure that a multi-agency response to the persistent disruptive behaviour of children is sufficiently described in threshold tools; explore with primary and secondary schools how multi-agency involvement could be improved both prior to and at the point decisions are being made about permanent exclusions.
Keywords: adolescents, death, young offenders, exclusion from school, violence
> Read the overview report

2021 – City and Hackney – Child R

Extensive physical injuries to a 2-year-old boy in April 2020. Child R was found unconscious by paramedics in the family home with bruising and injuries and was later found to have a bleed on his brain.
Learning: issues around information sharing, particularly regarding arrangements for transferring community health records and the transfer of cases between local authority areas; issues around the ability and confidence of safeguarding practitioners to recognise risk and act with authority in cases involving both domestic violence and child abuse; the importance of safeguarding practitioners including relevant adult males in their assessments of risk.
Recommendations: review policies covering the transfer and receipt of community health records to ensure the timeliness of record transfer, case closure and escalation; review procedures for the transfer of children in need cases, defining the requirement for formal handover meetings; local safeguarding children partnerships to promote training and awareness raising that reinforces the seriousness of domestic abuse in the context of children’s safety; ensure that local threshold tools sufficiently describe the significance of risk associated with domestic abuse, particularly when such abuse forms a repeating pattern; improve how practitioners engage with adult males that are significant to the lives of children.
Keywords: pre-school children, injuries, physical abuse, family violence, abusive men
> Read the overview report

2021 – Coventry - Amy

Disclosure of intrafamilial sexual abuse by a 15-year-old girl in June 2020. Amy disclosed that her father had been sexually abusing her since January 2019. Amy’s father is a registered sex offender (RSO), having been convicted of a relevant offence in 2015.
Learning themes include: professional awareness of the risks of intrafamilial child sexual abuse; professional curiosity and challenge regarding risk assessments; multi-agency offender and risk management; child vulnerability and adverse experiences impacting that vulnerability; mitigating and understanding risks such as drug use; and clarity regarding the definition of supervised contact.
Recommendations include: ensure an up-to-date risk assessment is completed when a RSO moves local area; build on and promote the partnership’s sexual abuse strategy 2021-23; review with relevant partners how child contact with RSOs is assessed and managed; ensure assessments of RSO contact requests are child-centred and holistic; build in ongoing oversight and safeguarding measures when a child is in contact with a RSO; conduct regular welfare checks with children having contact with an RSO, giving every opportunity for any concerns to be raised; provide children and families with full information about contact with a RSO, including information of their offending; the police and national probation service (NPS) to work together to ensure complementary conditions of RSO prison licences and sexual harm prevention orders; NPS to brief all staff on relevant effective practice guidelines on intrafamilial child sexual abuse; and the partnership to review how information is shared with schools.
Keywords: disclosure, fathers, intrafamilial child sexual abuse, prisons and prisoners, sex offender orders, sex offenders
> Read the executive summary

2021 – Dudley – Children Q and R

Serious injuries to two unrelated children, Child Q aged 4-years-old and Child R aged 7-weeks-old, whilst in their parents’ care in December 2020.
Learning: there was a lack of clarity about the men involved in the children’s lives; domestic abuse didn’t appear to have been considered by professionals; and there was disagreement between medical and children’s social care professionals about the cause of the injuries.
Recommendations: decision making at strategy meetings should include all appropriate agencies; the children’s workforce should feel confident recognising potential non-accidental injuries; and the development of a practitioner forum should be considered, where medical and social care staff can gain an understanding of each other’s roles.
Keywords: family violence, interagency cooperation, non-accidental head injuries, parents with a mental health problem, physical abuse, threshold criteria
> Read the overview report

2021 – Ealing – A, B, C

Reviews two cases involving serious youth violence resulting in serious injuries to a young person. Identifies learnings through which to improve local safeguarding practice and strategic understanding. Case one concerns the arrest of a 15-year-old boy (B) for the attempted murder of a 14-year-old boy (A) in September 2019. Both A and B were known to children’s social care and police. B was subject to a child protection plan, and there were concerns about his mother’s parenting ability and about him being exploited and coerced to sell drugs. B has diagnoses of autism and ADHD and has mental health issues caused/exacerbated by cannabis addiction. Case two concerns an attack on a 15-year-old boy (C) by members of a rival gang in February 2020. C’s family had been known to children’s social care since 2010. C had previous engagement with police and the youth justice service.
Learning themes include: the significance of education non-attendance, school exclusions, unmet special needs, and learning difficulties; the impact of adverse childhood experiences; the importance of prevention and early intervention; the significance of neighbourhood gang activity; the need to understand risk in a place-based way; the challenge of effective information sharing, including when both adult and children’s services are involved; managing extrafamilial risk through child protection plans; the need to educate and support parents managing risky situations; disclosures of gang-related activity or engagement in serious youth violence; the need to balance high caseloads with building trusting relationships with adolescents; the use of enforcement; and the importance of discussing young people in a non-judgmental way.
Recommendations: n/a
Keywords: adolescent boys, child criminal exploitation, child protection services, drugs, gangs, violence
> Read the executive summary

2021 – Ealing - Child C

Malnutrition of a 3-year-old girl in 2020.
Learning includes: health visitors must ensure that the correct level of need is recorded on case management systems; work needs to be undertaken to ensure that all heath visiting staff understand the levels of need set out in procedures and understand how to apply in practice; there is a need to remind GP staff to contact health visitors directly regarding children that raise concerns; GPs are able to weigh children and spot a malnourished child and to recognise the need for urgent referral; professionals need to be reminded of the need to effectively coordinate and manage case transfers; hospital staff need to be trained to understand the significance of safeguarding, the processes for referral and the respective roles of agencies; processes for case handover within the hospital need to ensure that safeguarding is considered at each handover point; professionals have an active responsibility to seek information from strategy and other planning discussions to which they have been invited but didn't attend.
Recommendations: Makes no recommendations but the serious incident report and root cause analysis completed as part of this review identify actions to address concerns.
> Read the overview report

2021 – Ealing - James

Death of a 10-year-old boy in August 2020. James died because of restricted airways after his mother gave him an excess dose of melatonin, prescribed to help him settle at night, and put him to bed with a sponge in his mouth.
Learning includes: there was a significant level of contact between the family and agencies, services were maintained and there was multi-agency oversight; during this contact James’s mother was inconsistent in her presentation; James’s mother refused offers of support through children in need services; there was no contact between agencies and James’s father.
Recommendations include: collaborate and co-produce with disabled children and their parents, information about and service delivery of child in need services; review information provided to parents about the Direct Payment System and their responsibilities to inform funders of situations where family members or partners are employed; review the approach to engagement of fathers as single agencies and as a partnership.
Keywords: infanticide, children with learning difficulties, abusive mothers, family finance, mental health, coronavirus
> Read the overview report​

2021 – East Sussex – Child W

Death of an 8-week-old infant girl in September 2018. The post mortem revealed non-accidental head injuries and fractures. The father was subsequently convicted of murder and mother was convicted of allowing death.
Learning includes: consider predisposing risks and when deciding if a pre-birth assessment is required; the need to support children in care and care leavers who become parents as a part of corporate parenting; consider the additional support a family may require following an early birth and when a baby is in a neonatal unit; seek information from other local authority areas if a family have moved and it is believed there is historic safeguarding information; ask partner agencies to check what historic safeguarding information they hold on family members, and proactively share information when concerns emerge. 
Recommendations include: alert the Department of Health and the Home Office to the need to review national guidelines so that CT scans and full skeletal surveys are carried out immediately on infants and young children who have died from unexpected or unexplained causes, and where there are siblings who may need to be safeguarded; the safeguarding partnership and partner agencies to explore how they can use multi-agency programmes to promote the safe handling of babies.
Keywords: infant deaths, physical abuse, adults in care as children, information sharing, medical assessment
> Read the overview report

2021 – Gloucestershire - Child sexual exploitation

Response to three separate cases in summer 2020 involving child sexual exploitation (CSE) and where a young person had suffered significant harm. Common themes from their home environment included: domestic abuse; child neglect; parental mental and emotional health issues; and parental use of alcohol and drugs. During their adolescent years each went on to be exploited by older males, resulting in significant emotional harm, in addition to serious physical and sexual assaults. There was a pattern of alcohol and drug use, many missing person episodes, and self-inflicted injuries.
Learning points focus on: contextual safeguarding; commissioning services; perpetrator disruption strategy; multi-agency planning pathways; missing children and multi-agency child exploitation (MACE); and the CSE team.
Recommendations to the partnership include: the partnership should develop a new child exploitation strategy, based upon the principles of contextual safeguarding which include the identification of relevant pathways and the commissioning of services; all agencies should introduce a trauma informed referral assessment process which is child and young person focused; CAMHS should review the current referral process to ensure that it is child and young person focused, and that the new referral process is widely understood and promoted across partner agencies; and the local constabulary should review compliance with their vulnerability identification screening tool (VIST) safeguarding policy in relation to adolescents and ensure measures are in place to improve the identification and reporting of adolescent risk.
Keywords: adolescents who go missing, adverse childhood experiences, child sexual exploitation, child mental health services, contextual safeguarding, sexually abused adolescents
> Read the overview report

2021 - Hammersmith and Fulham, Kensington and Chelsea, and Westminster - Adam

Murder of a 17-year-old boy in a knife attack in 2019. Adam and his family were well-known to several services.
Learning themes include: child criminal exploitation (CCE) and the response of services; school attendance and involuntary school transfer; the effectiveness of social work interventions and collaborative working with youth offending, early help and family support services; relocation of children and their families; and significance of race, ethnicity and religion.
Recommendations to the partnership include: the police and the local authority (LA) should collaborate to develop responses to serious youth violence (SYV) and criminal exploitation that combine work on individual and family safeguarding, CCE and extra-familial harm, locality policing and the disruptive policing of organised criminal activity; the LA should ensure schools have effective approaches to improving school attendance and supporting children not in mainstream school; ensure that FE colleges are fully integrated into local safeguarding partnership arrangements; ensure that where there are concerns about CCE, the assessment provides a cumulative account of possible risks; the LA should provide clear guidance to social work managers as to their role in assessment and risk management arising from SYV; when several of the LA’s services are working with a child or family at risk because of SYV, there should be a shared plan and joint staff supervision; the partnership should engage with other agencies and LAs to produce a protocol for the relocation of families; the partnership should ensure that assessments always explore family history and experiences that are specific to ethnicity, race and religion; and where young people have been taken abroad, professionals should devise the best steps to identify them on their return to the UK to support their reintegration.
Keywords: child deaths, child criminal exploitation, contextual safeguarding, ethnicity, homicide, young offenders
> Read the overview report

2021 – Harrow – Child M

Death of a 12-year-old boy in 2020 due to multi-organ failure, sepsis and cerebral palsy. Concerns were identified regarding neglect. Child M had significant disabilities and complex chronic medical needs.
Learning includes: a need to better understand Child M's lived experience and his family's coping mechanisms; insufficient case co-ordination and development of agreed ways to maintain health and minimise risk of harm; a need for a review of the respective roles of school nursing assistants and school nurses; a need for debate about the extent to which existing service user information systems support or constrain information exchange; a review of the extent to which education, health and care plans (EHCP) or non-school attendance policies are being applied to those in special education facilities.
Recommendations include: develop child-centred guidance on the meaning and application of mechanical and physiological or medical restraint to children in the community who are vulnerable by virtue of physical or learning disabilities; ask agencies to remind professionals of the existence and importance of compliance with the existing 'was not brought' policy; review special schools to provide confirmation that non-school attendance responses are of comparable or superior standards than those applied to non-disabled pupils; children's social care disability service to discuss and agree the co-ordination role that it could play in complex cases.
Keywords: children with disabilities, child neglect, non-attendance, school attendance
> Read the overview report

2021 – Hertfordshire – Child L

Serious injuries to a 20-month-old boy in 2018. Child L and his half-brother were made subject to an interim care order.
Learning includes: there was no shared understanding of the mother's learning needs or her emotional needs, and there were differing perceptions of her; when extended family are providing support, it is important to balance the strengths alongside the risks and to understand the nature of the relationships between family members; all behaviours must be viewed as potential trauma and the impact of this trauma on the lived experience of the child.
Recommendations include: to build on the multi-agency understanding of risk for children under a child in need plan to include dynamic risk assessments and challenge from partner agencies; to explore how a list of children on a child in need plan can be shared with the multi-agency safeguarding network; ensure that private pre-schools and nurseries are meeting the required standards of safeguarding, and to consider raising the issue with Department for Education to bring private providers under the same guidance as statutory services.
Keywords: physical abuse, adults with learning difficulties, risk assessment, trauma, nurseries
> Read the overview report

2021 - Hounslow - Family X

Removal of four siblings from the care of their mother in April 2020. The siblings were placed in the care of their father and his partner. Family X had been known to child protection services since 2013, and the children placed on child protection plans under the category of neglect in 2018 and 2020.
Learning themes include: the voice of the child; communication and collaboration around child protection medical assessments; indicators of child abuse and neglect; understanding of multi-agency child protection plans; missed health appointments; threshold criteria; decision-making within the child protection case conference process; disguised compliance and professional curiosity; and opportunities for children to make disclosures.
Recommendations to the partnership include: ensure all agencies use the quality of care assessment tool and training programme; compile a checklist of required information to be provided to initial child protection case conferences and to be subsequently updated for review conferences; ensure that the use of multi-agency safeguarding chronologies is standard practice; include details concerning both parents and all relevant family members in safeguarding chronologies; highlight to all agencies the importance of the voice of the child, including the significance of what they feel unable to talk about; ensure all information from and about children is recorded, shared between agencies, and acted upon; and support agencies in challenging the decision that a referral has not met the threshold for intervention.
Keywords: child neglect, children in violent families, medical care neglect, siblings, substance misuse, voice of the child
> Read the executive summary

2021 – Isle of Wight – Child I

Suicide of a teenager in 2019. Child I had a number of vulnerabilities and needs relating to challenging behaviour, substance misuse, emotional wellbeing (including suicide attempts), poor school attendance and missing episodes.
Learning themes include: the need to consider early help support for adolescents; the importance of a whole family, strengths-based approach; ensuring a holistic view is taken of the child/family; and importance of full consideration of a child/family’s history.
Recommendations include: managers should ensure the voice and experience of the child is taken into account in all work undertaken by partner agencies with families; ensure awareness of the ‘was not brought’ policy and procedures across health services, including CAMHS; and ensure the promotion of whole family, strengths-based approaches to support positive engagement and support. Practitioners should: ensure full consideration of Early Help assessment and planning for adolescents; recognise importance of full consideration of a child/family’s history so events are not seen or responded to in isolation and patterns in behaviour can be identified to better inform support and interventions; ensure a holistic view is taken of the child/family to try and fully understand what is going on rather than just the presenting issue; ensure that families are fully supported to follow up on signposted services.
Keywords: suicide, early intervention, child mental health, family dynamics, voice of the child
> Read the overview report

2021 – Kent - Jesse

Suicide attempt of a child. Jesse was taken to hospital with non-serious physical injuries. They had previously expressed that they were transgender and autistic.
Learning themes include: clarity on the process of diagnosis of autism spectrum condition (ASC); the need for support and expertise to guide staff on gender dysphoria; effective multi-agency working including professional challenge where there is a concern that any partner agency is not following policy; and the importance of the voice of the child over the voice of the parent.
Recommendations include: all relevant agencies to remind staff of the formal screening and referral pathway for ASC and to follow NICE guidance in the support and treatment for ASC screening and management; agencies must give definitive guidance to staff on their stance on necessity for ASC referral and diagnosis; the partnership should seek assurance that issues of waiting lists for ASC assessment and diagnosis are being addressed; the partnership are to provide training to professionals regarding gender dysphoria along with the learning for this review; assessment frameworks should give due regard to impact of culture and ethnicity; and agencies must provide evidence regarding the requirement to record ethnicity, other protected characteristics and vulnerabilities in records.
Keywords: autism, child mental health, gender identity, transgender, suicide, ethnicity
> Read the overview report

2021 – Kent - Kyle

Hospitalisation of a 3-month-old boy with a fractured femur in 2019. A skeletal survey found Kyle had other fractures of different ages, including multiple fractured ribs. There were also concerns that Kyle was failing to thrive, was severely underweight and was likely to be subject to neglect.
Learning themes include: improving engagement with fathers; the quality of assessments including the training staff receive in undertaking assessments and confidence in oversight and challenge; whether assessments include sufficient focus on parental capacity, the impact of substance misuse, mental health, and domestic abuse on the child; and multi-agency working, agency checks and communication.
Recommendations: N/A
Keywords: assessment [social work], child neglect, failure to thrive, fathers, fractures, physical abused infants
> Read the overview report

2021 – Lewisham - DB

Critical illness of a 13-month-old boy in early 2020. DB was brought to hospital by his mother, in a critical condition suffering from respiratory distress. He was significantly underweight, with severe vitamin D deficiency and sepsis.
Learning themes include: communication, including record keeping and IT systems; assessment and the use of professional judgement; challenges and impact for professionals working with parents who have significantly harmed their children; and the voice of the child.
Recommendations to the partnership include: ask the clinical commissioning group (CCG) to ensure there are effective systems of communication between GPs and health visitors (HV) when concerns arise outside the time frame of link meetings; ask the CCG to provide assurance that notifications are routinely made to the HV service if children are not brought for developmental reviews or immunisations; consider how to raise awareness of the ‘Think Family’ approach across the workforce; consider requesting independent scrutiny of health visiting practice to ensure that practice issues identified in the report are not systemic to the service; review the current cultural competency training offer and ensure that it includes a mix of evidence-based approaches and tools to support the development of the workforce; share the findings of the report with NHS Digital for resolution on national IT challenges; the NHS Trust should consider including a prompt to explore the father’s role in the family in the new birth visit, assessment form and review the HV contact policy to consider whether all cases that are ‘stepped down’ from targeted to universal services should be discussed in reflective spaces.
Keywords: child abuse, child growth, health visitors, infants, mixed ethnic group, nutrition
> Read the overview report

2021 – Lewisham and Greenwich – Child DA

Hospitalisation of a 3-month-old girl in March 2020. Test results confirmed that DA’s head injury was consistent with a non-accidental injury. At the time of this report both the police investigation and care proceedings are ongoing.
Learning themes include: working with families who have moved between local authority areas, including issues of threshold and information sharing across boroughs; professional curiosity and risk assessment regarding roles of partners/fathers and family history; understanding and analysing impact of family history of trauma, and inter-agency communication about family history and associated risks.
Recommendations include: consideration should be given to exploring family history by way of a genogram or ecomap at the first visit by a new service/professional; names and details of fathers (and other significant adults in the child’s life) should always be accurately recorded; if the conclusion of a child and family assessment is to refer to another borough, the originating borough’s assessment should still include a recommendation as to any future services or intervention and recommendation as to whether threshold is met for early help, child in need or child protection planning; consideration to be given to introducing an expectation that a discussion takes place between parents and health professionals regarding any additional support that is needed when a baby is prescribed medication for reflux; and agencies must ensure that a family’s housing status is clearly understood and recorded on file, and that any moves between boroughs are clearly recorded so that any necessary support is put in place quickly.
Keywords: domestic abuse, infants, non-accidental head injuries, professional curiosity, police, unknown men
> Read the overview report

2021 – Lincolnshire - J

Death and serious harm of 2-month-old twins. Orel was presented at hospital unresponsive with a significant brain haemorrhage and died of his injuries. Benedict was also found to have subdural haemorrhages for which he was treated. Father was convicted of murder and grievous bodily harm.
Learning focuses on: premature twins; the impact of cultural expectations; appropriateness of accessing only universal services; communication between professionals and parents who do not have English as their first language; and parental knowledge and understanding of local community services.
Recommendations include: implementation of translation services in children's health and maternity services, and supporting professionals in the effective and authoritative use of interpreting services; audit all agencies' use of interpreting services to ensure that practice reflects policy; seek assurance that routine enquiry is conducted within a frame of interest, professional curiosity and effective questioning; seek assurance that health professionals consider the vulnerabilities of a mother/child(ren) irrespective of whether there are voiced or observed concerns; and seek assurance that health agencies have the appropriate tools to support the holistic needs of teenage and young parents, and that the safeguarding partnership consider the benefits of adopting a teenage pregnancy pathway.
Keywords: premature infants, infant deaths, head injuries, culture
> Read the overview report

2021 – Lincolnshire - Sue, Hayley, Sarah and Daniel

The case concerns the murders of Sue and her daughter, Hayley, aged 13-years-old, by her daughter, Sarah and Sarah's boyfriend, both aged 14-years-old at the time of the incident in April 2016.
Learning includes: the long-term effects of domestic violence and abuse on victims and those who are exposed to its effects needs to be better recognised and understood by those working with troubled adolescents and their carers; greater professional curiosity is needed to look at underlying needs, particularly when considering disruptive behaviour by adolescents; family group conference did not facilitate wider family support and a plan to assist aunt; and questions whether the team around the child process was robust enough to identify the full picture of their needs and address underlying causes of adolescent trauma.
Recommendations include: evaluate the capacity and performance of services to address the needs of adolescents with difficult or risky behaviours, but without diagnosed mental health illness; improve awareness of trauma informed practice and adverse childhood experiences, particularly concerning the long-term impacts of domestic violence and abuse on children and parenting capacity in order to develop strategies for better professional assessment of these; review how social work expertise is accessed by team around a child processes to encourage professional curiosity and to support complex needs where there is not an incident or trigger for direct social work intervention or assessment; and seek assurance that cumulative and whole family perspectives are strengthened in assessment and support work.
Keywords: homicide, mental health issues, parenting capacity, risk assessment, professional curiosity
> Read the overview report

2021 – Luton - Oliwer

Death of a 6-year-old boy in December 2019. At the time Oliwer’s death was unexplained but a post-mortem examination revealed he had an underlying metabolic condition. Oliwer had autism and prior to his death there had been concerns about his diet and general health.
Learning themes include: the importance of expressing professional differences of opinion; dental neglect as a possible indicator of wider child maltreatment; the risks of confirmation bias; the importance of professional curiosity; the role of strategic oversight and management in cases where children have complex needs and involvement with multiple agencies; and the management of cases where children appear to be in need of support rather than protection.
Recommendations to the partnership include: support dental practices in identifying neglect, seeking specialist safeguarding support, and sharing information; evaluate the assessment process for children with complex additional needs and special educational needs (SEN); ensure schools and their staff are provided with enough support and supervision in evaluating and responding to welfare and safeguarding concerns; consult with agency partners regarding the clarity of threshold guidance, how threshold assessments and decisions are applied and interpreted for children with complex additional needs and SEN, and how to support challenge and escalation when professional differences of opinion emerge; explore which role within the current professional network is best placed to act as lead professional for children with complex needs and SEN; and consider the creation of a process and information sharing agreement between agencies regarding all children whose absence from school is consistently unexplained.
Keywords: assessment [social work], child deaths, child neglect, language, special educational needs, additional needs and disabilities, threshold criteria
> Read the executive summary

2021 – Manchester - Baby R

Death of a 23-month-old infant. Baby R was found dead at home with inflicted injuries. A police investigation found that Baby R’s mother was responsible, though she has no memory of this. The father was found guilty of the offences of coercive and controlling behaviour, common assault and criminal damage.
Learning themes focus on domestic abuse and include: the importance of routine inquiry; and responding sensitively to those seeking help for domestic abuse.
Recommendations to the partnership include: professionals who work with the victims of domestic abuse should be aware of other agency’s roles and responsibilities and domestic abuse policies should be updated to reflect the need to make victims aware that when a crime is disclosed, the police have a duty to record it under national crime recording standards and that an investigation can proceed without the support of a victim; support the implementation of the safe and together model across the multi-agency partnership so that people who experience domestic abuse are effectively supported and safeguarded; work with the community safety partnership to look at a campaign or information/resource for the website to support employers with domestic abuse policy and response plans; and the community safety partnership should seek any known information about how victims of domestic abuse locally have experienced the use of the DASH framework and the importance of making sure it is used in a person-centred way.
Keywords: amnesia, abusive men, disclosure, domestic abuse, infant deaths, infanticide
> Read the overview report

2021 – Manchester - Baby T, Kimmy and Chad

Death of a 10-month-old infant. In the morning Baby T was found to be unresponsive, was taken to hospital and was pronounced dead. The cause of death could not be ascertained and was therefore considered to be a sudden unexpected death in infancy.
Learning is embedded in the recommendations.
Recommendations include: update the safer sleeping practice for infants guidance to incorporate the messages for this review and recent SCR research; concerns about hostility and aggression towards professionals should be addressed as part of core group activity and should inform any risk assessments around the children; consider what action is necessary to ensure that the neglect of children is addressed locally; assurance from partner agencies that they enable, train, support and resource professionals to consider the lived experience of children and that this is reflected in decision making, work with parents, reports, assessments and meetings; and encourage professionals analysing what they know about the child’s life, particularly incidents of concern, and recording the impact, talking to parents, making plans and considering how if adults/professionals do not make sense of difficult and complex circumstances, how can they expect children to do so.
Keywords: sudden infant death, parenting capacity, adverse childhood experiences, alcohol misuse, voice of the child
> Read the overview report

2021 – Manchester - O1

Significant brain injury to a 3-month-old baby in April 2017. Injuries were consistent with being shaken. Child O1’s mother pleaded guilty to charges of grievous bodily harm. At the time Child O1 was under a child protection plan following concerns of exposure to domestic abuse.
Learning themes include: partnership working including escalation processes, lead professionals and multi-agency chronologies; the quality of multi-agency assessments; the complexity of domestic abuse; the importance of professional curiosity and respectful scepticism and adherence to guidance in relation to injuries to non-mobile children; and building relationships with young people.
Recommendations to the partnership include: seek assurance through thematic and Section 11 audits that all agencies have embedded assessment standards that capture the importance of accessing the history of parents in the context of assessing parental capacity for change in line with the needs of their children; the ICON approach should be embedded across the partnership to inform advice, guidance, thinking and practice; promote and be assured that constituent agencies are demonstrating a pro-active approach to working with birth fathers; support the implementation of the safe and together model across the multi-agency partnership so that children who experience domestic abuse are effectively safeguarded; and promote the learning, implementation and uptake of adolescent mental health services through the iThrive model.
Keywords: adolescent mothers, assessment [social work], domestic abuse, infants, non-accidental head injuries, shaking
> Read the overview report

2021 – Medway – Baby Harris

Death of a 15-day-old boy in June 2019. Baby Harris was found dead in the family home, after having been asleep in his parents’ bed.
Learning: lack of professional understanding around the lived experience of Baby Harris’ older brother, Child A, which could have alerted professionals to risks and harm; invisibility of unborn Baby Harris and Child A, partly due to inconsistent parental engagement with services; a lack of access to and understanding of the family's history by agencies resulting in parental risk factors not being identified; issues around multi-agency responses to domestic abuse, including issues with information sharing; safer sleep messages provided to the family were difficult to put into practice due to the family's living arrangements.
Recommendations include: improving engagement with children and having an understanding of the lived experiences of children; improving the quality of assessments where children and unborn children are experiencing neglect; improving the understanding of the cumulative effects of neglect; ensuring that there is sufficient staff capacity in social work services to offer the conditions for good social work practice.
Keywords: infant deaths, sleeping behaviour, children in violent families, child neglect, parents with a mental health problem, voice of the child
> Read the overview report

2021 – Merton - Baby Grace

Death of a 1-month-old girl in September 2017. Evidence showed that Baby Grace had been shaken on three separate occasions and had 27 fractures.
Learning themes include: helping parents to manage possible stresses and triggers which may lead to shaking a baby; involving fathers in ante-natal and post-natal assessments and care; and assessing possible risk of domestic abuse through routine enquiry and other measures.
Recommendations include: the partnership should ask the clinical commissioning group (CCG) to review the effectiveness of the local approaches taken across ante-natal and post-natal care to support parents in responding to crying by babies; share the resources used by health visitors to support new parents so that they can be accessed by other supporting professionals, such as children’s centres; the CCG should ask the providers of local maternity and health visiting services to review the approaches taken to include fathers, including the use of leaflets or other media aimed specifically at men; the hospital trust should continue to report the outcome of its annual review of midwives’ training in domestic abuse to the partnership; the CCG should review joint protocols and practice in the handover and transfer of information between the midwifery, health visiting services and GPs to ensure that best practice is in place, particularly when the midwifery contact with mother and baby continues beyond the health visitor new birth visit; and review the awareness of ‘Clare’s Law’ within the local community and how it is included in professional procedural guidance and the training of key practitioners working with women.
Keywords: crying, domestic abuse, infant deaths, maternal health services, midwives, shaking
> Read the overview report

2021 – Merton – Child H

Death of a 5-year-old girl in 2020. Emergency services were called to an address where a woman and 5-year-old child were found with serious injuries, stab wounds.
Learning includes: the initial phase of the Covid-19 pandemic highlighted the risks to children when not in school regularly; the need for interpreters in health settings and children inappropriately being used to interpret for their parents; pain may impact an adult’s ability to function and their parenting capacity; the need for a holistic view of an individual’s life in assessments within health, care, and education settings to promote the welfare of children and ensure that families are not left isolated.
Recommendations include: the safeguarding partnership should consider how all statutory partners and relevant agencies can take responsibility for promoting school attendance for the children of families they work with and to identify those who might be out of sight; the safeguarding partnership must be provided with assurance, from health providers, that professional interpreters are offered for all consultations where an adult does not use English as a first language unless this would unnecessarily delay essential immediate emergency treatment; and when an adult is presenting with severe or chronic pain, with no clear cause, health professionals must consider whether the adult has any caring responsibilities and if the adult is a parent or carer then there should be a conversation with them to check on the needs of the child.
Keywords: child deaths, coronavirus, parenting capacity, schools, maternal health, interpreters
> Read the overview report

2021 - Mid and West Wales - 7/2018 (Young person B)

Death of a 14-year-old boy in September 2018. Young person B took his life whilst at school. He had a diagnosis of attention deficit hyperactive disorder (ADHD), a hearing impairment and had experienced bullying.
Learning addresses: education and transitional arrangements; education and support for special educational needs (SEN); restorative practice; children’s and young people’s voices and influence; child health; drug treatment in school-age learners; adverse childhood experiences (ACEs); and unexpected deaths in childhood.
Learning points include: the local safeguarding board to support the development of a rapid response model, to provide timely and enhanced support to families, peers and the wider community when unexpected deaths occur; evidence will be required to demonstrate that the views of children with additional learning needs (ALN) and their families are considered in meetings and decision-making regarding their individual development plans (IDPs); schools and local authorities to ensure that their practice, training and policy guidance on bullying is compliant and acknowledges the added vulnerabilities of children with ALN, mental health issues, ACEs, or disabilities; local authorities and educational institutions must demonstrate their compliance with the ‘Keeping learners safe’ audit tool and how they review their safeguarding arrangements; the local authority should consider reviewing their process in relation to school transport arrangements, to ensure that children with vulnerabilities are adequately safeguarded, particularly when concerns of bullying are raised; and schools need to consider how they ensure communication with parents is timely, proportionate and effective, in addressing any concerns in respect of a child’s wellbeing.
Keywords: attention deficit hyperactivity disorder, suicide, secondary schools, bullying, special educational needs, additional needs and disabilities, prescription drugs
> Read the overview report

2021 - Milton Keynes - Child G

Sexual abuse, including rape of a 16-year-old by her brother over a five-year period.
Learning explores: the degree to which professional curiosity and authoritative enquiry were exercised when responding to both Child G’s concerning behaviours and gender identity; the extent to which holistic assessments of the family were undertaken particularly taking account of working with a family with additional learning needs; the quality of risk assessments carried out in relation to Sibling 1 that took account of both his mental health, learning needs and the risk he potentially posed to children and vulnerable adults he had access to; and how effectively agencies worked together and shared information about Sibling 1’s risk and Child G’s safety.
Recommendations include: all agencies need to ensure that professional practice is child focused, focuses on safeguarding and considers the lived experience of all the children in a family; a need to raise awareness of the nature and prevalence of child sexual abuse and possible indicators of when it is present in family settings; and all agencies need to develop a greater knowledge and understanding of the impact of autism and other learning difficulties on the capacity of individuals to function and to make appropriate choices.
Keywords: siblings, sibling sexual abuse, professional curiosity, adults with a learning disability, rape, risk assessment
> Read the overview report

2021 – Northamptonshire – Child Ay

Death of an infant in 2019. Child Ay was found lifeless in the parental bed, having died during the night. The mother and father had consumed a large quantity of alcohol and have subsequently been convicted of child neglect.
Learning themes include: knowledge and awareness of the mother’s vulnerabilities, in particular whether she had a learning difficulty or disability, and how professionals would respond to these conditions to support her in providing safe care for Ay and her siblings; the father’s role in the house and the level of his drug use; alcohol use by both mother and father; neglect; and safer sleeping.
Recommendations to the partnership include: ensure that professionals have a stronger understanding of learning difficulties/disability and the difference between both of these terms, and guidance on supporting individuals with these needs; ensure that there is improved professional understanding of parental alcohol misuse and how this can be harmful to children; professionals should take steps to discover more about fathers and male carers within a household; review neglect training to ensure that it is multiagency focused for consistency; consider implementation of the Panel’s suggested prevent and protect practice model for reducing the risk of sudden unexpected death in infancy (SUDI); ensure fathers and anyone else who has child caring responsibilities are aware of safe sleeping advice; and inform the child death overview panel that a joint home visit following the death of Child Ay would have assisted the neglect enquiry.
Keywords: adults with a learning disability, sleeping behaviour, sudden infant death, substance misuse, poverty, neglected children
> Read the overview report

2021 – Northamptonshire - Child Az

Death of a 6-month-old boy in April 2020. The father made an emergency 999 call as Child Az was not breathing. Both parents were said to have been drinking, with father appearing to be drunk. At the inquest, the coroner’s narrative raised concerns in respect of unsafe sleeping.
Learning themes include: recognition of the impact of poverty and homelessness on children; the impact of the Covid-19 pandemic; the importance of the use of interpreting services; disguised compliance; the impact of poverty and homelessness on the lives of children; recognising when a child has additional needs and the vulnerability of disabled children; pre-birth assessments; and safeguarding awareness amongst police officers.
Recommendations to partner agencies include: when a child and family assessment is undertaken, especially when a family is homeless, a holistic assessment must be made of the family’s needs; it is unacceptable professional practice to accommodate children who are homeless and separate them from their parents, as proposed by the local authority; where there is concern about a mother’s alcohol consumption during pregnancy, practitioners need to be aware of the impact on the unborn baby of the risk of foetal alcohol syndrome; a shared understanding of the criteria for referral to the disabled children team needs to be put into place throughout the partnership; a disabled child needs to be seen as a child first and foremost, who has additional needs; any professional working with a family where there is a child with additional needs to be aware of the safeguarding risks to all children in the family; and practitioner training should be considered concerning the safeguarding needs of disabled children.
Keywords: alcohol misuse, foetal alcohol syndrome, homeless families, language, poverty, sleeping behaviour
> Read the overview report

2021 - North Wales - NWSCB1 / 2021

Death of 21-month-old in January 2020 by drowning in the bath unattended. It is noted that the subsequent police investigation found that the death, whilst avoidable, did not constitute child neglect in accordance with the Children and Young Persons Act 1933 section 1 and the inquest recorded a verdict of accidental death.
Learning is embedded in the recommendations
Recommendations include: ensure that the child’s lived day-to-day experiences are understood within the context of preventative services where the focus is on the ‘family’ and directed by adult parent led engagement; ensure that organisational processes recognise the fluidity of the continuum of need and the dovetail between preventative services and the duty to assess care and support needs; ensure that practitioners have the confidence to utilise escalation processes; consider what more, if anything, can be done by organisations and practitioners in this regard; consider what can reasonably be expected, when information is provided, and the parents or carers have capacity; and ensure a shared agency and multi-agency understanding consideration should be given to the role and responsibilities of community mental health team and peri-natal mental health services (including eligibility thresholds) in respect of professional referrals at identified times of patient and family crisis.
Keywords: child deaths, drowning, parenting capacity, postnatal depression, preventive services
> Read the overview report

2021 – Nottingham – Child R

Serious injuries to a 6-year-old child in 2018, which later required neurosurgery. The mother was charged with neglect and the mother’s partner was sentenced to nine years imprisonment for grievous bodily harm against Child R.
Learning focuses on: compliance with child protection procedures and the arrangements for the child protection medical examinations; assessment of risk, the impact of confirmatory bias and misunderstanding of terminology; the transfer of cases.
Recommendations include: ensure that multi-agency child protection procedures are effective in respect of strategy discussions and child protection medicals; chronologies should be completed as part of the referral to social care to highlight patterns of physical injury; consider an awareness raising campaign within the wider children’s workforce focused on physical harm in children and consider whether the terminology around non-accidental injuries should be changed.
Keywords: physical abuse, bruises, non-accidental head injuries, family violence, medical assessment
> Read the overview report

2021 - Oldham - Child L

Serious violent offence committed by an adolescent in 2018. Child L is a child looked after (CLA) who was placed out of their hometown and has a history of involvement with social workers.
Learning themes include: the need to balance hearing the voice of and engaging the child, against the ultimate priority of protecting them from harm; the timing of assessments and how they should inform planning and review processes; the need for robust multi-agency assessments, plans and reviews; multiple social worker changes and case handover arrangements; the lack of a single multi-agency forum where all key agencies could meet together to assess and plan around Child L; and the identification of offending-related risk factors.
Recommendations include: employ evidence-based solutions and training to support professionals, including foster carers, in engaging adolescents with significant attachment issues; update the single assessment every time a child’s social worker changes; ensure children are always informed of and given the chance to respond to a change of social worker; identify barriers and solutions to the completion of timely assessments; focus on the needs of the whole family; review the effectiveness of the missing from home service in tracking CLA and children placed out of area; implement best practice for multi-agency assessment and planning; and work with youth justice service (YJS) to enhance all agencies’ knowledge around offending-related risk factors and how and when they must consult YJS.
Keywords: abusive adolescents, assessment [social work], children in care, interagency cooperation, social workers, violence
> Read the overview report

2021 – Oldham - Child O

Death of a 2-year-10-month-old child in April 2018. The cause of death was unascertained. In 2017 Child O was found to have multiple fractures and became subject to a care order. Child O had complex health needs including cerebral palsy and epilepsy.
Learning focuses on: the role of expert court witnesses, and how their role is understood by professionals; the need for professionals to use the local bruising protocol for immobile babies and children; the need for professional curiosity and challenge, and co-ordination of this to gain a full picture of a child; the thresholds for the local children with additional needs team to become involved with a child, and the mechanisms for referral; the issue of ‘hidden males’ in families, and these males not being included in professional assessments; and the need for information-sharing between agencies, including children’s services and the police.
Recommendations: N/A
Keywords: child deaths, injuries, disabled children, expert witnesses
> Read the overview report

2021 – Oldham – Child P

Injury and mental trauma suffered by a 5-year-old child in September 2018 during a knife attack, including several family members. The father pleaded guilty to attempted murder.
Learning focuses on the following themes: the potential impact of ethnic, religious and cultural influences on families; the need for a robust response to domestic abuse, including information sharing and a joined-up approach; the impact of bereavement on families; working with fathers; effective multi-agency working.
Recommendations: use interpreters consistently when English is not the family’s or parents’ first language; the need for accurate family assessments, including the family’s background, culture and beliefs; ensure that the views of the multi-agency network are considered within the body and analysis of single assessments; comprehensive training to be undertaken for frontline practitioners on domestic violence and vulnerability factors, including an understanding of what partner agencies can offer; multi-agency training on bereavement and how to support bereaved families; all staff attending strategy meetings to be appropriately trained in relation to Working together to safeguard children 2018 and the actions that the police should take.
Keywords: bereavement, fathers, partner violence, interpreters, information sharing, culture
> Read the overview report

2021 – Oldham - Child Q and Child R

Thematic review concerning two children from different families who experienced significant harm from adults who exploited their vulnerabilities. Both children attended a special school for children with autistic spectrum disorder (ASD).
Learning themes include: risk in the context of child sexual exploitation and additional needs; response of services to families of different cultures and social circumstances; management of complex and challenging cases; application of thresholds; voice of the child; exclusion from school and home schooling; children with additional needs who go missing; forced marriage; and support for parents after a child’s diagnosis of additional needs.
Recommendations for the partnership and partners include: alert the Child Safeguarding Practice Review Panel that viewing children with additional needs as not able to make credible witnesses, is preventing the possibility of prosecuting offenders; explore whether children with additional needs, who make allegations of abuse, are underrepresented in cases progressing to prosecution; consider whether current practice takes account of cultural and social circumstances; seek assurance that trigger plans and advocacy services are being used when children with additional learning needs go missing; seek assurance that parent/carer assessments are completed with parents of children with additional learning needs who are excluded from school and being home schooled; seek assurance that children with learning difficulties/ASD receive appropriate assessment and have access to specialist services when they are exhibiting challenging behaviours; support practitioners to identify and manage cases where forced marriage is a potential issue; and ensure that additional tailored support is made available to parents of children with learning disabilities.
Keywords: autism spectrum disorder, child sexual exploitation, culture, children who go missing, exclusion from school, special educational needs, additional needs and disabilities
> Read the overview report

2021 - Oxfordshire - Child R

Death of a 13-year-old girl in February 2013. Child R took her own life in an out-of-county residential home, following time spent in foster care and a psychiatric unit. Child R had been sexually abused by a family member and had experienced neglect and emotional abuse.
Learning themes include: working to keep children safe within their families; placement planning and managing the complex needs of children in care; and suicide risk and prevention plans for children in care.
Recommendations include: the partnership should ensure that practitioners are confident to carry out early help assessments and that they ask questions to understand the child’s needs within their family context; there should be evidence that the partnership’s neglect strategy is being implemented; the Child Safeguarding Practice Review Panel and the Department for Education should use learnings from this review to address the national issue of placements to meet children’s needs in their local area; there should be a clear local system for the commissioning and quality assurance of placements for children placed out-of-county; there should be a clear local system of scrutiny of the healthcare of children with complex needs, including those placed out-of-county; all placement plans should outline expectations regarding staffing levels, how often staff should check on young people, and the meaning of ‘waking night cover’; and where a young person has been identified as being at risk of suicide, placement plans should include a specific suicide prevention plan.
Keywords: suicide, residential child care, placement, sexually abused children, risk assessment, safety planning
> Read the overview report

2021 – Oxfordshire – Jacob

Death of a 16-year-old boy who was found dead in his bedroom in April 2019. There was insufficient evidence that Jacob had intended to end his life.
Learning: concerns about professional knowledge, skills and safeguarding systems for children at risk of criminal exploitation; multi-agency coordination could have identified contextual risks; there was a focus on responding to Jacob's behaviours but not enough focus on reducing risks to Jacob in the community; issues of unconscious gender bias in relation to criminal exploitation; missing education playing a significant role in levels of risk not being identified; importance of agencies responding quickly at critical times in a child's life to keep them safe.
Recommendations include: a review of the effectiveness of the National Referral Mechanism (NRM); statute and guidance on schools who cannot be mandated to accept children on roll; a national review of placement sufficiency for children who need to be in care or placed under secure arrangements.
Keywords: child criminal exploitation, child deaths, adolescent boys, violence, children missing education
> Read the overview report

2021 – Portsmouth - Child J

Conviction of an adolescent male in August 2019 for the murder of an adult male. Child J was a child looked after (CLA) placed out of area and had a history of involvement with agencies. At the time of the incident there were fears relating to child criminal exploitation (CCE) and involvement with gangs and county lines.
Learning themes include: how adverse childhood experiences (ACEs) can impact a child and make them more vulnerable to exploitation; trauma-informed practice; identifying and acting on positive reachable moment opportunities; out of area placements; school exclusions; missing and return home interviews; the identification of CCE and modern slavery; and delays in the criminal justice system.
Recommendations include: ensure the local authority is appropriately briefed and suitable services are commissioned to help look after children who are placed at a significant distance from or have no family or home connection; highlight to professionals the importance of identifying and acting on a reachable moment for a child at risk of CCE; provide processes for escalation and action to effectively remove barriers to reachable moments; develop professionals’ knowledge and understanding of the impact of ACEs; support professionals in providing trauma-informed responses; work with education partners to keep exclusion from mainstream education to a minimum; ensure that professionals understand the use and implications of the national referral mechanism for identifying and referring potential victims of modern slavery; and ensure that the local area child exploitation strategy has a strong delivery plan and is well understood by all professionals and agencies.
Keywords: adolescents who go missing, adverse childhood experiences, child criminal exploitation, children in care, murder, placement
> Read the overview report 

2021 – Richmond Upon Thames – Maria, Luis and Carlos

Death of 10-year-old and 7-year-old boys and their mother and father in March 2018. The children, Luis and Carlos, and their father were found dead at the foot of cliffs in Sussex and their mother was found dead at the family home in London. 
Learning includes: consideration of the financial and homelessness support available to migrant families; ensuring the link between financial difficulty and suicide is incorporated into safeguarding adults and suicide prevention.
Recommendations include: the London Borough of Richmond Upon Thames addresses issues of financial and homelessness difficulties for all communities; links to domestic abuse are addressed in the development of the borough's violence against women and girls strategy; the borough ensures that issues of financial difficulty and links to suicide are incorporated into public health and suicide prevention work.
Keywords: filicide, murder, family violence, family finance, immigrant families
> Read the overview report

2021 – Sandwell – TS

Sudden unexplained death of a 5-month-old baby. An expert witness concluded that TS’s death met the criteria for a sudden infant death syndrome, but no criminal charges were made.
Learning includes: routine questions and assessments need to consider the relationship with all significant family members who are involved in the care of the child; social workers need to consider information held by all involved health professionals; professional curiosity about the child’s lived experience, including considering the impact of living between homes on babies; the Bruises and injuries in non-mobile children policy should be followed in all cases where a non-mobile child has injuries.
Recommendations include: ask the Department of Education and Department of Health to consider adding to guidance about routine questioning and assessments in domestic abuse whether any household members are experiencing domestic abuse in the child’s home; provide the opportunity for professionals to learn from research to inform practice; consider how to influence a cultural change across partner agencies regarding the role of fathers and secondary carers in families.
Keywords: sudden infant death, parenting capacity, partner violence, professional curiosity, information sharing, families
> Read the overview report

2021 – Shropshire - G Children

Concerns the neglect and maltreatment of six children (aged 2-16-years-old) by their parents, which came to light in March 2018. The eldest child had significant educational and additional needs and experienced the greatest level of neglect, abuse and maltreatment. The family moved 13 times between 2004 and 2017.
Learning considers: the recognition of abuse, maltreatment and neglect in the household; the quality and effectiveness of assessment, planning and intervention; opportunities to hear, and understand, the daily lived experiences of the children in the household; and the quality and effectiveness of multi-agency working.
Recommendations include: support all relevant practitioners to have sufficient knowledge about identifying and assessing neglect, and sharing concerns about neglect via the appropriate route; the partnership should seek assurance that children’s social care access information held by the early help service to inform assessments and decision making; seek assurance that concerns and referrals are not dealt with based on a hierarchy of referrer and that when, for example, neighbours and workers who may be perceived to have less status than others make referrals these are treated with an equal weight of importance; ensure that expectations around formal pre-birth assessments are clearly communicated, and understood, by all relevant agencies; and the partnership consider the best mechanism and criteria for escalating concerns where parents either overtly, or covertly, fail to engage, disengage or demonstrate inconsistent engagement with professionals.
Keywords: neglected children, special educational needs, additional needs and disabilities, interagency cooperation, disguised compliance, transient families
> Read the overview report

2021 – Somerset – Child Alex

Serious injuries to a 10-week-old infant in early 2020. Medical examinations determined that the injuries were caused by inflicted trauma.
Learning: consistency of social worker to coordinate holistic and purposeful assessment of parenting capacity; robust supervision and management oversight to support social workers to reflect on progress of assessment and consider likelihood and severity of risks as well as strengths and protective factors; police officers should escalate their concerns about the action or inaction of another agency where they consider that a child remains at risk of significant harm. Learning across the partnership includes: understanding and defining levels of need or statutory threshold; embracing and resolving professional differences as an opportunity to share expertise, evaluate need or risk and promote a culture of shared accountability; need for a clear process for transferring child in need cases between local authority children's social care services; the need for professional knowledge of safeguarding legislation, guidance and procedures.
Recommendations: Recommendations are embedded in the learning.
Keywords: infants, injuries, physical abuse, threshold criteria
> Read the overview report

2021 – Somerset – Child Charlie

Death of a 16-week-old infant in early 2020 whilst in the care of their father. The cause of death is the subject of ongoing criminal investigation.
Learning: future safeguarding practice will be strengthened by: reviewing the governance of multi-agency safeguarding arrangements for responding to the needs of children living with domestic abuse; there should be a focus on safe outcomes for children living with domestic abuse as opposed to an incident focused response; develop the culture of partnership working and therefore individual and collective accountability for safeguarding children; a partnership agreement and approach to share information and analyse the needs of children living with domestic abuse. Learning identified by individual agencies will support them to safeguard children by strengthening capacity to: recognise and consider the impact of domestic abuse on babies and children; identify the needs of a child and their family; reflect on the needs of a child and their family.
Recommendations: recommendations are embedded in the learning.
Keywords: infant deaths, family violence, children in violent families, information sharing
> Read the overview report

2021 – South Tees – Daniel

Life-changing injuries to a 17-year-old boy who was the victim of a shooting in March 2020. Daniel was a child in care at the time of the incident.
Learning: where concerns about a child have been identified and statutory agencies are involved, any significant changes in education that could have an impact on a child's safety or long term outcomes should be formally scrutinised by safeguarding partners; unless professionals are skilled in building relationships, being directive, supportive and non-judgemental in their work with parents, they are more likely to face resistance, ambivalence and disengagement; early intervention to prevent or disrupt involvement in street gangs, offending behaviours and youth violence needs to involve skilled and trained facilitators to work with young people.
Recommendations: urge the Department of Education to to set out a strategy for how it intends to improve residential care for looked after children in England; explore how schools and academies can be supported and challenged, but also held to account, by partner agencies when there is evidence that school exclusions or non-attendance is placing, or would place, a vulnerable child at greater risk.
Keywords: children in care, education, victims, violence, weapons
> Read the overview report

2021 – South Tees – Fred

Accidental overdose by an adolescent boy who subsequently recovered in June 2020.
Learning: always consider the impact of domestic abuse and/or adult substance misuse or overdoses on children of all ages, especially when a child is directly affected; consider multiple incidents cumulatively as well as in isolation and any contradictions between the child's expressed wishes and their lived experience; when undertaking S47 enquiries, preparing for initial child protection conferences or conducting assessments, obtain relevant information from GP records about all adults involved in children's care; need for awareness of the legal implications of a child being subject to a Special Guardianship Order (SGO) in terms of parental responsibility and potential eligibility for support services; consider calling a strategy meeting if a child under an SGO returns to parental care; need for practitioners to discuss concerns with the young person.
Recommendations: ensure that a child's perspective on what being safe physically and emotionally means to them is a starting point for any plan to safeguard them and that thought is given about how multiple plans in use for any individual child could be explicitly linked or streamlined; promote the use of evidenced- based tools to better support practitioners in understanding family dynamics and support for children, including who is best placed to do any direct work with a child or young person; raise awareness of the legal implications of a child being subject to a Special Guardianship Order in terms of parental responsibility and potential eligibility for support services; ensure relevant information about adults involved in caring for children is obtained from GP records at all stages of the child's journey; ensure that the response to neglect adequately focuses on the needs of adolescents.
Keywords: adolescent boys, substance misuse, family violence, voice of the child
> Read the overview report

2021 – South Tees – Kingfisher

Death of an infant girl and serious injury to a 2-year-old-girl. These were two separate cases that involved child neglect
Learning includes: consideration is needed of the parent's history and ongoing vulnerabilities and the impact this can have on children; a pre-birth social work assessment should be undertaken where there are risks and vulnerabilities that warrant involvement from children's social care; clarity around the roles of all professionals involved with a family such as recognising that support for care leavers from a Pathway Worker may not extend to the care leaver's child; a need for professionals to meaningfully consider and involve fathers in assessments and plans in respect of their children; professionals need to use specific neglect tools and understand the root causes of neglect and the impact on a child over time; and there is a need for professionals to robustly challenge themselves, each other and parents/carers when it comes to managing cases of neglect.
Recommendations include: ensure that professionals are aware of and use the local neglect strategy; assurance from the local authority regarding improvements in the use of the Graded Care Profile and evidence based practice in neglect cases; all plans for a child in need or for child protection need to provide a clear and detailed description of who is undertaking what work with the family, which takes their role and its limitations into consideration.
Keywords: child neglect, parents with a mental health problem, risk assessment, fathers, professional curiosity, substance misuse
> Read the overview report

2021 – South Tees – Liam

Hospitalisation of a 2-year-11-month-old boy due to ingesting multiple drugs
Learning includes: seek assurance from partners about how and when learning from previous serious case reviews or child safeguarding practice reviews will be embedded into practice; ensure that arrangements are made to allow safe and open conversations with people who are known or suspected of being victims of domestic abuse; assessments should be multi-agency and consider all information, including historical context around all cumulative risk factors; professionals may want to consider a more interactive method of working with families to ensure appointments are attended; the impact of mental illness, domestic abuse, drugs and alcohol on parenting capacity should be routinely included in child in need and child protection plans; the voice of the child and their lived experience should be evidenced and prioritised in assessments and care plans in a way that assesses any change to parenting capacity; ensure that professional curiosity and information sharing is exercised and where necessary escalate concerns - may wish to consider Working Together 2018 and detailed expectations of how local authorities, and wider partners, should respond to extra-familial harm; assessments should recognise contextual risks, and care plans should recognise the capacity of parents in providing support or where necessary escalating statutory interventions.
Keywords: voice of the child, drug misuse, maternal depression, neglected children, professional curiosity, children in violent families
> Read the overview report

2021 – South Tyneside – Child J

Severe non-accidental injuries to a 3-month-old infant in August 2019
Learning includes: fathers need to be as visible in all agencies' antenatal and postnatal care and support as mothers; pro-active and tenacious attempts need to be made to involve fathers in assessment and the planning and delivery of support for children, this may require a specific approach to engage them; and when vulnerable young women stay with friends or partners in houses of multiple occupation, professionals should show curiosity about the other residents, especially males, and consider whether they pose any risk.
Recommendations include: seeks assurance from all agencies that offer services to children and families that they have individually and collectively considered how best to improve arrangements to engage vulnerable young parents, especially fathers; ensure that all agencies keep fathers, as well as mothers, in mind especially during pregnancy and early babyhood; as well as assurance from Children's Social Care that pre-birth assessments are being done for all babies that need them, and that child and family assessments are shared more frequently and consistently with other agencies including GPs.
Keywords: abused infants, non-accidental head injuries, adolescent parents, parenting capacity, family support services, home visiting
> Read the overview report

2021 – St Helens – Charlie

Hospital admission of an adolescent girl in 2019 who was suspected to have been the subject of fabricated or induced illness (FII). Charlie’s mother was found unconscious by ambulance services after taking a drug overdose and had reportedly given Charlie tablets.
Learning: learning is embedded within the review.
Recommendations include: review data to benchmark the number of families with children who could be affected by parental opioid prescribing; parental substance misuse guidance should include further guidance regarding safeguarding concerns arising from parental dependence on prescribed drugs; a designated doctor to review Charlie's medical records to establish lessons on identifying and responding to indicators of FII, particularly in older children and adolescents; agencies identify how to improve practitioner engagement with fathers in safeguarding and child protection work; regular dip-sample audits of cases where child protection enquiries have concluded with substantiated concerns but where the decision was made not to proceed to a child protection conference.
Keywords: adolescent girls, addicted parents, drug misuse, prescription drugs, fabricated or induced illness (FII)
> Read the overview report

2021 – Sunderland - Child FC

Death of a 16-year-old boy from a drug-related overdose in September 2019. At the time Child FC was a child looked after but was living at home with his mother. There had been ongoing concerns about his mental health and his use of substances.
Learning themes include: understanding of Child FC’s vulnerabilities and needs and the risks to which he was exposed; quality and effectiveness of assessments and plans to keep Child FC safe; how well agencies communicated and collaborated; professional judgments and decision-making; working with parents; and engaging with adolescents.
Recommendations to the partnership include: urge the Department for Education to set out a strategy for how it intends to improve residential care for looked after children in England; build on work to develop a robust framework for multi-agency work with adolescents at risk, to ensure that strategies and service designs acknowledge that risks exist within peer groups and social networks as well as within families; consider how to improve collaboration between agencies so the expertise of practitioners in specialist services can be used more effectively to inform assessments and avoid the dangers of silo-working; seek assurance from partner agencies that managerial oversight in respect of casework and record keeping is robust and in line with best practice; consider how it can ensure that key tools, such as multi-agency chronologies and plans for children, including SMART targets, are used to support decision-making; ensure that professionals working with adolescents and their parents have the necessary skills to build and maintain high quality relationships
Keywords: care orders, child deaths, child mental health services, drug and alcohol services, parent-professional relationships, secure accommodation
> Read the overview report 

2021 – Surrey – Child B

Death of a 15-year-old boy in June 2017 by suicide.
Learning: practitioners across the multi-agency network face challenges when charged with responsibility for safeguarding children in mid-adolescence; effective plans for risk-taking, tolerating uncertainty, risk-minimisation and promoting safety rely on robust risk analysis; the principle of understanding behaviour as communication is as relevant for children in mid-adolescence as for younger children.
Recommendations: ensure that specialist mental health services engage in effective collaboration and co-working with the team around the child, the child’s parents, and the child’s informal network of care throughout their involvement with children; ensure that staff throughout the service are aware of and consider a range of potential sources of early help for children and families while waiting for specialist assessment or input.
Keywords: child deaths, suicide, self-harm, child mental health services, self-poisoning, psychoses
> Read the overview report

2021 – Surrey – Sudden unexpected death in infancy

Thematic review of 20 sudden unexpected deaths in infancy (SUDI) between April 2014 and March 2020 in Surrey.
Learning includes: along with greater risk associated with placing a baby on the front or side to sleep, there is also a greater risk to babies who are in a room alone; co-sleeping when a particular high-risk circumstance is present increases the risk to the baby compared to co-sleeping alone; there is extensive data to show that breastfeeding has a protective factor in reducing SUDI.
Recommendations include: ensure partners adopt a practice model encompassing reducing the risk of SUDI within wider strategies for promoting infant health, safety and wellbeing; fully implement the NICE guidance - Smoking: stopping in pregnancy and after childbirth; ensure that alcohol awareness training that promotes respectful, non-judgmental care is delivered to all health and social care staff who potentially work with patients or service users who misuse alcohol.
Keywords: sudden infant death, sleeping behaviour, parenting education, smoking, birth weight, literature reviews
> Read the overview report

2021 – Sutton – Child V

Near-fatal knife injury to a 17-year-old boy in December 2020. Child V had been subject to a child protection plan until March 2020.
Learning includes: the need to view children who are not in school, especially those with education, health and care plans (EHCP), as high risk and requiring a safety network of agencies to work together; there is a need for professionals to improve their understanding of the impact of cumulative harm on an adolescent who is struggling to find a safe transition into adulthood; there is a need to ensure that the work already undertaken to develop a contextual safeguarding approach is strengthened to include a wider range of agencies.
Recommendations include: ensure that there is an effective multi-agency partnership approach to identify critical indicators of the risk of extrafamilial harm by applying contextual safeguarding principles; ensure that there is a process in place for regularly reviewing children being removed from a child protection plan without the outcomes being achieved; ensure that children who are out of school are given opportunities to voice their views of their situation.
Keywords: adolescent boys, injuries, weapons, transition to adulthood, school attendance
> Read the overview report

2021 – Thurrock – Leo

Death of a 9-year-old boy in June 2019. Leo was found unresponsive in the family home, and taken to hospital where he was pronounced dead.
Learning: social workers should take the “think wider family approach”, considering all members of the family or household to assess their impact on the whole family; professionals should be involved in multi-agency meetings, including healthcare professionals, to ensure effective plans are in place; when families are living in poverty, the focus needs to remain on the cause and impact of poverty on the children, and professionals should escalate cases where families' access to funds and services is not sufficient; children's services and partners should use specialist assessment tools in cases of neglect to quantify needs and measure perceived improvements or deteriorations; when an adult or child is recognised as a carer, the full extent of their role and its impact should be clearly articulated in assessments and shared with partners.
Recommendations: makes no recommendations.
Keywords: child deaths, child neglect, child health, poverty, home environment
> Read the overview report

2021 – Torbay – C67 and C68

Non-accidental injuries to a 9-year-old girl in January 2018.
Learning includes: parents require effective education programmes that are delivered in a timely manner to assist them in effectively coping with family life and improve the lives of their children; there is a lack of confidence that decision making will be robust in similar cases where there has been a non-disclosure by a child but sexual abuse is suspected.
Recommendations: review the current process of the allocation of parental education programmes (including Triple P) to ensure that they are delivered at the earliest opportunity; review and identify all available options to improve the current provision of services for adolescents with complex behavioural issues; review training and guidance in respect of non-disclosure issues in sexual abuse cases.
Keywords: injuries, parenting capacity, home environment, child neglect, child protection registers, harmful sexual behaviour
> Read the overview report

2021 – Torbay – Child C80

Incidents of rape and sexual assault by a 16-year-old looked after child, referred to as C80, in the nursery where he was an apprentice. A sibling of C80 subsequently disclosed past experience of rape by C80.
Learning includes: a trauma informed approach could be further developed across the partnership; a child’s experience of sexual abuse should form an integral part of care plans and assessments even where this is not the primary reason for protection or intervention; it is not deemed necessary or appropriate that a child’s experience of sexual abuse, or other ACEs should be shared with employers; therapy should form part of ongoing care planning to ensure continuity, particularly when placements are disrupted; life story work with all children in care should be mandatory and timely; practitioners should be confident to identify and respond to sexual abuse indicators and to differentiate between ‘normal’ behaviour and that of concern or risk; there should be a timely transfer of information regarding vulnerable students between pre and post 16 education and training providers; there is no statutory guidance regarding the level of suitability assessment required for students attending placements as part of childcare studies; information that may be of safeguarding concern should be shared by referees with potential employers; CCTV should not replace in person observation; need for clarification regarding the layout/ design of toilet facilities in nursery settings; when sexual abuse is suspected, a single point of contact should be established that signposts to appropriate support services.
Makes recommendations to improve procedures for care experienced children and to strengthen approaches in the areas of recruitment, apprenticeship, supervision and safeguarding practice in early years settings. Includes recommendations for the Department for Education, regarding a review of the Early years foundation stage (EYFS) framework.
Keywords: abusive adolescents, children in care, child sexual abuse, nurseries, rape, sibling abuse
> Read the overview report

2021 – Torbay - C81

Serious concerns regarding a 17-year-old girl whilst in local authority care in October 2019. C81 was placed out of area, during which time she was reported as missing on 38 occasions. Missing episodes culminated in her jumping out of a window to avoid police, which resulted in injury. She had been exposed to neglect and sexual abuse within the family setting and was exposed to criminal and sexual exploitation for a number of years.
Learning focuses on: support, including child mental health services, and the independent reviewing officer (IRO); missing episodes, and response to these by practitioners; child criminal and sexual exploitation; disclosures of abuse and responses by practitioners; and placement of cared for children outside their home area.
Recommendations include: children’s services ensure there are robust handover processes in place for information transfers to new professionals regarding cared for children; children’s services should ensure that when a child moves into or out of area, the placement planning meeting reviews and shares relevant information pertaining to the child’s care plan; children’s services to review current missing persons practice and ensure that a comprehensive package of information in relation to previous missing persons episodes accompanies a young person when placed out of area; children’s services to contact the Child Safeguarding Practice Review Panel to support the development of a national protocol for return to home interviews for children in care who are placed out of area; and children’s services to review current placement plans to ensure that the impact of placement and the risks of contextual safeguarding are included within them.
Keywords: children in care, adolescents who go missing, child sexual abuse, child neglect, child criminal exploitation, child sexual exploitation
> Read the overview report

2021 – Wakefield – David

Sudden unexpected death of a 7-week-old boy in January 2020.
Learning includes: safe sleeping is an issue for services broader than health visiting and midwifery; the value of providing timely early intensive help; using chronologies and enquiring into relevant history; professionals developing and using focussed and respectful curiosity; using language that reveals vivid pictures of risk and neglect; neglect in areas of high deprivation; use of tool kits and evidence-based frameworks to guide and inform the collation and analysis of information about neglect; and ensuring primary care services have effective arrangements to identify and respond to neglect.
Recommendations include: development of a public information strategy that promotes safe sleeping for children under six months; substance misuse service should provide targeted lessons learnt for substance abuse practitioners; targeted lessons learnt should be provided to schools to include the importance of pupil file transfers when moving schools, the use of the neglect toolkit and oversight by designated safeguarding leads in schools; the Early Help Service should ensure that assessments are robust and timely and include information from all involved services; Early Help Assessments and plans should include specific reference to safe sleeping arrangements and incorporate the use of the neglect toolkit; and the Multi-Agency Safeguarding Hub (MASH) should ensure that the use of the neglect toolkit is being used within referrals to the service.
Keywords: child neglect, home environment, safety measures, home visiting, infant deaths, substance misuse
> Read the overview report

2021 – Wakefield – Jason

Death of a 3-month-old infant in August 2019. Jason had been co-sleeping with a sibling and his mother. Jason had already died when his mother contacted emergency services and he was taken to hospital.
Learning includes: some parents have difficulty assimilating and consistently following advice and the circumstances under which children's needs are neglected; the way parents respond to their children's needs is influenced by their own childhood experiences; parents who have experienced unstable or adverse childhoods can learn to just focus on their own needs because they have learnt not to depend on others.
Recommendations include: ensure multi-agency training includes curiosity about where children are sleeping as part of assessments; develop safe sleeping procedures emphasising the importance of ongoing risk assessment about safer sleeping for all services; consider how the use of the neglect toolkit is used routinely by services; encourage every GP practice to have a written protocol for discussing safeguarding concerns and follow-up.
Keywords: sudden infant death, sleeping behaviour, parenting capacity, parent-professional relationships, adults abused as children, adverse childhood experiences
> Read the overview report

2021 – Warrington – Case AB

Sexual abuse of three siblings by members of their extended family
Learning includes: the impact of neglect and adverse childhood experiences (ACEs) on children's social, emotional and cognitive development; seek to make sense of and understand the lived experience of children; seek to understand the lived experiences of parents and carers who may have experienced trauma, live with domestic abuse, substance abuse or mental health issues and the impact of this; remain mindful, when working with children and young people with special educational needs and/or disabilities (SEND), of the fact that not all disabilities are visible, and that some children may present as more able than they are; ensure effective communication between agencies; professionals must be alert to "exaggerated hierarchy", whereby professional status becomes magnified and other professionals perceive themselves to have comparatively lower status; prevent closed professional systems, where one agency assumes a dominant position or view of a case and fails to pay attention to conflicting information or information that fails to support their views and hypothesis; during the planning of any assessment, it is important to determine who knows the child(ren) and family and holds information about them; consideration of the impact of domestic abuse on the child/parent relationship; consideration of the impact of parental mental health in relation to parenting and the impact this can have on the child/parent relationship; and children and young people should be carefully matched when placed in foster care, with foster carers having a clear understanding of children's lived experience, any SEND and how this impacts in terms of meeting their needs.
Recommendations include: ensure information/concerns/allegations are communicated to children's social care in a timely manner; support information sharing between and within organisations, and address any barriers to information sharing, including neighbouring authorities; and ensure partner agencies are aware of the organised and complex abuse procedures and receive appropriate training and guidance.
Keywords: disclosure, sexual abuse, extended families, sex ring, voice of the child
> Read the overview report

2021 – Warwickshire - Jack

Death of an adolescent boy in 2020. Jack took his own life. Two months prior to Jack’s death the UK was in a COVID-19 pandemic lockdown. Prior to lockdown Jack had moved from his father’s to his mother’s house, and he was in the process of moving to a new school following fixed term exclusions.
Learning focuses on: risk assessment of domestic abuse by police in relation to children; lateral multi-agency checks and parental consent; excessive drinking by teenagers and signs of vulnerability and adverse childhood experiences (ACEs); signs of trauma resulting from ACEs; the police and education information sharing partnership Operation Encompass; and safeguarding and information sharing when students move schools.
Recommendations include: police ensure that when attending domestic abuse incidents the details of all children living in the household or living with the person reported to have carried out the abuse are recorded, risk assessed and considered for referrals; children’s services set guidance about the need to undertake lateral checks with other agencies on children and the threshold for dispensing with parental consent to do so; the safeguarding partnership develop guidance on the potential significance of underage drinking for vulnerable children under 14-years-old; the safeguarding partnership support staff in all settings to recognise the signs and symptoms of ACEs; police refresh Operation Encompass in schools and the guidance that a notification allows schools to monitor a child; and ensure that when students transfer to a new school all necessary information relating to a child’s welfare and safeguarding is transferred.
Keywords: suicide, adolescent boys, coronavirus, schools, children in violent families
> Read the overview report

2021 – Windsor and Maidenhead – Child T

Death of an 11-month-old girl in April 2020, due to asphyxiation. Child T was found by her birth mother, between the bed guard and the mattress.
Learning includes: need for effective and appropriate transfer of children’s cases between safeguarding agencies; children’s cultural and ethnic backgrounds should be considered in assessments and care planning; the voluntary sector, including specialist domestic abuse services should be part of safeguarding partnership arrangements; impact of trauma experienced by parents can affect their ability to care for their own children; need for professionals to fully understand the role of absent or non-resident birth fathers; the temporary safety of a refuge should not influence decision making in relation to the significant harm experienced by the children; professionals should have an understanding about safer sleeping and be able to question arrangements.
Recommendations include: families moving to refuge accommodation and making homelessness applications to a local authorities should be referred to the local children’s social care arrangements in the authority to which they are moving; survivors of domestic abuse moving from refuge, to new accommodation should be afforded a risk assessment as to its suitability; the Child Death Overview Panel, Public Health and Trading Standards should consider additional warnings regarding the safety of bed guards and their appropriate use in safer sleeping messages. 
Keywords: housing, infant deaths, local authorities, refuges, sleeping behaviour, sudden infant death
> Read the overview report

2021 – Wirral – Liam

Ingestion of a potentially fatal amount of methadone by a 20-month-old boy in the autumn of 2018. Both parents were arrested on suspicion of child neglect.
Learning: ensure that assessments collect and synthesise information from a range of sources; improve the quality of analysis of known risks; the importance of being tenacious about engaging fathers and understanding their role in the family; the particular challenges of working with families where children are placed with parents as an outcome of care proceedings; improve safeguarding of children living with parents when care proceedings have ended.
Recommendations: revise existing multi-agency safeguarding procedures, protocols and guidance in respect of parents who misuse substances; improve levels of basic awareness of substance misuse, specific safeguarding issues and how to obtain specialist advice; undertake a multi-agency audit of cases where children are living in households where adults are known to misuse drugs or who are now being treated with opioid substitute therapy.
Keywords: child neglect, fathers, substance misuse, care proceedings
> Read the overview report

2021 – Wirral - Matthew

Death of an 18-year-old boy in September 2019. Matthew was found by staff at his supported accommodation, having taken his own life. Matthew became a looked after child in early 2019 following the breakdown of his adoptive placement.
Learning themes include: professionals understanding the impact of past trauma and adverse childhood experiences (ACEs) on adopted young people; the nature of support given to children and families where there is a breakdown in the adoptive relationship; managing the sharing of historical information with children who have been in care; engaging with young people who are reluctant to accept support; and managing access to appropriate accommodation, and issues such as eviction due to behaviour.
Recommendations include: ensure the workforce is skilled in trauma informed practice and understanding the impact of ACEs; ensure access to support services for mediation between young people who have been looked after and their families; ensure there is a robust process for sharing children's services information with care leavers, and appropriate support is provided; identify good practice and develop strategies to ensure support services can productively engage with reluctant young people; and ensure children in care understand their life story and sense of identity.
Keywords: suicide, adolescent boys, placement breakdown, adopted children, children in care
> Read the overview report