Recently published case reviews

Last updated: 23 May 2022
Case reviews published in 2022

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 repository.

Case reviews describe children 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

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.
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 – 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.
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 – 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.
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 – 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.
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 – Blackburn with Darwen, Blackpool, Lancashire – Sarah

Death of an 8-day-old baby in Summer 2017 following head trauma caused by shaking.
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 – 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.
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 – 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.
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.
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 – 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.
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 – 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.
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 YS

Assault on a 7-month-old child by their father, resulting in life threatening injuries.
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 – 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.
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

Case reviews published in 2021

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 repository.

Case reviews describe children 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

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.
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.
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.
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.
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.
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.  
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.
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.
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.
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.
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.
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.
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 – 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.
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.
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.
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.
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.
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.
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.
 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.
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 – 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.
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. 
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.
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.
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.
 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 – 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 - James

Death of a 10-year-old boy in August 2020. James died because of restricted airways after his mother gave him an excess does of melatonin, prescribed to help him settle at night, and put him to bed with a sponge in his mouth.
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.
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 – 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.
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.
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 – 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.
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 – 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.
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 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.
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 – 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.
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 – 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. 
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.
 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 – 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.
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.
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.
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.
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 – 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 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 – Surrey – Child B

Death of a 15-year-old boy in June 2017 by suicide.
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.
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.
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.
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.
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 – 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.
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 – 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.
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

Case reviews published in 2020

Case reviews published in 2020

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 2020. To find all published case reviews search the national repository.

Case reviews describe children 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

2020 – Anonymous – Adolescent girl BR19

Child sexual exploitation and neglect of a 15-year-old girl. The review focuses on one child, BR19.
Learning: centres on the following themes: need for multi-agency planning and analysis of risk; impact of child sexual exploitation (CSE) and services for survivors of CSE who are parents; parental engagement and consent; professional challenge and escalation; professional curiosity of the child's lived experience; contextual safeguarding and perception of sexual activity between teenagers being consensual.
Recommendations: include: to strengthen multi-agency decision making and practice in relation to child protection processes; understand and respond to the links between adolescent neglect, CSE and contextual safeguarding; understand the impact of traumatic adverse life experiences on parenting through partnership assessments.
Keywords: child sexual exploitation, adolescent girls, child neglect, contextual safeguarding
> Read the overview report

2020 – Anonymous – Baby L

Serious injuries to a 3-month-old infant in December 2018. At the time of the reported injuries, the baby and their older half-sibling had been subject to child protection plans and to a Public Law Outline (PLO) process.
centres around: the effectiveness of pre-birth and post-birth multi-agency assessment, multi-agency case management, inter-agency communication and information sharing; how well practitioners considered the inherent vulnerability of babies to abuse and non-accidental injury, particularly in the context of the trilogy of risk; barriers to recognising and addressing over optimism in parents.
Recommendations: include: ensure that pre-birth assessments are completed on time by social workers and include all relevant information, and parents’ accounts and views are appropriately tested and triangulated by evidence from other sources; ensure that guidance on injuries to non-mobile babies has been widely disseminated to all front-line practitioners and embedded in practice.
Model: uses a Welsh model.
Keywords: infants, physical abuse, injuries, information sharing
> Read the overview report

2020 – Anonymous – Bilal

Serious neglect and physical and emotional abuse of a 9-year-old boy and his siblings by their parents.
the role of neighbours and local communities in recognising and responding to concerns about children and young people; areas that usefully inform practitioner learning and improvements in practice include taking a child-focused approach, cultural sensitivity and professional curiosity; contact with the family at transition from health visiting to school nursing services can help determine ‘school readiness’ of a child and to identify unmet needs.
Recommendations: identify how to report and share information about children who have not been seen for a significant amount of time and triangulate whether there are further concerns across agencies; ensure that children and young people who are home educated can access help and support to meet their needs via the current children and young people section of the local authority schools and learning webpage.
Keywords: witchcraft, religion, Childline, children with learning difficulties, culture
> Read the overview report

2020 – Anonymous – Child A and Child B

Sexual abuse of two children by a carer whilst in a long-term kinship care placement. An older sibling living in the same placement witnessed Child A being sexually abused by the carer and informed the mother and then the police. Carer received a custodial sentence for the sexual abuse of Child A and Child B.
includes: importance of robust exploration during the approval process for kinship foster carers; placement reviews for looked after children in kinship care placements should identify when national minimum standards are not met to avoid children remaining long term in inadequate accommodation; without consistent, rigorous and child focussed oversight by supervising social workers, shortcomings in the parenting capacity of kinship foster carers may not be identified or challenged.
Recommendations: include: ensure that social workers support children in kinship care to identify a trusted professional who will enable them to get their voice heard in the decisions which impact on their lives; ensure that social workers have access to regular supervision which provides opportunities for reflection and critical challenge with a specific focus on the effectiveness of care plans for looked after children.
Model: uses the Welsh Child Practice Review model.
Keywords: kinship foster care, child sexual abuse, children in care, voice of the child
> Read the overview report

2020 – Anonymous – Child N

Injuries to a 4-week-old infant in 2016. Civil court found that the injuries were caused by the father and that the mother failed to protect Child N. A criminal investigation in respect of both parents and the paternal uncle concluded with no further action in 2020.
includes: when one parent has mental health issues affecting their ability to care for the children, the assessment and plan needs to consider the impact on the other parent or carer; supervision for professionals needs to ensure they are focused on the child and not on the parent's histories and situations; professionals should seek to understand the nature of parenting relationships from the point of view of both parents or adults and the child, and not focus only on the mother.
Recommendations: include: confirm if formal pre-birth assessments are being undertaken in cases where a new baby will be the subject of a child in need or child protection plan at birth; consider the benefits and practicalities of requesting that the information that a child is on a child in need plan is shared with all professionals working with the family.
Model: uses the Significant Incident Learning Process (SILP) model.
Keywords: physical abuse, infants, injuries, parents with a mental health problem
> Read the overview report

2020 – Anonymous – Child Sam

Serious, non-life threatening injuries to an adolescent in a targeted attack in 2019.
Learning: following any high-profile local incident, community tensions and anxiety are likely to be heightened; safeguarding partners need to be assured that they are sharing key information and that they are doing so securely in compliance with regulations; there are potential implications for children and vulnerable people who are ‘released under investigation’ especially when this is for an extended period.
Recommendations: local police should review its ‘released under investigation framework’ to ensure that professionals conducting reviews take cognisance of a suspect’s age, vulnerabilities and safeguarding risks; review the ‘Step Up & Step Down’ procedure to ensure that a multi-agency approach is taken when making decisions relating to levels of need.
Keywords: child criminal exploitation, substance misuse, coping behaviour, bereavement, family conflict, police
> Read the overview report

2020 – Anonymous – Child Tracy

Death of a 3-month-old girl in March 2019. Tracy was found deceased at home. Criminal investigation commenced by police and care proceedings instigated for siblings.
Learning includes: it is the responsibility of any professional who is working with a child and/or family to initiate an Early Help Assessment Tool (EHAT); anonymous reports of safeguarding concerns can create a challenge for professionals in identifying the facts and responding to safeguarding concerns in a timely and evidence based approach.
Recommendations includes: produce a pathway for professionals which details what support, processes and resources are available for engaging resistant families; ensure that information is available to the public on the timeliness of reporting concerns, as well as, the outcomes that are available to agencies in response to those concerns.
Keywords: infant deaths, child neglect, non-attendance, parental involvement, assessment
> Read the overview report

2020 – Anonymous – Child Z

Sexual assault and sexual exploitation of an adolescent girl between the ages 14-18-years-old.
Findings include: resource pressures manifested in high thresholds; medical focus was necessary but an early consideration of home situation would have been appropriate; local authority transfer requests were not founded on the best interest of the child; lack of understanding of the lived experience of Child Z.
Recommendations include: children who themselves have children should have their own social worker and their own separate plan for the avoidance of conflicts of interest.
Model: uses a hybrid model based on the Welsh Model.
Keywords: child sexual abuse, child sexual exploitation, teenage pregnancy, voice of the child
> Read the overview report

2020 – Anonymous – Children’s Case C

Severe neglect and abuse of a large group of siblings by their mother and father over many years. Care proceedings concluded in 2017 and the children are no longer under parents' care. Six of the siblings are now adults.
Learning: the overwhelming nature of the complexity and scale of the problems and of the oppositional, hostile behaviour of the parents; responses from all agencies to concerns and interventions were generally short-lived and episodic; children's lived experience was not fully appreciated.
Recommendations: develop a model for inter-agency practitioner supervision for complex cases where working together closely and consistently is of paramount importance; ensure that the use of the Public Law Outline is being used effectively to give local authority and social workers sufficient leverage with families who are deliberately obstructive by clarifying their concerns in a 'Letter before Proceedings' or further action.
Keywords: Child neglect, child abuse, hostile behaviour, disguised compliance, voice of the child
> Read the overview report

2020 – Anonymous – Family D

Sexual abuse and neglect of three siblings by their father over many years. The father was convicted of sexual offences and received a substantial term of imprisonment.
professionals need to act with caution when a victim makes a 'retraction' statement; professionals need to recognise when they come into possession of information concerning historical sexual abuse which should be shared with other agencies; providing the victims of domestic abuse with access to an Independent Domestic Abuse Advisor (IDVA) will help professionals recognise and respond to the impact of coercive and controlling behaviour.
Recommendations: partner agencies should ensure that their records capture the detail and rationale for actions and decisions, and that they have processes for timely sharing of information about incidents; when the word 'retraction' is used in connection with an investigation, the reasoning behind that decision should be documented in police records and shared with other agencies.
Model: uses Appreciative Inquiry (AI) methodology.
Keywords: child sexual abuse, child neglect, partner violence, disclosure
> Read the overview report

2020 – Anonymous – Family G

Chronic neglect and intrafamilial child sexual abuse of male and female children, aged between 3-to 9-years-old at the time abuse was first reported. The mother and her male partner were subsequently convicted of multiple offences of sexual abuse.
includes: information exchange between professionals must be comprehensive and timely; professionals need to recognise the different indicators of possible child sexual abuse so that potential indicators are not misunderstood, dismissed or ignored; professionals need to use curiosity, hypothesising and a critical analytical mindset throughout the risk assessment process; if an agency decides not to implement an important case conference recommendation, the relevant agency professional must notify the case conference chair with reasons.
Recommendations: include: professionals must have knowledge to enable them to identify and respond effectively to children who are or who may be at risk of suffering multiple categories of abuse; professionals must have knowledge of child sexual abuse, including female perpetrator behaviours; Achieving Best Evidence interviews and medical examinations must be child centred and undertaken in a timely way; effective management and multi-agency oversight must be child focused, analytical and reflective.
Model: uses the Significant Incident Learning Process (SILP).
Keywords: child neglect, child sexual abuse, abusive mothers, case conferences, professional curiosity
> Read the overview report

2020 – Anonymous - Georgia

Life-threatening self-harm of a 15-year-old girl in May 2019.
foster carers require training that is trauma-informed; when a child in care moves area it is important for all professionals to share information and for key professionals to speak to their equivalents in the new area; Independent Reviewing Officers (IROs) must focus on a child, regardless of the pressures that professionals working with the child are experiencing.
Recommendations: undertake a multi-agency audit to consider practice and processes when a child in care is placed outside of area; seek assurance that professionals in partner agencies are using appropriate formal processes to challenge other professionals if they are concerned about the plan for a child, or do not receive information that is required.
Keywords: self-harm, adolescent girls, foster care, information sharing
> Read the overview report

2020 – Anonymous – Harry

Attempted suicide of a boy aged under 16-years-old in 2019. Harry had experienced significant neglect, trauma, emotional and mental health difficulties.
Learning: the need for a greater appreciation of the impact of early childhood adversity and trauma and the importance of using this information to inform decision making and safety planning; importance of information sharing across borders and agency boundaries; the need for prompt action to secure the appropriate type of support and intervention when young people experience an acute and serious mental health episode. Identifies areas of good practice.
Recommendations: to inform the Child Safeguarding Practice Review Panel about the apparent lack of explicit guidance about the transfer of school records across borders in Scotland and England; to review and amend guidance and procedures on the management and information sharing practices between local community based child mental health services, acute health settings and community health services for situations where children re-present to an acute setting.
Model: Uses the SILP (Significant Incident Learning Process) methodology.
Keywords: self-harm, suicide, adolescent boys, adverse childhood experiences, information sharing
<> Read the overview report

2020 – Anonymous – Young Person B

Self-harm of a young female in June 2018. Young Person B took a significant overdose of her prescription medication, alongside over the counter medication, which caused a brain injury.
Learning: includes the importance of ensuring representation from schools at child protection conferences and in core groups even when the child or young person is not attending school; the need to risk assess access to prescribed medication for children and young people who self-harm; importance of understanding the potential adverse impact on the young foster person and on other children in the family of private fostering arrangements not being assessed.
Recommendations: ensure practitioners understand the signs of adolescent neglect and review the effectiveness of local approaches in addressing both chronic and acute factors; ensure that the voice of the child is more consistently acted upon; ensure private fostering is more effectively publicised across the partnership and children are identified, assessed and supported in their private fostering arrangement.
Keywords: self-harm, adolescent neglect, informal care, private fostering,  adverse childhood experiences
> Read the overview report

2020 – Birmingham – BSCB 2015-16/03

Serious injury to a 4-month-old baby consistent with shaking and an impact to the head in November 2015, resulting in permanent impairment. The mother was convicted of child cruelty to the baby and their sibling in March 2020.
if families do not want or refuse early help, concerns should be escalated; intervention pathways need to be clear; new birth visitors should have all the information before the first visit; there is a need to remain focused on all family members and their needs; information should be linked, shared proportionately and well-recorded; assessments should identify risks and vulnerabilities; referrals should be seen in context; importance of engagement with fathers.
Recommendations: improve provision and organisation of early help services including how new birth visits are carried out; Children’s Advice and Support Service (CASS )/ Multi-Agency Safeguarding Hub (MASH) should develop operational guidance to enable triggers where there are multiple referrals or contacts including using chronologies; there should be fast decision-making when there is an open case and another referral is made.
Model: uses a blended approach based on Root Cause Analysis.
Keywords: teenage pregnancy, parenting capacity, newborn babies, information sharing, head injury, bonding behaviour
> Read the overview report

2020 – Blackpool - Child CE

Death of a 10-week-old infant in March 2019. Cause of death was confirmed as overlay due to unsafe sleeping arrangements. Police investigation concluded with no further action taken.
being actively curious about members of the household, family dynamics and actual, or potential, risks to children is an important consideration for practitioners; contemporaneous record keeping is an essential requirement following all appointments and contacts; ensuring fathers are given the same advice and support as mothers is important; ensuring new parents think about safer sleeping arrangements for the baby is a core task for all professionals.
Recommendations: to review the current strategies and initiatives around safer sleeping advice, support and promotional materials and consider any changes which may promote knowledge and understanding.
Keywords: infant deaths, sleeping behaviour, fathers, professional curiosity.
> Read the overview report

2020 – Bromley – Leo

Murder of a 17-year-old boy with special educational needs (SEN) from multiple stab wounds believed to have been inflicted by several other young people. Leo had severe difficulties with speech and language and at the time of his death, he was living in supported accommodation for young people.
is embedded in the recommendations. 
Recommendations include: ensure that professionals have access to good training on the signs, symptoms and impact of speech, language and communication disorders; prioritising staff working with children at risk of offending; ask that agencies take all reasonable steps to identify and engage the fathers of children and young people with whom they are having contact; the Youth Offending Service should ensure that being charged with a violent offence triggers a multi-disciplinary assessment of need and risk.
Keywords: adolescent boys, murder, children with disabilities, violence, language, weapons
> Read the overview report

2020 – Buckinghamshire – Baby S

Death of a 5-month-old infant girl in April 2016 due to injuries caused by shaking. The mother stood trial in 2019 and was found not guilty of manslaughter.
includes: a more ‘enquiring’ approach to the familial circumstances might have highlighted a variety of additional needs and better-informed agency responses; professional curiosity is required and justified in all situations, not just troubling situations.
Recommendations: GP practices should capture which adult presents a child in records and ensure that immunisations or other medical interventions have fully informed consent, from a parent or person with parental responsibility; NHS Trusts should remind staff that effective record keeping requires evaluated observations of a child’s familial circumstances, behaviours of its members and any additional support needs.
Keywords: infant deaths, shaking, parenting capacity, professional curiosity
> Read the overview report

2020 – Buckinghamshire – Child V

Unexplained death of a 2-year-7-month-old girl in December 2018. Child V experienced neglect and delayed development.
includes: when the siblings of an unborn baby are subject to a child in need plan (CIN) the multi-agency CIN meetings should discuss the likely effects and ensure there is multi-agency agreement prior to closure of the plan; conduct a parenting assessment so that practitioners have realistic expectations of parents and to minimise the vulnerability of children; need to use processes and tools to identify, assess and respond to neglect; the voices and lived experiences of children should inform all assessments and interventions; there needs to be a multi-agency assessment if there is a disclosure of sexually harmful behaviour; strained professional relationships can impact on multi-agency cooperation and safeguarding practice.
Recommendations include: improve the early identification of and response to neglect; remind partner agencies about the decision making process prior to closure of a CIN or child protection plan; consider the development of pathways with adult services to assist with the assessment of parents and carers when there are concerns about their cognitive ability; identify the barriers to the effective use of tools to support the early identification, assessment and analysis of neglect, specifically, Graded Care Profile 2; robustly monitor and evidence the impact of the voice of the child in practice; identify and address barriers to the effective use of the escalation policy.
Keywords: child death, child neglect, neglect identification, assessment, voice of the child
> Read the overview report

2020 – Buckinghamshire – Serious youth violence: thematic serious case review

Review of the services provided for three adolescent boys following a serious knife crime in 2018 in which one of the boys was seriously injured. Considers what led to the boys’ involvement in serious youth offending and ways in which professional interventions may have safeguarded them more effectively.
is embedded in the recommendations. 
Recommendations include: ensure that primary schools are able to identify children who show severe behavioural difficulties, respond to their needs and make an appropriate referral for additional early help services; ensure that early help interventions are family-focused and take a full account of the child's history; ensure that secondary school transfer arrangements identify any child who has shown severe behaviour problems in primary school; ensure that policies, procedures and practice reflect the best current thinking about contextual safeguarding risks; and ensure that agencies and partnerships actively engage with Black and minoritised ethnic communities over the prevention and reduction of serious youth violence.
Keywords: adolescent boys, contextual safeguarding, exclusion from school, family violence, gangs, child mental health
> Read the overview report​

2020 – Bury – Isabella

Death of a 14-month-old girl in August 2019.
considerations should be given as to how professionals engage with fathers. If a father has not engaged, it should be clearly recorded that he remains an unassessed risk; if a parent does not consent to local authority support for a child in need, careful consideration should be given to escalating the protection provided; information about avoidant behaviour should be shared with all other professionals involved.
Recommendations: ensure that the language change - 'was not brought' is reinforced across partner agencies and that practitioners are trained to realise 'medical neglect' and recognise missed appointments as an indicator. The universal use of the language term will emphasise parents’ and carers’ responsibility to take a child in their care to health appointments and will deliver a clearer marker to identify neglect.
Keywords: child deaths, medical care neglect, sudden infant death, premature infants, parenting capacity, developmental disorders
> Read the overview report

2020 – Cambridgeshire and Peterborough – Jack

Serious harm suffered by a 3-month-old baby boy because of multiple injuries, including fractures and bruising of the brain in May 2017.
Learning: identifies lessons in relation to: effectiveness of assessments, consideration and management of risk; injuries to pre-mobile babies need to be viewed from a perspective of potential risk; consider risk of neglect where a child’s weight is varying; need to involve and support fathers; need to share information to allow robust discussion of concerns.
Recommendations: ensure procedures on pre-birth assessments are consistent, contain guidance on timescales and ensure sufficient challenge; all agencies should understand legal orders and their implications; ensure child protection plans are SMART using tools to measure progress; review and reissue guidance for parents with mental health problems, on joint working, and on bruising in pre-mobile babies.
Keywords: newborn babies, parenting capacity, feeding behaviour, adults with learning difficulties, information sharing, risk assessment
> Read the overview report

2020 – City and Hackney – Child C

Death of a 15-year-old boy in May 2019 as a result of being stabbed. A 15-year-old boy was found guilty of Child C's murder, and a 16-year-old boy and 18-year-old male were convicted of manslaughter.
exclusion from mainstream school can heighten risk; education settings need access to local intelligence; clarity is needed about interventions to mitigate extrafamilial risk; involving and supporting parents is essential to effective safety planning; inconsistent judgements about risk creates uncertainty; poor case recording can directly impact on practice.
Recommendations: review processes that involve the application of risk gradings for young people at risk of serious youth violence; exhaust all kinship options as part of a safety plan for children who are at risk of serious youth violence; schools should ensure they have a detailed understanding of the potential safeguarding needs of any child at risk of permanent exclusion; ensure that policy, procedure and guidance is sufficient to ensure the active consideration of racial and cultural identity as part of the safety planning process involving extrafamilial risks.
Keywords: weapons, child deaths, exclusion from school, contextual safeguarding, record keeping, child criminal exploitation
> Read the overview report

2020 – Cornwall and Isles of Scilly – Child C

Death of a 16-year-old girl in 2018, assumed to be suicide.
it's essential that practitioners understand parental capacity, strengths and attitudes to increase the effectiveness of interventions and avoid placing additional stress on children and their families; child sexual exploitation (CSE) requires a different focus from other forms of child abuse; adolescents can be exposed to a wider range of risks than younger children and concentrating on a single issue may lead to an over optimistic assessment of risk; assessments should include listening and responding to children's views.
Recommendations include: develop a research-based risk management strategy designed to address the specific features of adolescent risk taking and suicidal ideation; promote the concept of contextual safeguarding and ensure that it is adopted by practitioners and managers working within the child protection process.
Keywords: adolescent girls, child sexual exploitation, suicide, contextual safeguarding
> Read the overview report

2020 – Coventry - Serious case review of eight children

Serious sexual abuse of eight children, several of whom have disabilities including one child with serious physical and learning difficulties, by members of Family S between August 2010 and May 2016.
the need to hear the voice of the child, and not the louder voice of adults; need to develop knowledge of sexual abuse in relation to disabled children and ways to provide opportunities for non-verbal children to communicate; and the impact of gender on the response of services.
Recommendations: develop skills and knowledge in communicating with children who disclose sexual abuse; embed understanding of grooming and sexual offending in practice; and ensure a clear pathway is in place for identifying and working with complex intrafamilial sexual abuse.
Model: uses a systems-based methodology.
Keywords: child sexual abuse; children with disabilities, children with learning difficulties; extrafamilial child sexual abuse; disclosure, voice of the child; harmful sexual behaviour
> Read the overview report

2020 – Cumbria – Child CH

Death of a 14-year-old girl in June 2018.
risk assessments need to be holistic, shared across agencies and reviewed regularly; perceived risk can increase professional anxiety and be a barrier for access to services and placements; and when a child in care is particularly vulnerable, there should be a plan for service delivery which takes this vulnerability into consideration.
Recommendations: request assurance on the commissioning arrangements for placements for children who require stable and safe care; ensure that information about looked after children is shared with a placement or hospital when a child is moved; and write to the Department for Education and Ofsted about the challenge in finding placements for children with significant risks and vulnerabilities.
Model: uses the Significant Incident Learning Process (SILP) model.
Keywords: child mental health, children in care, placement breakdown, runaway adolescents, self harm, suicide
> Read the overview report

2020 – Dudley – Child A

Death of a boy aged under 3-months-old in June 2019. Child A was found unconscious on the sofa at home in the morning, and taken to hospital by ambulance where he was confirmed dead.
includes: parents should have been challenged about their use of cannabis and they should have been offered early help; there were opportunities for professionals to have visited the family home prior to the discharge of Child A, which may have identified the need for more support.
Recommendations: include: ensure that training of professionals includes the impact that cannabis use can have on parents’ ability to care for their children; promote the feasibility of conducting the antenatal and postnatal visits jointly, and ensure that the Graded Care Profile 2 (GCP2) tool is utilised where concerns are raised regarding home conditions and potential neglect.
Keywords: sudden infant death, sleeping behaviour, substance misuse, drugs
> Read the overview report

2020 – Dudley – Child D

Placement of a 12-year-old girl in secure accommodation in May 2019.
Child D’s aggressive behaviour may have impacted professionals’ perspective and response to the case; despite being on a child protection plan, outcomes did not improve for Child D; and there appears to have been a lack of cohesion in care planning.
Recommendations: analyse themes and trends from return home interviews to inform service provision; consider developing a strategy to manage highly complex and high-risk cases; review escalation around the legal gateway process.
Keywords: adverse childhood experiences, child sexual exploitation, disguised compliance, family dynamics, runaway children, secure accommodation
> Read the overview report

2020 – Dudley – Child L

Death of an infant girl aged under 3-months-old in September 2018. Cause of death was attributed to airways obstruction in the context of co-sleeping. Parents were cautioned for child neglect and drug possession offences.
includes: importance of enquiries about sleeping arrangements and the number of bedrooms in general as this can provide a clearer indication of where family members are sleeping and counteract disguised compliance when speaking with professionals; lack of professional curiosity surrounding why older sibling was living with her grandmother.
Recommendations include: ensure the Graded Care Profile 2 (GCP2) tool is utilised in every case where concerns are raised regarding home conditions and potential neglect; ensure that the Clutter Image Rating Scale (CIRC) is utilised where clutter is identified as a factor; review multi-agency training to ensure that training on neglect includes professional curiosity, disguised parental compliance, and the avoidance of normalising poor conditions.
Keywords: sudden infant death, sleeping behaviour, child neglect, substance misuse
> Read the overview report

2020 – East Riding – Baby B

Life-changing injuries to a 10-and-a-half-month-old infant in November 2013 due to shaking. Mother’s partner was convicted of causing grievous bodily harm and was imprisoned. Mother was convicted for neglect and received a suspended sentence.
concerns made anonymously should be treated as seriously as those that are not anonymous; health visitors and school nurses provide a useful link between schools and health services; where professionals have personal or professional relationships with a service user or someone closely involved with the service user, there is the potential for professionals’ boundaries to become blurred.
Recommendations: practitioners must ensure that they are complying with current legislation, statutory guidance and agency polices relating to information; ensure that the minutes of strategy discussions are included within the case record of all agencies involved in the meeting and include the arrangements for review.
Keywords: physical abuse, shaking, child neglect, parent-professional relationships, health visitors, school nurses
> Read the overview report

2020 – Gloucestershire – Children of Family Y

Significant and chronic neglect of four siblings over many years. The eldest sibling committed intrafamilial child sexual abuse on his three younger siblings on numerous occasions from 2012 to 2016. Both parents were charged with neglect offences.
Learning: includes:
practitioners should improve their awareness and personal knowledge in being able to recognise and identify symptoms of child sexual abuse and neglect; risk assessments must be carried out with the rationale recorded and supervised; 'was not brought' is a more relevant term than 'did not attend' as the emphasis is placed on the parent or carer who does not bring a child to an appointment.
Recommendations: include: all safeguarding partner agencies should ensure that staff are aware of the signs and symptoms of child sexual abuse and know what to do if they are seen or suspected; assure that staff complete background chronologies on their case files on children and families subject to child protection enquiries; ensure that staff capture the voice of the child in safeguarding cases and focus on the experience and impact on children.
Keywords: child neglect, child sexual abuse identification, non-attendance, voice of the child
> Read the overview report

2020 – Gloucestershire – Lauren

Sexual abuse, sexual exploitation and rape of an adolescent girl over many years. Lauren was placed in foster care under an emergency protection order when she was 17-years-old.
includes: the importance of an effective professional response to the sexual abuse and exploitation of children; the importance of recognising the specific needs of disabled children and young people and responding appropriately; recognising, assessing and responding to adolescent neglect; understanding relational and developmental trauma; dealing with professional disputes and differences of opinion in ways that put the child and young person at the centre.
Recommendations include: sexual exploitation itself should be addressed directly instead of just focusing on addressing family difficulties or programmes designed to educate young people; ensure that children who are subject to a child in need or child protection plan because of sexual exploitation have a disruption plan in place which would be incorporated into these wider plans; professionals need to support young people and address their fears and reluctance, alongside recognising their capacity; consider how best to address victim blaming language; focus on restorative practice principles that foster and enhance partnership working and a culture where respectful professional challenge is productive and welcomed.
Keywords: adolescent girls, child sexual exploitation, child sexual abuse, children with disabilities
> Read the overview report

2020 – Gloucestershire – Liam

Sudden unexpected death of a 1-month-old boy in 2019.
pre-birth planning and assessment is important in ensuring early understanding of possible risks; practitioners should be equipped to recognise possible feigned compliance and to address this in assessments and plans; record keeping was not of sufficient content or quality to know what was happening to the family and what risks were identified.
Recommendations: where information is missing and reliant on another practitioner or agency to provide it, this should be addressed by practitioners through the escalation policy; practitioners should be equipped to assess the significance of substance misuse and poor maternal mental health and its impact on parenting capability and put in place an appropriate plan of support and intervention.
Keywords: sudden infant death, drug misuse, sleeping behaviour, parenting capacity, adults abused as children
> Read the overview report

2020 – Gloucestershire – Megan

Neglect and abuse of a 6-year-old girl over a number of years. Megan was placed in the care of her paternal grandmother in 2012 via a Special Guardianship Order (SGO). She was neglected and physically abused by her father, her paternal grandmother and her grandmother's partner.
Learning: there is a need for practitioners to improve their awareness and personal knowledge in being able recognise and identify the signs and symptoms of all child abuse; agencies should have robust record keeping and management systems in place.
Recommendations: develop a safeguarding pathway for the application of family members for Special Guardianship Orders. The process will include utilising a Family Group Conference and to apply for an interim Kinship Foster Placement to allow safeguarding to remain in place whilst a detailed viability assessment of the prospective guardians' capabilities is conducted.
Keywords: kinship foster care, special guardianship orders, child neglect, child abuse, voice of the child, professional curiosity
> Read the overview report

2020 – Greenwich – Child A

Death of a 15-year-old boy in September 2019. Child A was fatally stabbed after responding to a message on social media to meet some friends.
there is a disproportionality of Black boys of African Caribbean heritage who are more likely to be susceptible to risks of criminal exploitation and this is mirrored in other national and local reviews, studies and case reviews; housing services weren’t engaged in multi-agency discussions about how agencies were seeking to reduce the risks to Child A; frequent moves between boroughs hampers and delays services to children and their families.
Recommendations include: ensure practitioners in early help services are equipped to work with children and families affected by criminal exploitation; ensure staff are equipped to identify, assess and make plans for children whose learning disability increases their susceptibility to criminal exploitation, where contextual safeguarding is an issue; ensure that guidance, best practice and training around multi-agency safeguarding discussion and meetings involves housing services.
Keywords: child deaths, weapons, social media, children with learning difficulties, housing, child criminal exploitation
> Read the overview report

2020 – Hertfordshire – Child K

Death of a 16-year-old boy by suicide.
focuses on: understanding Child K as an individual - a relational approach; identifying and responding to Child K’s emotional/mental health needs and his needs arising from his autism; responding to families; family safeguarding; working with adolescents at risk.
Recommendations: consider a trauma-informed relational approach; consider whether practice and service provision is sensitive to the cultural, historic and gender context of families, including those outside of the main Black and Minority Ethnic groups; and review cases of domestic abuse before closure to confirm that couples and children have been signposted to counselling or meditation services.
Keywords: autism, child mental health, ethnic groups, family violence, suicide, threshold criteria
> Read the overview report

2020 – Hillingdon – Child X

Death of a 7-year-old boy in December 2016. Inquest concluded Child X was unlawfully killed and his mother died by suicide.
information sharing within the police did not always work well; information held by friends and family should be taken seriously and support should be given to help them share information; there was a lack of focus on the potential impact of the mother’s alcohol use and mental health on her role as a parent.
Recommendations: guidance from the College of Policing should be unambiguous that, in cases of sexual assault, a victim care plan should be delivered by the police force where the victim resides; GPs should always ask patients whether they have any dependents when alcohol misuse is a problem; Local Safeguarding Partnership to consider, with national organisations, whether a helpline for families concerned that a child is at risk could be developed and publicised.
Keywords: alcohol misuse, filicide, mothers, mental health problems, child protection, crisis intervention
> Read the overview report

2020 – Hounslow – Sasha

Death of a 17-year-old girl by suicide in August 2017.
assessing competence, resilience and emotional attachment disorder in adolescents and considering the impact of adverse childhood experiences (ACEs) and impact of cannabis use; using a holistic family approach to assessing children and young people where their parents have difficulties; recognising when young people are carers; the importance of reflective supervision.
Recommendations: to work with the Safeguarding Adults Board to develop a ‘Think Family’ approach; review how practitioners are supported and trained in assessing adolescents who have complex and unresolved emotional issues, possibly coupled with drug use and impulsivity; promote awareness of and response to contextual safeguarding.
Keywords: adolescents, suicide, adverse childhood experiences, drug misuse
> Read the overview report

2020 – Hull – Baby B

Serious non-accidental head injury and bite marks to Baby B, a 20-week-old baby, in December 2016. Baby B’s father was found guilty of grievous bodily harm and received a 12-month prison sentence.
maintain a focus on fathers of children to establish more clearly the implications of their needs and role in the family; need to ensure that the Local Safeguarding Children Board escalation policy is disseminated across the whole safeguarding partnership to ensure practitioners and managers challenge when there is a difference of opinion.
Recommendations: children’s social care to ensure that multi-agency child in need plans are in place for children in need; partner agencies to brief their staff on their responsibility to ensure child in need plans are in place.
Keywords: non-accidental head injuries, partner violence, teenage pregnancy, professional curiosity, premature infants, parenting capacity
> Read the overview report

2020 – Hull – Child H

Death of a 9-month-old child in February 2014 as the result of a hypoxic brain injury. The mother was convicted of causing or allowing her child's death; her male partner was convicted of murder.
includes: if duty officers in children’s services do not routinely communicate with the referring practitioner before making decisions about a referral, misunderstandings can occur and this leaves children vulnerable; need for agreements and plans to be monitored, reviewed, checked and shared with other agencies; all family members, especially those living in the household, should be subject to assessments, both to determine risk and to confirm and assess their ability to protect children in the family; need to engage men; unaddressed domestic abuse can leave some children vulnerable and with ineffective help.
Recommendations: makes no recommendations but sets out questions and issues for the safeguarding board to consider around practice, procedures and strategies.
Keywords: brain injury, disguised compliance, parenting capacity, family violence
> Read the overview report

2020 – Kent – Child I: Carys

Death of a 16-year-old girl in 2017 by suicide.
focuses on issues around: initial responses to disclosures of child sexual abuse; use of child sexual abuse pathways and associated support; responses to the mental health needs of Carys; education settings being identified as key safeguarding partners; sharing of adult safeguarding information and concerns; accurate record-keeping by professionals; follow-up for children not brought to health appointments.
Recommendations: ensure rigorous promotion of the role of the Sexual Assault Referral Centre to ensure victims of sexual abuse, including non-recent abuse, are being offered holistic support; explore ways to widely promote existing pathways and opportunities to respond to mental health issues in children and young people, including the policy to manage self-harming and suicidal behaviour; request assurance from Health partners that missed health appointments for children are subject to robust and consistent follow up.
Keywords: suicide, disclosure, child sexual abuse, adolescents, non-attendance
> Read the overview report

2020 – Kent – Suicide: thematic analysis

Thematic review of adolescent suicides, analysing five reports relating to the suspected suicides of young people between May 2014 and June 2018.
the interface between different specialist health services and other organisations is a vital, but vulnerable, line of demarcation and may be decisive in determining effective service response; suicidal ideations and suicidal plans may not be a reliable indicator of intent to commit suicide, therefore a comprehensive assessment is required; consideration should be given to a 'trigger event phase' that may capture deterioration in presentation; consideration should be given to how to support family survivors of suicide.
Recommendations: GPs and school teaching staff should be an integral part of the inter-professional holding network and receive training commensurate with this role; professionals need to have greater awareness of young people's use of online activity and social media; professionals need to respond with a comprehensive and immediate psychosocial assessment of the young person and their engagement in a therapeutic relationship; ensure that there is timely and proportionate access to mental health services with emphasis on direct positive engagement, comprehensive assessment and necessary treatments; listening to and learning from young people and their families must be used in creating preventative suicide strategies.
Keywords: adolescents, suicide, children with a mental health problem, health services, assessment, interagency cooperation
> Read the overview report

2020 – Luton – Child G

Neglect and sexual abuse of a secondary school aged child. Legal proceedings took several years and Child G is now an adult.
missed opportunities for a holistic and multi-agency assessment and response to Child G’s emotional needs; no evidence of chronologies being maintained or information being collated to enable a wider understanding of Child G’s history; there was a need for better management and supervision; ensure appropriate use of specialists to provide advice on how to engage with the child or adult if they have learning needs; practitioners need to be curious about the causal nature of behaviour and seek to explore alternative reasons.
Recommendations: ensure that agencies have in place and follow effective safeguarding supervision and management oversight procedures, and remind agencies of the importance of appropriate challenge and escalation; establish clear self-harm procedures and pathways; ensure that effective support is provided to disabled children and their families to enable them to communicate and effectively participate in plans; ensure compliance with the procedures for child protection medicals and the inclusion of consultant paediatricians in strategy discussions or meetings.
Keywords: child neglect, child sexual abuse, children with disabilities, behaviour, supervision
> Read the overview report

2020 – Manchester – Child U1

Death of child under 3-years-old in January 2018. Partner of Child U1's childminder was found guilty of the child's murder, and the childminder was found guilty of causing or allowing the death of a child. Both received prison sentences.
a decision that the injuries were due to a medical cause rather than non-accidental injury meant that professionals did not query an alternative diagnosis; deference to the medical clinicians involved made challenging medical professionals difficult.
Recommendations: highlight the need for: professional curiosity, professional challenge and information sharing within and between agencies; assessments to include an understanding of care arrangements and an assessment of the carers; and an understanding of differential diagnosis and when bruising is present where non-accidental injury should be considered. 
Keywords: child deaths, child minding, physical abuse identification, professional curiosity, unknown men, information sharing
> Read the overview report

2020 – Manchester – Child W

Non-accidental injury to a 4-month-old child in 2018, attributed to shaking. The mother received a custodial sentence.
includes: provide child impact chronologies to understand the daily lived experience of children; the views, wishes and feelings of children are critical to effective interventions; a trauma-informed approach to assessment, incorporating a strengths-based methodology, can be invaluable when adverse experiences in childhood have been identified; cannabis use, particularly if prolonged, is a significant feature contributing to poor mental health and compromised parenting; family engagement is critical to keeping children safe; consider the possibility of abusive head trauma in cases where there are young babies and children and domestic abuse is present.
Recommendations include: planning and interventions should be informed by a conceptual model of change, particularly when working with families struggling with interrelated mental health issues, alcohol or substance misuse; ensure that a trauma-informed approach to planning and interventions is embedded into practice, particularly where adverse childhood experiences have been identified.
Keywords: shaking, infants, substance misuse, trauma-informed practice, assessment
> Read the overview report

2020 – Medway – Faith

Historical sexual abuse of an adolescent girl. In 2016, prior to Faith's 18th birthday, Faith disclosed that she had been sexually abused for several years by a neighbour, and that her mother had been aware this was happening.
includes: over many years the signs and indicators that Faith had been sexually abused were not recognised and acted upon and her voice was not heard; assessments and plans were limited in their analysis of the history of both parents, the dynamics of relationships within the family and relevant health information; there was no clear plan to give Faith a permanent safe home and the legal framework was not used effectively.
Recommendations include: develop a multi-agency whole family approach to work with complex families; seek evidence from children’s services that the cause of placement breakdown is analysed and that findings are incorporated into ongoing planning for the child; ensure that all practitioners have the required knowledge and skills and confidence to recognise and respond to child sexual abuse within the family including hearing the “voice” and lived experience of the child.
Keywords: child sexual abuse, child abuse identification, exclusion from school, family violence, placement breakdown, voice of the child
> Read the overview report

2020 – Medway – George

Death of a 3-year-old boy in February 2018 in Croydon. George had been in the rear passenger foot well of a car when the front passenger (the mother's partner, 'A') pushed his seat back twice and crushed George.
the impact on George of witnessing domestic abuse and unpredictable changes of residence was underestimated; George's presence was not adequately recorded during some incidents; the need for professionals to record and assess incidents considering information on all individuals present; the need for professionals to define demonstrable change in the situation of a child at risk or vulnerable adult before concluding sufficient improvement.
Medway agencies to improve methods of reporting and responding to incidents involving safeguarding issues and vulnerable adults.
Keywords: child neglect, transient families, parenting capacity, family violence, mothers, abusive men
> Read the overview report

2020 – Merton – Child D

Death of a 7-year-old girl in November 2017. Child D was murdered by her father in the family home.
points relate to: mental health risk assessments; multi-agency assessments; thresholds and ‘step-up’ and ‘step-down’; the use of interpreters and cultural sensitivity in assessments where English is not the first language; considering and assessing coercive control and disguised compliance; information sharing; and sexual abuse.
Recommendations include: seek assurance that in mental health assessments following attempted suicide where the adult has responsibility for children, that risks to them and partners are considered, including where the dependent is seen as part of the patient’s perceived ‘problem’ or ‘protective element’; review multi-agency approaches to assessing for the possibility of sexual abuse of children.
Keywords: child deaths, abusive fathers, deception, disguised compliance, suicide, partner relations
> Read the overview report

2020 – Newcastle – Laura

Sexual abuse of a girl aged between 11- and 19-years-old who has ADHD, a learning disability, speech and language difficulties and behavioural difficulties. Laura disclosed a history of sexual abuse by her mother's partner in 2017 when she was 19-years-old.
includes: there was a lack of professional awareness of Laura being at heightened risk of sexual abuse due to her learning difficulties and disabilities; unchecked assumptions can inhibit professionals from exploring what may be happening to a child in their family; professionals in contact with children should regularly update records about family members and seek out information about significant males in a child's life; professionals may not always consider the possibility of child sexual abuse, unless there is a disclosure or the presence of recognisable signs and symptoms.
Recommendations include: an authority wide, multi-disciplinary strategy for prevention, identification and response to familial child sexual abuse; ensure that professionals understand that concerns about the behaviour, health, wellbeing or safety of children with disabilities may be attributable to familial sexual abuse, even if this is later discounted.
Model: uses a systems methodology.
Keywords: child sexual abuse, children with learning difficulties, children with disabilities, abusive men, unknown men
> Read the overview report

2020 – Norfolk – Child AG

Neglect of a 2-year-old boy in 2018 who presented at hospital severely malnourished and had fractures of varying ages.
includes: issues around the assessment of risk and impact of domestic abuse on the mother and children; issues around how the parents' learning difficulties were understood in relation to their parenting; issues concerning how child neglect is understood by practitioners and the ability of services to identify and recognise malnutrition; assessments by medical practitioners should not take precedence over concerns raised by other professionals within a safeguarding network; issues around professionals’ competence in working with and understanding the culture of a Traveller family.
Recommendations include: review the ability of partners to deliver the neglect strategy; equip practitioners with the confidence and skills to work with clients from diverse cultural backgrounds, including Gypsy, Traveller and Roma communities; local health agencies to review the effectiveness of faltering child growth management.
Keywords: child neglect, nutrition, adults with learning difficulties, medical assessment, culture
> Read the overview report

2020 – Norfolk – Child AI

Significant burns to a 5-and-a-half-year-old child in August 2019.
includes: staff should consider when families use emergency departments whether it’s because they don’t want professionals to visit the family home; anti-social behaviour (ASB) officers should consider the impact of ASB in a safeguarding context when a child is present and share this with appropriate agencies; the number of perceived minor injuries to a child should be viewed in relation to parenting capacity and the ability to keep children safe.
Recommendations include: equip frontline staff with the skills to work with clients who may have a learning difficulty; promote the Family Network programme to build relationships with the wider family and support families when services are no longer needed; develop guidance for transferring safeguarding records from early years to schools to facilitate appropriate information sharing at the point of transition.
Keywords: burns, anti-social behaviour, parenting capacity, people with learning difficulties, information sharing, unknown men
> Read the overview report

2020 — Nottinghamshire — Child RN19

Death of a 15-year-old child in 2019 who was found to be emaciated but otherwise well cared for.
parents and professionals should remain curious about what their children are thinking, feeling and accessing on mobile devices; social isolation can have a negative impact on emotional and psychological health; school staff should act on healthcare concerns by offering referral to appropriate services; GPs should use tools to recognise faltering growth and eating disorders are part of the differential diagnosis for this.
Recommendations: review material available to parents to help them recognise the signs of anorexia nervosa and the importance of early diagnosis in children; consider requesting a national review on elective home education (EHE), changing non-statutory guidance to improve opportunities for promoting the welfare of children receiving EHE; raise awareness of early recognition of children with eating disorders and professional curiosity and how to promote this within systems.
Keywords: child deaths, anorexia nervosa, body image, eating disorders, home education, help-seeking behaviour
> Read the overview report

2020 – Plymouth – Baby F

Life-changing head injury of an 11-week-old boy in September 2016. Baby F was seen at hospital twice prior to his life-changing injuries. His parents were subsequently charged in connection to the injuries.
includes: it is important to seek engagement with both parents to assess their mental health; supervisors need to be vigilant to ensure the most vulnerable families are discussed at supervision; and when parents have their own needs, there is a risk that the focus on the child will be lost.
Recommendations include: guidance on the detection and management of unusual medical presentations in non-mobile babies should be applied consistently by all agencies and counsellors should follow guidelines on safeguarding children.
Model: uses Partnership Learning Review.
Keywords: bonding behaviour, family dynamics, non-accidental head injuries, physical abuse identification, postnatal depression, unknown men
> Read the overview report

2020 – Plymouth – Baby G

Death of a 6-month-old baby boy due to a significant head injury attributed to shaking in May 2017. Father was charged with manslaughter and received a prison sentence.
Learning includes: the need for clear and accurate information sharing and for all agencies to seek information if they believe an assessment is being conducted; importance of professional curiosity for clinicians when presented with unusual signs and symptoms.
Recommendations include: ensure that partner agencies recognise that minor presentations can represent injuries which may be a sign of serious abusive trauma; promote awareness among parents and professionals of the “crying curve” (“purple crying”) and the impact on parents of coping with inconsolable crying; reflect on the diagnosis and treatment of depression in new and prospective parents and how this can impact on parenting capacity; develop a programme of intervention to engage fathers and prospective fathers; engage, reassure and educate parents about infant crying and strategies for coping and impulse control.
Keywords: infant deaths, shaking, crying, fathers, professional curiosity
> Read the overview report

2020 – Portsmouth – Child H

Death of a 9-year-old boy in August 2018. Child H was found unresponsive in the family home and later pronounced dead.
Learning: there should have been a professional focus on managing Child H's disabilities rather than seeing a child who was disabled and neglected; the need for information sharing between appropriate agencies when a child has a child in need plan; importance of professionals escalating concerns about parental capacity in a timely manner, particularly when a child has complex needs; family medicine management should be checked by professionals on a regular basis when prescribed medicines form part of a child's health and safety plan.
Recommendations include: increasing knowledge across services on how concerns about a child's welfare might be managed; children's social care to review their local policy on child in need cases to ensure the policy clearly reflects the need to involve partner agencies, particularly in cases involving children with disabilities; local NHS Trusts to review their policies and procedures on recognising and responding to medical neglect.
uses a model of learning based on a Soft Systems Methodology.
Keywords: children with disabilities, child neglect, medical care neglect, drug misuse, child health services, information sharing.
> Read the overview report

2020 – Portsmouth – Child I

Death of a 9-week-old infant in 2018.
practitioners working with families should take every opportunity to remind parents of key safe sleeping messages tailored to their needs; health practitioners are in a key position to identify domestic abuse and to initiate support and safety for victims; good practice was shown by the neonatal doctor in following up after Child I was not brought for a repeat blood test.
Recommendations: support professionals working with universal and high risk families to identify safe sleep risks, emphasising ‘out of routine’ events such as going to a party or on holiday; support professionals in discussing alcohol consumption with parents and highlighting what happens on those occasions when they may binge or drink more than usual; Portsmouth hospital should review and improve continuity of carer arrangements, especially when there is staff sickness.
Keywords: alcohol, sleeping behaviour, infant deaths, child neglect, parenting education, hospitals
> Read the overview report

2020 – Redbridge – Baby T

Death of an 11-month-old girl in October 2017.
Learning themes include: decisions made by Home Office about Mother’s claim for asylum and asylum support; effectiveness of Home Office asylum seeker support services and ‘mainstream’ health and social care services; impact of frequent moves of Mother and Baby T; use of interpreting services in supporting Mother and Baby T; ‘lived’ experience of Baby T; indications of trafficking or exploitation concerns and agency responses; ‘hidden males’.
Recommendations: remind practitioners about policy and practice in respect of modern slavery; ensure that advice to parents on caring for crying and sleepless babies is accessible in all community languages; Home Office to ensure pregnant asylum seekers and asylum seekers with young children are referred to local primary care service at the point of first contact.
Keywords: asylum seekers, babysitters, interpreters, language, maternal health services, temporary accommodation
> Read the overview report

2020 – Richmond – St Paul’s School

Review commissioned in April 2017 following five convictions for sexual offences of adults who had previously worked at St Paul’s School London.
Learning: accepting responsibility for past abuse must be a foundation for moving forward and developing an effective safeguarding culture; schools face difficulties in balancing a response to allegations of abuse that takes account of employment law, education legislation and good safeguarding practice; there are gaps in the national safeguarding system in relation to the recruitment and regulation of teachers, the Disclosure and Barring Service and the way in which information is shared across national organisations.
Recommendations: Charity Commission should make explicit their expectations regarding best practice at times of crisis and specifically that protecting the reputation of the charity includes openness and honesty about any poor practice; Home Office should establish a system of advocacy and support for complainants in child sexual abuse cases both pre- and post-trial to ensure consistency between areas.
Keywords: teachers, institutional child abuse, adults sexually abused as children, abused men, media coverage, recruitment
> Read the overview report

2020 – Rochdale – Child A1

Death of a 4-month-old infant in May 2018 whilst in the care of a family member overnight. Police initiated an investigation but no charges were made. 
is embedded in the recommendations.
Recommendations: ensure that Special Circumstances Forms generated by midwifery services are shared by key agencies, such as general practitioners (GPs) and health visitors; ensure that information sharing and discussion take place routinely between midwifery and GP practices where issues are identified, and concerns are raised in order to understand the holistic family circumstances; where parental alcohol and substance misuse are risk factors, practitioners are able to consider any other caring responsibilities for children including babysitting arrangements.
Keywords: infant deaths, alcohol misuse, sleeping arrangements, extended family
> Read the overview report

2020 – Salford – Baby MD

Death of a 5-week-old infant in August 2018. Baby MD had been placed by mother in the parental bed to sleep during the night and was found lifeless the following morning.
trauma-informed practice can support service users in forming effective working relationships with practitioners; case transfers should ensure all relevant information, including significant historical risk factors and parental adverse childhood experiences (ACEs) is shared; there is a need to explore more effective safe sleep interventions for vulnerable families.
Recommendations: ensure that multi-agency partners have considered the relevant learning points and developed implementation plans in order to support safeguarding practice when working with complex families with multiple risk factors.
Keywords: sudden infant death, sleeping behaviour, trauma, adverse childhood experiences
> Read the overview report

2020 – Salford – Helen

Delay in responding to potential trafficking of a female child in 2019.
immigration identification documents are not evidenced-based; need for professional curiosity; need for professional advice in a timely manner and to escalate concerns to enable a multi-agency approach; need for a multi-agency approach to age assessment and to have a pathway to resolve disputes on the presenting age of an individual; consider the child’s views at all times.
Recommendations: Local Safeguarding Partnership should ensure that a local, multi-agency, effective pathway is developed and embedded to address concerns that a presenting adult may be a child and that the risk of trafficking may be present; UK Visas and Immigration should ensure robust identification procedures and have a consistent approach to directing practitioners with concerns if someone with an adult ID is thought to be a child.
Keywords: child criminal exploitation, child trafficking, homelessness, interagency cooperation, interpreters, voice of the child
> Read the overview report

2020 – Sandwell – JS

Serious physical harm and neglect of a 6-month-old baby by their parents in January 2017. JS was born prematurely to teenage parents supported through the Family Nurse Programme. 
for professionals includes: recognise when a multi-agency approach is needed and what support may be needed; consider whether their service is best placed to deal with the presenting issue; follow guidance, protocols and procedures; share information; be able to recognise a safeguarding concern and access supervision from safeguarding lead; challenge robustly when parents do not listen to advice and instructions or administer medication which is not approved for a child; consider whether all children who attend A&E with excessive drowsiness without an immediately identifiable cause should have their urines sent for toxicology.
Recommendations include: ensure that pre-birth protocol is embedded and used in all appropriate cases; ensure that thresholds are properly understood; ensure that health partners have in place robust provisions for supervision and ‘did not attend’ (DNA) policies; roll out a neglect identification tool; launch a prevention campaign aimed at parents and carers about the safe handling and storage of drugs.
Model: uses a systems review methodology.
Keywords: child abuse identification, child neglect, information sharing, inter-agency cooperation, newborn babies, teenage parents
> Read the overview report

2020 – Sandwell – Child NS

Death of a 2-month-old child due to asphyxiation. Mother found Child NS lifeless in the bed beside her after waking up following a night out.
includes: information about all members of the family should be sought from GPs during assessments and conferences; assessments of a child’s needs should consider any additional needs of siblings; and practitioners need to bear in mind that parents might not disclose key information.
Recommendations include: improve the effectiveness of informing parents about the dangers of co-sleeping; consider how to promote the wellbeing of all immediate family members who have experienced a neonatal death; and consider how to ensure the needs of siblings are considered collectively as well as individually.
Keywords: disguised compliance, infant deaths, pregnancy, professional curiosity, siblings, sleeping behaviour
> Read the overview report

2020 – Sefton – Beatrice

Injuries to an 8-week-old girl in 2019. Beatrice was taken to a walk-in centre concerning a rash and was found to have unexplained bruising. An ambulance was called and Beatrice was taken to hospital where scans showed 13 fractures to ribs and legs of differing ages.
local authorities should liaise around support to care leavers living across boundaries; where there is a history as a care leaver, background information should be sought from the responsible authority; police should take a more holistic view of a person's circumstances and consider information sharing to protect a child, even in cases where the child is not yet born.
Recommendations: agencies working with care leavers must be aware of the right for care leavers for service provision up to the age of 25-years-old; request guidance on information sharing between local authorities where care leavers are not living in the area of the responsible authority; ensure information sharing policies are in place and include all cases, not just those managed under formal child protection procedures.
Keywords: injuries, asperger’s syndrome, suicide, mental health, parenting capacity, professional curiosity
> Read the overview report

2020 – Sheffield – Archie

Death of a 15-year-old boy in May 2018. Archie was fatally stabbed by another young person.
embedded in the recommendations but also includes: impact of bereavement must not be underestimated.
Recommendations: when a parent elects to home educate their child, the local authority should seek reassurances that the child is receiving a balanced education, including a home visit for an assessment by a trained professional; local authority must develop and communicate a clear escalation process for children not on school roll; ensure that structures are in place to assess, refer and intervene with vulnerable people who may be exploited by gangs and organised crime groups; implement child protection conferences that assess risk and develop plans in line with increased understanding of contextual safeguarding.
Keywords: adolescent boys, child deaths, bereavement, child criminal exploitation, home education
> Read the overview report

2020 – Solihull – SC17 Unborn Baby A

Death of an unborn baby due to suicide of the mother who was 37-week pregnant in April 2019.
identifies strong practice, particularly in relation to prompt follow up when the mother did not attend or could not be contacted by the midwife, social worker and housing officer.
Recommendations: substance misuse midwifery team should consider informing women on the substance misuse pathway that a positive toxicology result will lead to a referral to social care at the point of testing; conduct a review analysing current referral processes and pathways.
Keywords: suicide, substance misuse, pregnancy, partner violence
> Read the overview report

2020 – Southampton – Freddie

Sexual abuse of a boy under 8-years-old from January 2014 to October 2016.
includes: importance of management support and supervision when working with intrafamilial child sexual abuse; the value of seeking additional input from specialised services in helping professionals remain objective and child focused; not letting biases of professionals towards parents hamper judgements and undermine decision making.
Recommendations: ensure that the plans for children subject to child protection plans are fit for purpose and have pace; examine blocks and barriers to effective multi-agency work around the issue of child sexual abuse; and increase the knowledge and confidence of practitioners in assessing and working with cases involving child sexual abuse.
Keywords: child sexual abuse, harmful sexual behaviour, child neglect, physical abuse, interagency collaboration
> Read the overview report

2020 – South Gloucestershire – Toby

Death of a 5-week-old infant boy in January 2018. Cause of death was initially assumed to be sudden infant death syndrome (SIDS), but the post-mortem found numerous rib fractures and evidence of non-accidental head injury.
lack of collaborative working between health professionals has an impact on information sharing and parents’ and children’s vulnerabilities not being properly understood or responded to; a lack of clarity within health agencies about why information is being shared, what to do with it and whether to follow it up results in ineffectual information sharing.
Recommendations: develop systems and tools to enable midwives to facilitate the reporting of low-level concerns such as maternal presentation; observations about father’s presence, interaction with baby and professionals and their role in parenting should be routine; improve the capacity for midwives to work in a continuity of care model, especially where additional needs are known or suspected.
Keywords: infant death, fractures, physical abuse, non-accidental head injuries, midwives.
> Read the overview report

2020 – St Helens – Child B

Disclosure by a 14-year-old girl in January 2019 of four offences of rape by an adult male.
relates to: the multi-agency sexual exploitation process; child in need/child protection; the significance of neglect as a factor which underlies adolescent vulnerability; bullying; early intervention to prevent child sexual exploitation; information sharing; school nurse involvement; safeguarding roles and responsibilities; public awareness of child exploitation; the voice of the child.
Recommendations: ensure that children and young people assessed as at high or medium risk of sexual exploitation are immediately flagged on the information systems of all agencies who are in contact with them; ensure that the support provided to children and young people at risk of sexual exploitation also considers the current and future needs of younger siblings living in the same household.
Keywords: rape, disclosure, grooming, bullying, assessment of children, child sexual exploitation
> Read the overview report

2020 – Staffordshire – Child D

Death of a 6-week-old infant in April 2014. Both parents received prison sentences for offences of child cruelty and causing or allowing the death of Child D in 2019.
identifies no specific learning regarding predisposing factors, known needs or risk factors relating to the family that would have raised concerns to a level that would have led to different level of intervention being offered or undertaken. 
Recommendations include: ensure that midwifery, health visiting and early help assessment records include a standard section that prompts practitioners to ask questions about whether either parent or carer has any other children and if so the level of contact held with their children.
Keywords: sudden infant deaths, injuries, health visitors, contact
> Read the overview report

2020 – Sunderland – Baby Kate

Death of a 10-month-old girl, Baby Kate, who died four days after admission to hospital with a serious head injury. Medical investigations also revealed a second injury.
includes: practitioners finding limitations in available pathways; systems and practices struggling to deal with the nature of domestic abuse and coercive control; the need to equip practitioners with training and tools to assist in dealing with disguised compliance; the need to consider risks to children as part of a wider picture recognising the full impact of abusive situations.
Recommendations include: consider how domestic violence perpetrator work is incorporated as an action into child protection plans; ensure practitioners understand coercive control, and that tools and processes are in place that support in evidencing and acting upon concerns; regional medical practices consider how information on adult patients is shared within ongoing safeguarding children processes.
Keywords: infants, non-accidental head injuries, disguised compliance, partner violence
> Read the overview report

2020 – Surrey – Child A

Death of a 4-week-old infant in April 2017. Cause of death was identified as sudden unexpected death in infancy (SUDI) associated with co-sleeping.
includes: services thinking about children within the context of their family and being mindful of repeat patterns of behaviour within families; professionals recognising when parental deflection may create risk for a child; professionals being aware of indicators of abuse and understanding when to share information about these indicators.
Recommendations include: ensure school staff have training on indicators of abuse and have the competencies to safeguard children; information sharing training should include the directive that when parents do not give permission to share information, staff should consider if a child is at risk of harm before a decision to not share information is made; when there is disparity between parent’s views and those of their children, professionals should maintain focus on the child.
Keywords: infant deaths, sudden infant death, sleeping behaviour, siblings, single parent families
> Read the overview report

2020 – Surrey – Child G

Review of the support received by Child G between 2014 and 2019, including in relation to allegations of sexual abuse by her special guardian in August 2018.
includes: communication challenges across partnerships working with a family with multi-faceted needs; the Special Guardianship Order report and recommendation was not subject to sufficient scrutiny; the need for professionals to be aware of the possibility of trauma and current abuse, in children presenting with distress and high levels of disturbance; delays to accessing therapeutic support.
Recommendations include: ensure that family support is consistently applied and not stepped back due to resource pressures; ensure there are mechanisms to review caseload size and social work shortages; review of processes for undertaking Special Guardianship assessments; review training on trauma-informed practice and sexual abuse.
Keywords: special guardianship orders, child sexual abuse, voice of the child, child neglect, sex offender, disclosure
> Read the overview report

2020 – Surrey – Children HH, II and JJ

Sexual assault of a child and possession of indecent images in August 2015.
the lack of certainty in the assessment of those who access indecent images of children; the danger of relying on earlier assessments without reviewing them with agencies involved; the importance of identifying what changes in an offender or their situation might lead to that offender being assessed as presenting a greater risk of carrying out harmful behaviour.
Recommendations: work with other bodies to review the approach to families in which a member has committed offences in relation to online indecent images of children; ensure that professional staff have sufficient skills and knowledge to work with those who access indecent images of children online and their families.
Keywords: abusive fathers, child abuse images, child sexual abuse, sexually abusive parents, risk assessment, internet
> Read the overview report

2020 – Surrey – Baby KK

Death of a 9-month-old infant, from heart failure and chest infection in April 2016. Baby KK was born prematurely and experienced health problems including bronchiolitis, sepsis and injuries requiring nine hospital admissions during his life.
need for understanding of roles in partnership working relationships so that opportunities for review and assessment of a child's needs are not missed; tendency for hospital professionals to focus on the presenting illness or injury and not to consider other explanations; limited involvement of hospital professionals in safeguarding work; reluctance of general practitioners to refer directly to children’s social care; and the fluctuating nature of neglect and the inconsistent ability of parents may undermine professionals’ ability to see and respond to neglectful parenting.
Recommendations: makes no recommendations but poses several considerations for the safeguarding board and partner agencies for the eight findings identified.
Model: uses the SCIE Learning Together model for case reviews, a systems approach which provides a theory and method for understanding why good and poor practice occur.
Keywords: infant deaths, child neglect, information sharing, parenting capacity, family violence, professional curiosity
> Read the overview report

2020 – Surrey – Baby LL

Death of a 4-month-old boy in May 2016. The post mortem identified the cause of death as acute pneumonia.
Learning includes: issues of professional psychiatric opinion undermining social workers' views on the risks posed by parents; the need for consistent safeguarding practices in paediatric and accident and emergency teams, so that opportunities to identify hidden injuries are not missed; professionals sharing information on the presenting evidence, but not always clearly communicating underlying concerns and relevant historical information; GPs should have access to the records of family members to understand a family's history and be aware of risk factors and past child protection concerns; the importance of professionals understanding financial challenges faced by families, and identifying risks that financial pressures may pose to children.
Recommendations: makes no recommendations.
Model: uses SCIE Learning Together systems model.
Keywords: infant deaths, siblings, child neglect, parental capacity, history
> Read the overview report

2020 – Surrey – Family M

Serious harm and sexual abuse of children whilst living with a relative under a Special Guardianship Order. The review concerns six children, of whom four were removed from one situation where they were likely to suffer significant harm to another situation where they experienced severe abuse.
the need to share information across the multi-agency network; practitioners need to be equipped to undertake assessments which include hearing the voice of the child, understanding the meaning of a child’s behaviour, and maintaining professional curiosity; friends and family assessments should always include consideration of the impact of placement on all children in the household.
Recommendations: ensure that there is a focus on the voice and lived experience of children in assessments and interventions; consider the child’s history, the history of their care givers and the motivation underlying their application to look after the child; the Safeguarding Children Partnership should work with partner agencies to develop a strategy on recognising and working with child sexual abuse within the family; and agencies should evaluate their supervision systems and provide an opportunity for practitioners to analyse complex family situations.
Keywords: special guardianship orders, kinship foster care, voice of the child, deception, professional curiosity, information sharing, child abuse
> Read the overview report

2020 – Sutton – Child O

Serious harm suffered by a 11-week-old baby boy as a result of head injury indicative of abusive trauma in October 2016.
focuses on the following themes: timely record keeping and information sharing, including relevant past histories; engagement with fathers, young people and hard to reach individuals, including at or below the child in need threshold; high quality, reflective, restorative supervision and management oversight; planning to achieve outcomes; professional scepticism/challenge; adherence to agency and multi-agency policy, procedures and good practice in a timely way, especially when dealing with new born babies; consider the impact of adverse childhood experiences; incorporate family culture and context into assessments; quality assurance of supervision for health providers.
Recommendations include: ensure the needs and risks of new born babies are given sufficient attention in their own right; promote restorative practice; seek multi-agency involvement before closing a child in need case.
Keywords: supervision, record keeping, parenting capacity, non-attendance, non-accidental head injury, newborn babies
> Read the overview report

2020 – Sutton – Child T

Death of a 17-year-old boy by suicide in November 2019.
Learning includes: there needs to be a personalised approach to identifying a child's needs, to ensure that children with autism spectrum disorders (ASD) and conduct disorders are effectively safeguarded within education settings; it is crucial for services to listen to the child and to question the child's field of perception.
Recommendations include: promote a family-based practice model across the safeguarding partnership that is underpinned by trauma informed, contextual and restorative principles; ensure that the SEND partnership conducts a review to address the issues holistically before consideration of an exclusion; challenge agencies and partnerships in how they listen to young people for transition to adult services.
Keywords: suicide, adolescent boys, autism, listening, transition to adulthood
> Read the overview report

2020 – Swindon – Child G

Death of a 10-week-old baby boy in March 2017. Child G was a twin, born prematurely and spent the first six weeks of his life in hospital. When discharged the twins lived with their mother and father, and older half sibling (Child I) and Mr B, Child I’s father who pleaded guilty to the manslaughter of Child G.
Learning includes: evidence that there was a potential systemic weakness in the way that information about unborn babies is sought and shared; professionals should always be alert to the possibility that family members may not always tell the truth.
Recommendations include: ensuring that staff use the correct unambiguous terminology; professionals should consider consulting with the GP's of parents as this will avoid missing information on parental mental health and parenting capacity; professionals should document and share any history of risk/vulnerability when making referrals and providing or seeking information.
Model: sets out findings using the Welsh Model methodology.
Keywords: infant deaths, premature infants, professional curiosity, non-accidental head injuries, family violence, disguised compliance
> Read the overview report

2020 – Tameside – Child V

Significant non-accidental head injuries to a 7-week-old infant in 2018, attributed to shaking.
Learning: focuses on the following themes: preventing abusive head trauma; opportunities to consider safeguarding in health appointments pre- and post-birth; information sharing to enable wider safeguarding.
Recommendations include: explore opportunities locally for professionals to be more aware of the significance of adverse childhood experiences and the importance of proactive professional enquiry regarding family histories.
Model: uses the Welsh Child Practice Review model.
Keywords: infants, shaking, physical abuse, adverse childhood experiences
> Read the overview report

2020 – Thurrock – Frankie

Death of a 15-year-old boy in the summer of 2018. Frankie was fatally stabbed when attacked by a group of adolescent males in London.
Learning and recommendations
are integrated and include: ensure timely notifications to relevant persons when a child dies outside of the area in which they reside; improve notification processes for agencies when a child becomes the subject of a child in need plan; review permanent exclusion processes within schools to reduce the potential for safeguarding risks to children at risk of exclusion; understand how to incorporate the concept of contextual safeguarding in the assessment of risk to children in the future; evaluate how partner agencies support families affected by gang association; assess how partner agencies share intelligence related to gang affiliations; recommendation made to the National Child Safeguarding Practice Review Panel to consider a national thematic review because of the prevalence of similar incidents across the country.
Keywords: murder, adolescent boys, social work, crime, exclusion from school, information sharing
> Read the overview report

2020 – Thurrock – Sam and Kyle

Death of a 2-year-old boy in January 2018. Cause of death was unascertained. Sam’s older sibling Kyle was placed on a child protection plan after Sam’s death, and subsequently placed in foster care.
there is an impression of agencies working in silos rather than developing a shared understanding of the case; professionals concentrated on their own engagement with parents and their compliance, rather than attempting to place the child at the centre.
Recommendations: review procedure for the escalation of concerns and for resolving differences of view between professionals and agencies; explore better co-operation between agencies when handling complex or persistent cases; review inter-agency procedures for establishing agreement with families of written care plans.
Keywords: child deaths, information sharing, teenage pregnancy, parenting capacity, neglect identification, voice of the child, siblings
> Read the overview report

2020 – Walsall – Alex

Significant injuries to an 11-month-old boy. Alex was admitted to hospital with cardiac and respiratory failure from suspected non-accidental injuries.
expediting social work assessment timescales may impact the quality of assessments; children who are looked after may be at risk of harm and being in foster or connected care does not automatically mean safety; professionals should recognise the difference between various fostering arrangements and prioritise visits and reviews accordingly.
Recommendations: assessments for connected carers should include a thorough review of family dynamics and explore motivations to care for children; ensure that unannounced visits to connected carer placements are undertaken during the assessment phase and post placement; when children are placed in another local authority, social workers should seek support from where the child has been placed and reciprocate arrangements with other local authorities; that recommendations are raised with the Family Justice Board and the Department for Education.
Keywords: infants, injuries, children in care, kinship foster care, assessment
> Read the overview report

2020 – Waltham Forest – Child C

Death of a 14-year-old boy in January 2019. Child C was stabbed by four men, one of whom was sentenced to life imprisonment.
time spent out of school constitutes a significant risk to children who are vulnerable, and the current arrangements governing home education contribute to this risk; failure to capitalise on a ‘reachable’ moment for a child who was being criminally exploited.
Recommendations: government to review the guidance on home education; implementation of a national system for responding to exploitation of children by county lines gangs; and a review of arrangements for recovering children to ensure they are brought back by adults with skills relevant to working with children who are being criminally exploited.
Keywords: child criminal exploitation, child deaths, adolescent boys, exclusion from school, home education, information sharing
> Read the overview report

2020 – Waltham Forest – Child D

Unexplained death of a 4-month-old baby boy in November 2018.
includes: assessing the needs and risks of families experiencing domestic abuse is a complex task; some practitioners are still not confident about using escalation; practitioners don’t always record important information which results in significant information not being shared when required; there is a tendency for some practitioners to minimise the significance of parents using alcohol and being over optimistic about reports by parents of their alcohol consumption.
Recommendations: makes no recommendations but raises questions to Newham Safeguarding Children Partnership and Waltham Forest Safeguarding Children Board.
Keywords: infant deaths, partner violence, alcohol misuse, information sharing, optimistic behaviour
> Read the overview report

2020 – Waltham Forest – Khalsa

Unexpected death from bronchial asthma of Khalsa, a 14-year-old boy, in October 2019.
communication between multiple medical services and trusts did not allow practitioners to understand and contribute to the risk discussion; the need to create systems that enable young people to have a voice to participate in their health plans, specifically when this may be overridden by parental influence; the perception of asthma as not being potentially life threatening can impact on how some professionals engage in professional curiosity.
Recommendations: ensure timely information sharing between multiple universal services and acute hospital trusts; and increase awareness of asthma and its management across agencies and communities.
Keywords: child deaths, children at risk, children with a chronic illness, voice of the child, fathers, information sharing
> Read the overview report

2020 – Wandsworth – Child A

Injury and acute illness of a 6-month-old boy, taken to hospital in March 2018. Hospital staff found that Child A had a fractured rib and was seriously underweight and malnourished with a throat abscess.
professionals should be able to assess when to explore parental backgrounds, indicators of vulnerability, and adverse childhood experiences; training for practitioners in neurodiversity; how professionals should use feelings of unease or discomfort to inform assessment and decision making; the role of early help services in working with and supporting vulnerable families.
Recommendations: strengthening professional training and screening on autistic spectrum disorder, ADHD and anxiety disorders, and what such difficulties mean for parents' understanding of information from health agencies; when children's services check if a child and their family are known to the service, the whole family and household should be included; reviewing the effectiveness of the mechanism for alerts to community health services of children attending accident and emergency and other urgent care NHS services.
Keywords: infants, child neglect, adults with disabilities, adults with learning difficulties, malnutrition, fractures
> Read the overview report

2020 – Wandsworth – Frankie

Death of a 3-year-old boy in July 2016. Frankie was a hospital inpatient for life threatening asthma leading up to his death, and died within 24 hours of discharge.
medical neglect is less understood across all agencies and within the health system which is a weakness in the multi-agency children safeguarding system; consider the impact of parents' social class upon relationships with health professionals; parental challenge around medication is common but there is a lack of robust strategies to manage this in the hospital; absence of other categories of neglect appear to have reassured practitioners.
Recommendations: hospitals to explore how clinical teams manage parental consent for emergency treatment; hospitals must review how they manage severe illness in children when a parent favours alternative therapy; GPs and health visitors must have an agreed plan when following up issues of concern with families; all services must be able to evidence how their workforce participates in reflective safeguarding supervision which supports their learning and development.
Keywords: child death, medical care, child neglect, prescription drugs, parent-professional relationships
> Read the overview report

2020 – Warwickshire – Alice and Beth

Death of two sisters aged 3- and 1-years-old in 2018. The mother was convicted of murder and imprisoned.
where a family moves between areas, the new authority and relevant partners need to be informed; where possible more information should be achieved and explored when referrals come to the multi-agency safeguarding hub (MASH) to better understand the nuances of the referral; when concerns raised about parents can be easily refuted there is a danger that professionals can be prone to dismiss other information in the same vein.
Recommendations: encourage professionals to adopt an investigative, questioning and professionally curious approach when considering the history of a case; ensure that professionals understand and adhere to the policy on 'Protecting children who move across local authority borders’; ensure that GPs are clear on the pathways and procedures for making timely referrals to children services.
Keywords: abuse allegations, child deaths, filicide, professional curiosity, housing, referral procedures
> Read the overview report

2020 – Warwickshire – Amy

Disclosure of sexual abuse by a 12-year-old girl, Amy, who was sexually abused by her mother's partner and gave birth as a result of rape.
agencies not recognising and responding to issues of coercive and controlling behaviour; agencies not putting the child first; agencies not recognising anger in a child as an appropriate response to trauma; agencies failing to provide effective advocacy for the child.
Recommendations: when a new adult joins a family, who are open to children's services and are deemed to be vulnerable, partner agencies should assess any risk of significant harm posed by this adult; children's services use information from all sources, and use 'healthy’ scepticism and cautious optimism, when making decisions concerning families; front facing staff in health and social care receive training to identify indicators of coercive and controlling behaviour; children brought to an antenatal clinic should be seen on their own at some point on first appointment.
Keywords: child sexual abuse, sexually abused girls, pregnancy, voice of the child, abusive men
> Read the overview report

2020 – Warwickshire – Child K

Injury of a 12-week-old girl, taken to hospital in January 2017 with a skull fracture. Parents stated that the mother dropped Child K during a domestic abuse incident.
includes: although guidance and procedures do not differentiate between day time and out of hours child protection situations, in practice out of hours services cannot fully replicate daytime services; inter-agency strategy discussions should be held whatever the circumstances for child protection enquiries; clarify in emergency situations if children are protected and accommodated under Section 20 or Section 46 of the Children Act 1989; written agreements, asking that one parent ensures there is no contact between another parent and their children, may not be realistic and may provide false assurance in cases of domestic abuse.
Recommendations include: consider how effective current police structure is in ensuring that Warwickshire Police can fulfil their roles as stated in Working Together 2015; Warwickshire Police to consider whether officers involved in child protection investigations have sufficient participation in inter-agency safeguarding training.
Keywords: infants, injuries, family violence, physical abuse, siblings, voice of the child.​ infants, injuries, family violence, physical abuse, siblings, voice of the child
> Read the overview report

2020 – West Sussex – Baby T

Death of a 10-week old baby boy in 2017 as the result of non-accidental head injuries. Baby T’s father was convicted of manslaughter and grievous bodily arm and received a custodial sentence.
Learning: preparation for parenthood needs to involve both parents learning practical and emotional aspects of caring for a new born baby, managing crying, and access to advice and support when needed; when a baby is taken to hospital with symptoms indicating potential harm, consider the possibility of non-accidental injury.
Recommendations: Safeguarding Partnership should continue to use ICON: Babies Cry, You Can cope! and DadPad (prevention of abusive head trauma tools) and evaluate these programmes; medical professionals should provide documented analysis of any symptoms of non-accidental head injury.
Keywords: infants, crying, physical abuse, shaking, fathers
> Read the overview report

2020 – West Sussex – Child U

Death of a 3-month-old boy in 2017. Child U died after reportedly falling from his parent's bed onto the floor.
the need for professionals to ask detailed questions about the use of prescribed or over the counter medication and consider the impact of any dependence on parenting, including the impact of withdrawal; the importance of information sharing about a parent's misuse of prescribed drugs; if there is a lack of certainty in a child protection case, considering a timely high-level meeting of professionals from the main agencies involved.
Recommendations: that local substance misuse training covers risks from prescription and over the counter drugs and the need to share information; consider the government's review of prescription drugs to determine if findings can be used to strengthen local safeguarding practices.
Model: Significant Incident Learning Process (SILP) methodology.
Keywords: infant deaths, head injuries, drug misuse, prescription drugs
> Read the overview report

2020 – West Sussex – Child V

Concerns that an infant was seriously harmed due to fabricated or induced illness (FII) in 2017.
the potential for parents to act as conduits for information between professionals which may become a route for misinformation; where a child has been identified as a child in need, a child in need plan should be the overarching planning and review process; professionals should maintain focus on the needs of the child; the need for professional curiosity and scepticism with regard to possible neglect and abuse.
Recommendations: the need to deal with fabricated or induced illness (FII) as robustly as other forms of abuse and neglect, following local and national guidance; early recognition and action in respect of perplexing presentations; practitioners have a basic understanding of the features of perplexing presentations and FII; when there are unexplained concerns about feeding and weight gain, the parent-child relationship should be considered as well as possible medical causes.
Model: Significant Incident Learning Process (SILP) methodology. 
Keywords: infants, fabricated or induced illness (FII), physical abuse, child neglect
> Read the overview report​

2020 – West Sussex – Family W

Significant neglect of two siblings, including neglect of their physical, emotional, social developmental, health and medical needs.
at times the focus was on the adults rather than the lived experiences of the children; over-optimism about the likelihood of the adult carers improving their care of the children; a lack of challenge to adult family members which led to gaps in information. Identifies good practice, including: direct work carried out by the school nurse, which allowed the child’s voice to be heard and shared; recognition by dentist that one of the children’s decayed teeth and bleeding gums were indicative of neglect.
Recommendations: highlights the improved outcomes that have been identified and should be addressed, including: multi-agency partners can evidence a shared responsibility for the safeguarding and protection of children; multi-agency assessments, risk assessments and effective safety plans are secured and monitored within the child protection conference process, to ensure the best outcomes for children; amend the pathway for capacity assessments of carers with learning difficulties so that they can be undertaken at an earlier stage.
Keywords: child neglect, parenting capacity, adults with learning difficulties, optimistic behaviour
> Read the executive summary

2020 – Wiltshire – Child L

Significant non-accidental injuries to a 3-year-6-month-old girl. Child L's father was convicted of grievous bodily harm and sentenced to 9 years in prison.
focuses on: issues around communication and information sharing between agencies; reluctance to initiate early help assessments; the need for curious and holistic practice and getting the whole picture by knowing the whole family; the need to engage with fathers and male carers, instead of the focus being primarily on the mother.
Recommendations: revise midwifery and health visitor pathways; revise multi-agency protocol on bruising and injuries in non-mobile babies and children, including guidance for parents; a thematic review into significant physical injuries to children under 1-year-old; a pilot project focused on engaging fathers and developing models of good practice.
Keywords: pre-school children, injuries, abusive fathers, communication, information sharing
> Read the overview report

Case reviews published in 2019

Case reviews published in 2019

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 2019. To find all published case reviews search the national repository.

Case reviews describe children 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

2019 – Anonymous – A serious case review (SCR) commissioned under Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006

Sexual abuse of three girls by their male foster carer. The victims, Grace, Lisa and Carey provided evidence to convict the perpetrator, who was sentenced to 9 years imprisonment.
includes: mishandled or ineffective investigation of child sexual abuse is especially damaging for the victims and leaves them in greater jeopardy; presentation of perpetrators as pillars of the community and hiding in plain sight; role of local authority designated officer (LADO) has a significant role in regard to any criminal investigation, enquiries and assessment as to whether a child or children are at risk or in need of services. 
Recommendations to LSCB include: ensure that an apology and an appropriate account of the lessons learnt is provided to the three ‘children’; ensure that all practicable steps have been taken to identify and contact any other children who were placed with the perpetrator.
Keywords: child sexual abuse, adults abused as children, foster carers, disclosure, professional curiosity
> Read the overview report

2019 – Anonymous – Child 1

Life threatening injuries to a child attributed to physical abuse. Child 1's sibling was referred for paediatric assessment, which also identified abuse. Mother and partner were arrested and prosecuted.
risk and harm from control and coercion represents a different threat to other forms of domestic violence and abuse; intimidated adults and children are unlikely to disclose information; prior history of domestic violence and abuse is a significant indicator of higher risk in subsequent relationships.
Recommendations: issues for national policy considerations include: guidance on coercion and control as a safeguarding issue and the implications for practice; guidance and arrangements for training for magistrates in regard to domestic violence and abuse.
Keywords: physical abuse, family violence, disclosure, voice of the child
> Read the overview report

2019 – Anonymous – Child A19

Death by suicide of a teenage girl in January 2019.
early help for young people suffering self-harm and/or suicidal tendencies needs development to promote multi-agency working; responses to a young person disclosing sexual abuse may be more effective if they feel included in discussions regarding decisions and potential outcomes; training required to assist social workers exercise their right to disclose information confidentially.
Recommendations: to enhance the use of the self-harm referral pathway and refer young people when support is needed; to ensure similar enquiries are managed by the police in a sensitive manner when a young person feels unable to proceed with a prosecution and victims are better informed if there is no intention to speak to the alleged perpetrator.
Keywords: child sexual abuse, self harm, threshold criteria, voice of the child, suicide
> Read the overview report

2019 – Anonymous – Child F

Death of a 14-year-old young person from an aggressive malignant tumour.
Child F’s voice was heard but was not understood and acted on; evidence of poor inter-agency communication and information sharing; the need to manage conflict and work with challenging carers whilst not losing focus on the child; quality of care issues raised by Child F received an inadequate response by Children’s Social Care.
Recommendations include: children cared for by the Local Authority should be provided with advice either from an independent legal advisor or advocate when they are in disagreement with professionals or carers; raise awareness regarding prevalence and symptoms of brain tumours in children and young adolescents; foster carer recruitment, training and supervision should encompass lessons from this review. 
Model: uses a systems approach with the practitioners’ event based on the Child Practice Review Model.
Keywords: voice of the child, advocacy, foster parents, neglecting parents, professional attitudes, terminally ill children
> Read the overview report

2019 – Anonymous – Child H

Attack by a dog staying within the household of a severely disabled 10-year-old girl in January 2018.
lessons to be learned about the way professionals communicate and make decisions to safeguard children: as part of a standard risk assessment, a dog should be considered in the same way as any other safeguarding hazard within a household; although the Child Protection Conference system is managed by Children’s Social Care, it is the multi-agency group who are the decision makers; when an abused or neglected child is made subject of a Section 47 Enquiry, the strategy meeting should always consider the need to safeguard any siblings.
Recommendations: to consider how the lived experiences of children with severe disabilities and/or limited communication abilities can be represented and heard particularly when significant decisions are made about them; promote good practice whereby practitioners ask parents whether there are pets in the households they visit; review training around assessing parenting capacity to change and working with behaviours of feigned compliance, resistance and deceit.
Model: uses a bespoke ‘systems review’.
Keywords: biting, fractures, home environment, non-verbal communication, partner relations, risk assessment
> Read the overview report 

2019 – Anonymous – Child K

Death of a young boy as a result of injuries sustained as a consequence of his mother’s actions.
a more thorough assessment of mother’s background would have identified high risk factors including a family history of mental illness and childhood abuse; no-one knew the mother used illegal drugs and parents were not challenged regarding their lack of engagement with the drug project; the risk the father posed to his child was not assessed by the time Child K was born; concerns about the family were not discussed at the multi-disciplinary team meetings held at the GP practice; parents were often not present for planned visits.
Recommendations: practitioners must be provided with appropriate knowledge and skills to identify those at risk of developing mental health problems; relevant learning is disseminated to organisations, such as faith establishments, that are likely to encounter people at times of crisis; provide information to be used by GPs when referring women for terminations.
Keywords: adverse childhood experiences, paranoid personality disorder, parent-professional relationships, professional curiosity, risk assessment, sex offenders
> Read the overview report

2019 – Anonymous – Katie

Sexual exploitation of a 14-year-old girl from September 2016 to March 2018.
Learning: use of language by some practitioners from a range of agencies in a number of settings to describe typical behaviours of young people experiencing child sexual exploitation (CSE) suggest understanding the dynamics of CSE requires a step change; impact of neglect and emotional abuse on adolescents is often underestimated; more robust connections need to be made between CSE and other forms of criminal exploitation, e.g. drug use; taking personal and professional responsibility to ensure the system is working for every child.
Recommendations: to ensure that there is a ‘golden thread’  that links strategy, policy and practice and that practitioners are competent in working with children who are potentially or actually victims of CSE; consider the value of applying a ‘contextual safeguarding’ approach to safeguarding adolescents taking into account the influence of peers, school and community; check that practitioners understand their responsibilities to relentlessly pursue any concerns that the system is not working for the child.
Model: uses the Significant Incident Learning Process (SILP) model which focuses on why those involved acted as they did at the time.
Keywords: emotional abuse, exclusion orders, grooming, homeless adolescents, parenting capacity, rape
> Read the overview report

2019 – Anonymous – John

Multiple unexplained injuries to a disabled 2-year-6-month-old boy between October and December 2016. John suffered serious significant leg fractures more than once, with X-rays showing healing rib fractures; he was a child with disabilities who was not independently mobile and was pre-verbal.
Learning: John’s disability needs were a distraction leading to a lack of focus on the vulnerabilities/risks to John following domestic abuse incidents; where there is suspicion of a potential non-accidental injury a formal Child Protection Medical should be undertaken to assess risk and inform decision-making; the response to the third incident of domestic abuse was not robust and left John and siblings at risk of harm; the Child in Need plan was not child focused.
Recommendations to the LSCB: to seek assurance that the multi-agency response to domestic abuse is in line with its policies and procedures; to assure itself that the daily lived experience of children is central and captured in all the work partners undertake to promote their health and wellbeing.
Model: the review adopted a systems based approach.
Keywords: adults abused as children, children with disabilities, developmental disorders, risk assessment, supervision
> Read the overview report

2019 – Anonymous – Patrick and Patricia

Concerns about the risk of sexual abuse of two half-siblings aged 10 and nearly 6 years old, and about the drift and delay in planning for their future.
includes: there is a difference between the risk of reoffending and the risk of harm that a convicted sex offender might pose to a child in their family; the need for social workers to understand other agencies’ risk assessments; the importance of keeping historic ‘risk’ alive; the importance of pre-birth assessments and child protection conferences; the effectiveness of step-down and escalation.
Recommendations to the LSCB include: amend Child Protection procedures to state that when a child is subject to a child protection plan and a parent or carer is on the sex offender register, their sex offender manager should be a part of the core group; when children’s names are on a Child Protection plan and there are concerns about possible sexual abuse, risk of sexual abuse is the most appropriate category.
Keywords: child sexual abuse, sex offenders, risk assessment, recidivism
> Read the overview report

2019 – Anonymous – Sexual abuse by a local authority foster carer

Sexual abuse of eight primary school aged children by an approved local authority foster carer. The foster carer was a man in his 50s who, along with his wife, had fostered more than 30 children, placed by the local authority since their approval in 2001.
lack of rigour and thoroughness in assessment and approval process in recruitment and approval of prospective foster carers; arrangements for placement of children was above the approved level and outside the approved age range; shortcomings in procedures and practice make looked after children more vulnerable to abuse and less likely to report it.
Recommendations: to apply standards of good practice to all aspects of recruitment of foster carers; foster care placements must be made as far as possible with carers who have been assessed as able to meet their needs; that systems for granting exemptions to the approved number of children placed in a foster home operate in line with fostering regulations; provide assurance that arrangements for supervision and oversight of the work of foster carers are effective.
Keywords: bruises, child sexual abuse, hostile behaviour, private foster care, voice of the child
> Read the overview report

2019 – Birmingham - BSCB 2017-18/01

Death of a 2-month-old baby girl in January 2017. A post-mortem found eight rib fractures sustained over a 24-hour to twenty-day period. Baby's mother was found guilty of manslaughter and received a custodial sentence.
Learning: the need for effective liaison and communication between local authority social care teams; professionals should understand the addictive nature of drug and alcohol dependency and that non-attendance at substance misuse appointments could be an indicator of abuse; professionals need to be mindful of disguised compliance and an over optimistic mind set.
Recommendations: an appropriate action and implementation plan should be devised to ensure lasting improvements to practice and services aimed at safeguarding and promoting the welfare of children.
Keywords: child deaths, infants, physical abuse, substance misuse, optimistic behaviour
> Read the overview report link

2019 – Bolton – Baby C

Death of a baby within a week of birth. Both parents concealed the birth, death and burial of Baby C.
Learning: as the deliberate concealment from all agencies of the pregnancy and subsequent death of Baby C could neither have been predicted nor prevented, this review only looks at potential interventions which could support practice and lessen the likelihood of similar events happening in the future.
Recommendations: consider developing a system of notification letters to the GPs of parents who have experienced the traumatic loss of a child through adoption (older sibling had been removed from parents' care and adopted); explore the possibility of whether, under the General Data Protection Regulation (GDPR), notification outlining the information the GPs will need to know could be legitimately sent, in the interests of the parents, when consent cannot be obtained; seek reassurance that suitable provision is available to support women who want to break the cycle of repeat pregnancy and care proceedings.
Keywords: infant deaths, newborn babies, parenting capacity, family planning, adoption, deception, family violence
> Read the overview report

2019 – City and Hackney – Rachel

Death by suicide of a 16-year-3-month-old girl in January 2017.
Learning: the reliability of a young person taking prescribed medications and the possibility of secreting medication to use later to overdose; the LSCB should seek to learn from the wider picture and research into adolescent self-harm and suicide to consider prevention and treatment options in the commissioning and provision of local services;  teachers may not have had training in young people’s mental health especially acute mental ill-health and its management; the need to increase understanding of the impact of social media on young people’s decision-making and actions.
Recommendations: expedite publication of a Local Strategy for Prevention of Suicide by Young People and whether this should be a Strategy to prevent harm and suicide by young people; to raise awareness and learning between schools about children’s mental health and risk; to seek reassurance from partners that there is a robust and coordinated response to suicide by a young person, to identify and mitigate the impact on other children and young people.
Keywords: anorexia, child mental health services, disguised compliance, emotional disorders, psychological effects, self harm
> Read the overview report

2019 – City and Hackney – X

Death of a 16-year-old boy by suicide in October 2016.
includes: more preventive approaches are needed to support young people who are anxious and help prevent them acting on suicidal thoughts; more support should be available for young people to talk to others if they are feeling anxious or depressed.
Recommendations include: raise awareness about the use of and impact of illegal drug use by young people; consider the role of drug and alcohol use in mental health assessments of suicidal young people; schools should ensure that a child’s vulnerabilities including mental health issues should be passed onto a new school when a child transfers.
Keywords: suicide, mental health, adolescents, anxiety
> Read the overview report 

2019 – Croydon – Child A and Baby N

Death of a 2-and-a-half-week-old boy in March 2016 due to a non-accidental head injury.
Learning includes: agencies need to ensure that they record full details of both the baby’s father and all members of the household; Children’s Services need to ensure that they have understood medical information and not be entirely led by medical opinion; professionals in MASH need to discuss and evaluate information, not just share it.
Recommendations include: ensure the participation of agencies in serious case reviews, both in relation to attendance at meetings and responding to requests for information; findings of research into head injuries in children to be included in inter-agency training; seek assurances from partner agencies that managers are equipped with the skills and knowledge to provide effective oversight of child protection cases.
Keywords: decision-making; non-accidental head injuries; infant deaths; information sharing; managers; professional curiosity
> Read the overview report

2019 – Croydon – Child Q

Death of a 16-year-old boy following a road accident in 2017.
to provide support to parents as early as possible in a child’s life paying particular attention to attachment in early years and experiences of separation and loss; equip children’s workforce to provide a trauma informed response to adults and children; Child Q’s behaviours were not adequately addressed in school, which led to exclusion; ensure that transfer or transition arrangements are as robust as possible; Child Q required intervention and treatment for various emotional and mental health issues, but treatment was unacceptably delayed.
Recommendations: to strengthen working protocols between Adult Mental Health and Children’s Services to facilitate development of integrated whole family health care pathway; to influence the Department for Education (DFE) to review alternative education and agree a consistent methodology of working with high-risk pupils in a multi-agency context; join up multi-agency risk and safety planning forums to improve services for children at high risk in the community, such as gangs, serious youth violence, missing and all forms of exploitation.
Keywords: early intervention, gangs, placement breakdown, preventive services, threshold criteria, young offenders
> Read the overview report

2019 – Croydon – Child Y

Death of an adolescent boy due to a fatal stabbing.
early help and prevention is critical; schools should be at the heart of multi-agency intervention; disproportionality, linked to ethnicity, gender and deprivation, requires attention and action; an integrated, whole systems approach is needed across agencies, communities and families.
Recommendations: review evidence-based practice to revise and publish Croydon’s model of intervention to effectively respond to vulnerable, risky, and gang-linked young people; review service arrangements and introduce support for mental health patients to support a child’s relationship with their parent and provide support to the care giving parent; ensure adequate sustainable resources are in place to support the multi-agency response to address gangs and serious youth violence.
Keywords: gangs, school adjustment, weapons, violence, peer groups, social media
> Read the overview report

2019 – Croydon – Vulnerable adolescents

Thematic review of 60 vulnerable children known to Children's Services (23 girls, 37 boys) aged between 10 and 17-years-old following the deaths of three children.
Learning includes:a holistic approach to the child and family is needed, complemented by an integrated multi-agency response; making a difference to children's outcomes cannot be achieved by professional intervention alone and there is a need to understand and embrace family, kinship and communities; schools should be equipped to respond to challenges presented by children with high risk behaviour and placed at the heart of multi-agency service provision.
Recommendations include: consider how awareness raising about the impact of adverse childhood experienced (ACEs) will be built upon to include professionals, families and the community; establish a data set about the most vulnerable children in Croydon to inform risk management strategies and service provision; consider how the involvement of professionals, families and the local community might be achieved, to explore how to address disproportionality.
Keywords: adolescents, adverse childhood experiences, children’s attitudes, education, gangs
> Read the overview report

2019 – Dudley – Child A

Serious physical harm to a 10-week-old infant in September 2016.
assessments are biased towards assessing mothers, rather than assessing both partners equally; there was an over-reliance on the Family Nurse Programme (FNP) by all partner agencies involved; processes designed to safeguard children were not followed when bruises and marks were identified.
Recommendations: consider how to reduce professional anxieties around sharing information with partners; foster a culture where professional curiosity is increased; and assure that professionals’ response to indicators of domestic abuse is in line with policies and procedures.
Keywords: adolescent parents, disguised compliance, infants, physical abuse, teenage pregnancy, unknown men
> Read the overview report

2019 - East Lothian and Midlothian - Child R

Emergency admission to hospital of a male under 18-years-old in 2016 with acute severe nutritional failure.
inability to comply as well as enmeshed relationships should be considered if plans are not progressing as expected; there is a gap in the provision of multi-disciplinary intensive family home support exploring and challenging family dynamics; there is a vulnerability at transition into adulthood, despite Getting it Right for Every Child (GIRFEC) processes applying up to the age of 18, especially for those who leave school or who have complicated or challenging needs which do not fit into a medically defined category.
Recommendations: children with severe obesity affecting functioning should be supported via the GIRFEC pathway; everyone with parental rights and responsibilities should be consulted with and recorded on all agencies' GIRFEC paperwork; the GIRFEC pathway should be followed during transition especially once a young person who has a child's plan has left school, to ensure ongoing support and planning.
Keywords: nutrition, obesity, encopresis, attachment behaviour, professional curiosity, school attendance
> Read the overview report

2019 – East Sussex – Child T

Death of an 18-year-6-month-old male in May 2017. Child T had been in hospital for three months prior to his sudden and unexpected death.
prior to admission to hospital there was limited consideration of the child’s lived experience; trust was placed on what the mother was saying without considering the impact on Child T; mother’s avoidant behaviour was not effectively identified or challenged; professionals need to remember a person is a child until they are 18 years old.
Recommendations: to ensure that any child with a serious health condition has a written down multi-agency plan to coordinate and review the child’s health care and support needs; to ensure that education providers take responsibility and the initiative to make available appropriate diabetes education and practical information in schools and colleges.
Keywords: malnutrition, mother-child interaction, obesity, threshold criteria, transition to adulthood, child neglect
> Read the overview report

2019 – Greenwich – Child U

Death of an 8-week-old boy in September 2016 due to non-accidental injuries.
finds that there were no significant deficits of policy, procedure or practice, but opportunities for learning across the network include: scope for greater professional curiosity; greater precision in record keeping; more consideration of the significance of birth fathers/relevant men; enhanced recognition of the need for interpreters.
Recommendations: LSCB to identify and support opportunities for 'evidence-based' programmes directed toward reducing the risk of head injuries in very young children; Lewisham & Greenwich NHS Trust (LGT) to: develop an information sharing pathway when a pregnant woman attends their services and is booked at another hospital; remind staff of the need for compliance with Trust guidelines on the use of interpreters; to consider including 'safeguarding concerns' tick box to GP discharge letters.
Keywords: migrants, infant deaths, interpreters, language, medical assessment, parenting education
> Read the overview report

2019 – Hertfordshire – Child I

Death of an infant boy under 1-year-old in April 2017 due to drowning.
includes: housing providers may have indications that families with young children are struggling and may benefit from support; family might have benefited if greater consideration was given to social factors including ethnicity, apparent isolation, historical mental health concerns and status as asylum seekers; ensure good communication between GP and maternity services, sharing information on previous parental mental health and details of previous pregnancy complications.
Recommendations include: seek assurance from health providers that social and medical risk factors in pregnant women are communicated to maternity services by GPs; seek assurance from the police that when responding to domestic abuse all relevant information is shared with partner agencies; seek assurances from housing commissioners that staff making home visits receive suitable training in recognising and responding to concerns about vulnerable adults and children.
Keywords: accidents, asylum seekers, drowning, housing, infant deaths, pregnancy
> Read the overview report

2019 – Isle of Man – Several children

Review of the practice and care of several children between 2002 and 2011 in the Isle of Man. 
includes: need for staff to fully understand the behaviours and presentation that is indicative of sexual abuse; need for staff to understand the factors that have an impact on disclosure; need for professionals and sectors to enhance their confidence and build opportunities to hear the voice of children and young people; importance of professional curiosity and for professionals to respectfully challenge each other.
Recommendations: review single agency training on child sexual abuse to ensure sufficient focus on the key indicators and disclosure process; provide clarity on the use of professional meetings as a tool in dealing with difficult and complex cases, highlighting the opportunity they provide for multi-agency reflection.
Keywords: child sexual abuse, foster care, disclosure, professional curiosity
> Read the overview report

2019 – Kent – Child H

Death of a 5-year-old boy in June 2018. Mother killed herself and Child H during planned unsupervised contact outside the family home.
information about the mother’s mental health history was not passed on to the health visitor so her initial assessment did not take this into account; most professionals did not immediately consider the issue of the mother’s employment when assessing risk following the incident of domestic abuse; the DASH risk assessment tool has insufficient focus on emotional abuse and mental health issues and too much focus on physical harm; male victims of domestic abuse do not see themselves as victims; mother’s relationship with Child H could be described as enmeshed which may explain the homicide-suicide incident.
Recommendations: to require Kent Police to resolve difficulties causing delays in providing CAFCASS with relevant information when they are undertaking safeguarding checks; to ensure when Police Officers take a person to the hospital it is possible to pass on relevant information confidentially to a clinician in a speedy time-frame; to develop an increased understanding of the needs of men as victims of domestic abuse and what this means about the nature of services provided.
Keywords: female offenders, mother-child relationships, narcissism, parents with a mental health problem, emotional abuse, information sharing
> Read the overview report

2019 – Kirklees – Child D

Serious assault of a 22-month-old boy in February 2018. The mother’s partner was arrested on the day of the assault and subsequently served a 21-month custodial sentence.
the mother's parenting capacity was not assessed despite the family being known to agencies for at least 10 years; the mother did not appear to recognise her own vulnerability or that her relationships with abusive men put herself and the children at risk.
Recommendations: seek assurance from partners that the voice of the child and lived experience of the child is the primary focus of all agency interventions, risk assessments and child protection processes; use validated parenting assessments for parents with vulnerabilities, including their own adverse childhood experiences, which can indicate that parenting may be compromised.
Keywords: physical abuse, unknown men, partner violence, home environment, parenting capacity
> Read the overview report

2019 – Lambeth and Bromley – Child K

Death of a 5-and-a-half-year-old boy, Child K, in November 2016 following injuries sustained during an assault by his mother’s boyfriend. He was convicted of Child K’s murder and sentenced to life imprisonment.
includes: full assessments must be made of accommodation arrangements of offenders when they are known to have been domestically violent to adults and/or children; awareness of the vulnerability of victims of domestic abuse whose immigration status is not secure.
Recommendations include: ensuring that staff involved in cases involving domestic abuse are aware of arrangements for sharing information about offenders; that the risks to children, including emotional abuse are assessed when assessing incidents of alleged domestic abuse; reviewing how families experiencing domestic abuse with no recourse to public funding are supported.
Model: uses the Welsh Child Practice Review methodology, a model that takes a multi-agency collaborative approach, focussing on systemic strengths and weaknesses.
Keywords: child deaths, family violence, homeless families; murder, prison and prisoners, interagency cooperation; no recourse to public funds
> Read the overview report

2019 – Lancashire – Child LK

Death of an 8-month-old girl in 2017. Her mother was subsequently convicted of her murder.
Learning: consider opportunities to ensure disguised compliance and focus on children to be examined regularly in staff supervision meetings; develop and implement guidance relating to looked after children who sustain injuries; consider options for ensuring continued and meaningful engagement of GP services throughout safeguarding processes; consider how non-statutory voluntary organisations can be identified and included in safeguarding processes; consider requiring the local authority to complete and share the outcome of an analysis of children placed at home, the circumstances and decisions which led to placements being initiated and how compliance is monitored, to ensure the safety of all children who are subject to home placement agreements.
Recommendations: there were no recommendations.
Keywords: pregnancy, foster care, people with learning difficulties, placement, non-accidental head injuries, abusive parents
> Read the overview report

2019 – Leeds – Billy

Physical abuse of a boy aged under 1-years-old in 2016. Billy was born prematurely and placed in foster care subject to an interim care order at 2-weeks-old.
includes: evidence of good practice with professionals working well together to do the best for Billy; some opportunities missed for professionals from different agencies and disciplines to formulate effective plans together; purposeful professional meetings may have promoted better clarity and more effective ways to have informed decision making.
Challenges include: consider how all involved agencies can contribute effectively to the formulation of a child’s plan; ensure the inclusion of hypothetical risks that may be predicted along with risks identified in a comprehensive assessment to better safeguard children.
Model: uses the Welsh model methodology.
Keywords: physical abuse, infants, substance misuse, parenting capacity, risk assessment
> Read the overview report

2019 - Leicestershire and Rutland – Child A

Non-accidental head injury to a 2-year-old boy, Child A, in February 2016. The injury was discovered during an unannounced visit by a social worker.
professionals need to retain open minded curiosity and consider all potential risks to children; and professionals should be supported in considering the impact on them of working with people who present as aggressive or with challenging behaviour.
conduct a multi-agency review of the use of the category of emotional harm in child protection plans; ensure that professionals understand the purpose of the Core Group and Child Protection Conference; and recognise the impact on practice when working with adults with violent and aggressive behaviour or disguised compliance.
Keywords: non-accidental head injuries, disguised compliance, children as carers, partner violence, physical abuse, mental illness
> Read the overview report

2019 – Lewisham – Child X

Death of an 11-year-old boy in May 2017.
Learning: the threshold for intervention due to neglect was too high; emergency contingency planning should be given more attention when working with families with children with life limiting conditions; and professionals would have benefited from a unified approach to working with a family they found hard to engage.
Recommendations: there should be clear guidance for staff where parents are reluctant to engage; ensure a system for identifying a Lead Professional for all children with complex needs is in place; and the ambulance service should review guidance on how police assistance can be used to ensure the welfare of patients.
Keywords: ambulances, children with multiple disabilities, fathers, medical care neglect, parent-professional relationships, parental involvement
> Read the overview report

2019 – Lewisham – Child Y

Death of a premature 9-week-old baby girl in June 2017 from unascertained causes. 
includes: the need for raised and constant professional curiosity; learning about invisible men; a greater willingness to escalate issues if agency responses appear insufficient; effective record keeping.
Recommendations include: policies and guidance should be amended to require midwives and health visitors to enquire about, observe and record, where and in what a baby is sleeping or is to be sleeping.
Keywords: sudden infant death, sleeping behaviour, professional curiosity
> Read the overview report

2019 – Lewisham and Harrow – Child LH

Physical abuse of a 4-year-3-month-old boy by his maternal aunt in 2017.
important to ensure that Special Guardianship Order (SGO) placements are supported by a robust plan that is tailored to the individual needs of the children (including any children who are existing members of the household) and their potential carers; practitioners should be aware that information from a DBS check may not contain significant pieces of information that should be included in any assessment prior to placing a vulnerable child.
Recommendations: ensure that for prospective SGO assessments, the needs of children already living in the household, and their wishes and feelings are fully considered; oversee a multi-agency review of current arrangements for Children in Need that are also subject to SGOs. This is to ensure that the needs of children in SGO placements are met wherever they are placed.
Keywords: kinship foster care, physical abuse, school attendance, home environment, family functioning, medical assessment
> Read the overview report

2019 – Lincolnshire – G

Neglect of four siblings over a period of several years.
includes: when professionals do not have an understanding of the family history, relationships and functioning it is difficult to have a clear picture about what daily life is like for the children; significant decisions should be informed through key assessments being completed, including pre-birth parenting assessment and risk assessments.
Recommendations include: seek assurance that the model used in assessing risk within conferences is being used effectively; seek assurance in the practice of Independent Child Protection Chairs and their management of conferences; consider establishing a practice by which CP plans should not be removed at the first review unless there are evidenced circumstances; seek assurance that the professional resolution and escalation procedure is understood and effectively applied in all partner organisations.
Keywords: child neglect, non-accidental head injury, heroin, neonatal abstinence syndrome, optimistic behaviour; teenage pregnancy
> Read the overview report

2019 – Medway – Learning for organisations arising from incidents at Medway Secure Training Centre

Institutional abuse of children at Medway Secure Training Centre (STC) in 2015.
includes: create safe working cultures within organisations, including safe recruitment, policies, training and supervision of staff; ensure statutory agencies’ arrangements for responding to allegations about adults who are in positions of trust are effective in protecting children from abuse; ensure appropriate, child focussed commissioning practice by national organisations responsible for contracts for service provision within the secure estate; consideration needs to be given to ensure the advocacy service is fully accessible and there are no barriers to children raising their concerns.
Recommendations include: re-launch awareness programme and training on safer recruitment processes and audit to ensure these messages are embedded; consider STC staff undertaking training in Adverse Childhood Experiences (ACEs) to better understand children’s needs and behaviours; consider the implementation of regular formal supervision processes for staff.
Keywords: institutional child abuse; whistleblowing; physical restraint; recruitment; secure accommodation, commissioning of services. 
> Read the overview report

2019 – Northamptonshire – Child Ab

Neglect and physical abuse of a child over many years. Child Ab and siblings were removed from the care of their mother and stepfather.
Learning includes: lack of curiosity about stepfather's past, or challenge to his dominance and control; need to question and challenge whether an adult who states that they are the parent of a child does indeed have parental responsibility; importance of professionals to challenge parental non-engagement with agencies and to be alert to disguised compliance; consideration of the national plans regarding home educated children and resources to enable elective home education to be effectively assessed and monitored.
Recommendations include: reinforce the requirement for professionals to maintain vigilance and professional curiosity when engaging with families where there are safeguarding concerns and a step-parent is present; consider the issue of elective home education and hidden children, which is a national issue, with a view to undertaking a future thematic review.
Keywords: child abuse, home education, professional curiosity, parental responsibility
> Read the overview report

2019 – Northamptonshire – Child Ap

Death of a 1-year-old girl in April 2018 due to a suspected non-accidental head injury.
there is a need for information sharing to support holistic assessment; professional intervention was adult focused and the children's voices were not fully sought or captured; it is important to assess significant male adults in the lives of children.
Recommendations: ensure that agencies involved in child protection processes work together and focus on the needs and wellbeing of children; ensure that agencies share all information known to them so that a holistic assessment of the family can be undertaken.
Keywords: child deaths, non-accidental head injuries, prisons and prisoners, drug misuse, denial, injuries
> Read the overview report

2019 – Nottingham – Child KN15

Death of a 13-year-old girl of unconfirmed causes in June 2015, two days after she had been reported missing from home. 
the importance of using assessments to support early intervention; the needs of children who live with adults who have reported mental health problems should be systematically assessed by all partner agencies to ensure that children and families receive the support they require; and assessments should explore the wishes and feelings of the child to understand the cause of a child's behaviour and underlying distress. 
Recommendations include: LSCBs should review policy and information sharing processes when a child moves school within and between local authorities; ensure that practice is consistent and child centred when potential safeguarding concerns are to be discussed with parents and carers.
Model: uses the Significant Incident Learning Process methodology, a learning model which engages front line staff and their managers in reviewing cases.
Keywords: child death, emotional abuse, parents with a mental health problem, partner violence, runaway children, schools, transient families
> Read the overview report

2019 – Oxfordshire – Child M

Death of a 5-year-old boy in March 2017. Child M died of stab wounds while in the family home with his mother.
Learning: those working with Child M and his mother had a limited understanding of possible risks to Child M; after the family moved to Oxfordshire no professional had a comprehensive knowledge of the mother’s mental health history as case transfer and closure summaries did not contain full details; there was no coordinated transfer with agreed objectives and plan.
Recommendations: to consider whether the LSCB’s current threshold of need document places sufficient emphasis on the need to consider previous and historical concerns; that mental health service providers and GPs have adequate arrangements in place to identify and assess the needs of children of patients being treated for psychiatric illnesses; to ensure  staff have clear expectations for obtaining and reading case histories; to seek reassurance that implementation of GDPR has not led to inappropriate limitations on information sharing.
Keywords: professional curiosity, filicide, threshold criteria, information sharing, mothers, history
> Read the overview report
> Read the executive summary

2019 – Portsmouth – Child G

Neglect of an adolescent boy over several years by his mother.
Learning: when assessing risk of harm to children with disabilities, it is important that the care of the disability does not distract, or mask, any actual or potential harm being caused; children with multiple and complex needs should always be offered an advocate when there is an expectation that they express their views and contribute to their own care arrangements.
Recommendations: promote greater understanding across the safeguarding partnership about mental capacity, decision making and implications for safeguarding of children aged 16-18 years old; seek clarification about the role of the MASH for when professionals from all agencies refer concerns about a child’s welfare or safety, and it is an open case to Children’s Services.
Model: uses a model of learning based on a Soft Systems Methodology.
Keywords: child neglect, children with disabilities, decision-making, parenting involvement, non-attendance, mothers
> Read the overview report

2019 – Reading – Child I

Serious incident involving a 4-year-old child who was admitted to hospital in June 2016 after ingesting a potentially lethal dose of a sibling's epilepsy medication.
thorough risk assessments should be undertaken when a partner has left a domestically abusive relationship but children are with the perpetrator; it is important to be aware of the pressures and difficulties faced by young parents; and all professionals who can offer insights into a family should be invited to meetings examining levels of need and risk for children and families.
Recommendations: promote awareness of the Escalation Policy; GPs should consider social issues in a child's life that may affect the ability of the parent or carer to maintain a medication regime when prescribing children medication; and the LSCB to seek assurance from Children's Social Care that issues highlighted are being addresses in a timely manner, particularly the application of Child in Need procedures.
Model: SILP methodology.
Keywords: adults in care as children, family violence, general practitioners, interagency cooperation, parenting capacity, prescription drugs
> Read the overview report

2019 – Sandwell – Child KS

Death of an 8-week-old baby in 2017.
KS died from an unascertained cause and there was no known action that professionals in Sandwell could have taken to prevent this death; if agencies had better shared information and complied with both national and local procedures, the level of support to her mother and her family could have been more effective but would not have affected the final tragic outcome for KS.
Recommendations: undertake a review of safeguarding training to ensure that pre-birth procedures are understood and implemented appropriately; seek assurance that health professionals engaged in antenatal and postnatal work are trained in the appropriate use and application of escalation procedures, issues of disguised compliance and over optimistic assessments.
Model: methodology is based on the ‘Welsh Model’.
Keywords: sudden infant death, sleeping behaviour, partner violence, parenting capacity, disguised compliance, housing
> Read the overview report

2019 – Staffordshire – Child E

Death of a 5-year-old child in July 2016. Child E's step-father pleaded guilty to manslaughter and no inquest was carried out.
a focus on the physical care of the children and home conditions diverted attention from other serious issues, including risk of being in contact with people who presented risks to the children; professional challenge and escalation is important in effective intra and inter-agency work; agencies that saw signs of concern dealt with them appropriately most of the time but some intra and inter-agency communication and information sharing could have been better.
Recommendations: more training on neglect and its impact on children; more understanding of legal processes and what local authorities must evidence to secure statutory orders; raise awareness of the Escalation Procedure and the importance of robust, respectful professional challenge between and within agencies; consider the introduction of a panel, chaired by a different professional to take a “fresh look” at cases that are making insufficient progress.
Keywords: assessment, child neglect, child deaths, home environment, optimistic behaviour, step-parents
> Read the overview report

2019 – Swindon – Child Q

Neglect of a 5-year-old girl in September 2015.
Learning: the number of children in the family and the number and range of professionals involved posed a challenge to effective communication; professionals were not curious enough about Child Q’s experiences and too quick to accept parents’ explanations without considering the whole context of her life.
Recommendations: develop a multi-agency policy for the management of non-attended appointments across multiple services; review of information sharing systems between hospitals, GP practices and child health professionals, focusing on communication; ensure that requirements for all children’s voices to be heard at child protection conferences are met and that those who cannot speak for themselves are adequately represented.
Keywords: pre-school children, school attendance, malnutrition, child neglect, home environment, child protection registers
> Read the overview report

2019 – Swindon – Child U

Death of a 1-year-old boy in November 2017 from unascertained causes.
Learning: the child’s experience must run through all work undertaken with families and thresholds should be focused on the impact of parenting on the child; professionals need to use the neglect framework and practice guidance to help them identify neglect; if a parent voices concern about being a parent due to their childhood experiences of sexual abuse, specialist support should be made available; when assessing if an injury is consistent with the story provided by the parent, consideration should be given to the child’s developmental stage.
Recommendations: to question how professionals in partner agencies make referrals that provide the evidence and information required when they have safeguarding concerns; to request assurance from partner agencies that professionals understand the risks of interfamilial sexual abuse and a parent’s adverse childhood experiences (ACEs).
Keywords: adverse childhood experiences, father-child interaction, neglect identification, mother-child relationships, nutrition, sudden infant death
> Read the overview report

2019 – Tower Hamlets – Baby ‘Adam’

Bruising first reported on a 6-week-old boy in March 2016, with further bruising and fractures documented over the next month and six days.
a hierarchical approach in the working environment leads to professional deference and makes challenging medical professionals and decisions difficult; child protection practice requires collaborative work and professional respect; needs of fathers must be properly assessed and engaged; change to modern service delivery models cannot guarantee continuity of care; service thresholds were applied that did not correspond to the needs described.
Recommendations: all agencies must undertake a review of internal and inter-agency information sharing systems including use of electronic recording, flagging and coding systems; community health visiting and children’s social care services must incorporate a ‘think family approach’ as standard; the LSCB must develop and agree a protocol for responding to bruising in pre-mobile babies and disabled children who are dependent and unable to communicate.
Keywords: adults with physical disabilities, father-child interaction, fractures, health visitors, medical assessment, optimistic behaviour
> Read the overview report

2019 – Tower Hamlets – Child Elias

Death of a 14-week-old boy from serious non-accidental injuries in July 2016.
Learning: failure of the systems and processes designed to safeguard children with inaccurate recording; the interface between Child in Need and Team Around the Child did not work well; system around midwifery care was disjointed with lack of communication between midwifery teams and midwives and GPs; insufficient focus of emotional impact of Elias and Child A’s diagnoses on their parents.
Recommendations: health services should review documentation and assessment tools and include household composition and functioning of the household; to seek assurance from health and partner agencies of emotional impact of having a child born with any abnormality/disability features within consultations with recognition of any risks to the child; all GPs to be notified of the pregnancy of all women registered in their care; to seek assurance that the application of thresholds is now consistent.
Keywords: bruises, burns, children with physical disabilities, congenital disorders, housing, murder
> Read the overview report

2019 – Walsall – Charlie

Death of an infant in November 2017 from injuries linked to being shaken three months earlier. Father was convicted of murder.
Learning: professional curiosity may lead to a fuller understanding of the lived experiences of children; accurate recording of assessments is vital for understanding risk; when children talk about their lived experience there should be adequate credence given; information held by agencies that indicate risk to children should be shared regardless of how or why that information is known.
Recommendations: specific programmes of activities to improve and embed a culture where Think Family and authoritative practice and supervision become the norm in practice considerations.
Keywords: infant deaths, shaking, voice of the child, professional curiosity
> Read the overview report

2019 – Wandsworth – Baby Eliza

Non-accidental injuries to a 4-month old girl in 2015. Baby Eliza was taken to hospital by ambulance where examination revealed unexplained cerebral bleeding thought to have occurred more than once.
need for thorough assessment of mother’s and wider family history, including trauma when assessing parenting capacity rather than depending only upon presentation and observations; need to avoid misplaced sympathy; need to consider correlation between animal cruelty and child abuse; importance of following best practice and compliance with established procedures; need for professional curiosity and mutual challenge; need for full, precise and accurate information recording and sharing; persistence in encouraging GP involvement; professional enquiry about men (resident or not) whose relationship and conduct had an impact on the case; need for an effective system for identifying safeguarding supervision cases.
ensure agencies are sharing, accurate and up-to-date information; use the case for multi-agency training; urge NHS England to ensure clinics inform GPs of terminations.
Keywords: non-accidental head injuries, record keeping, termination of care, teenage pregnancy, general practitioners, information sharing
> Read the overview report

2019 – Wiltshire Child K

Death of a 1-year-old boy, Child K, in June 2018. A post-mortem revealed injuries including bruises, scratches and a fractured skull.
includes: the importance of focusing on the child’s experience; remembering that a number of minor injuries, including bruising on a baby, may be an indication that the child is at risk of harm; and ensuring family history, background and contextual information is taken into account during the referral process.
Recommendations include: embedding the Early Help assessment process across the local authority; ensuring that staff are regularly reminded about the significance of bruising in non-mobile babies; and all agencies should be confident to question medical opinion provided as part of Care Proceedings.
Model: sets out findings using the Partnership Learning Review model.
Keywords: infant deaths, non-accidental head injuries, non-attendance, care proceedings, attachment behaviour, family violence
> Read the overview report

Case reviews published in 2018

Case reviews published in 2018

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 2018. To find all published case reviews search the national repository.

Case reviews describe children 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

2018 – Anonymous – Baby L

Death of a 3-month-old baby in 2016. An inquest recorded a verdict of death by natural causes.
Learning: partner agencies’ concerns were often not accepted by children’s social care; families do not fully understand the differences between Level 2, Level 3 and Child in Need within the Common Assessment Framework; lack of openness within children’s social care to escalate cases; uncertainty as to the appropriate response when the mother refused access to the health visitor and other workers; no consideration given as to why the mother was neglectful or what levels of support she had in the community.
Recommendations: the need to develop a broader agreement amongst partner agencies on the application of thresholds; to review the effectiveness of the escalation policy and its application locally; children’s services should develop clear practice guidance on the use of announced and unannounced visits; professionals leading on a Level 3 Common Assessment Framework (CAF) should ensure that GPs are fully informed of CAF activity in line with existing procedures.
Keywords: drug misuse, family support services, home environment, professional curiosity, threshold criteria
> Read the overview report

2018 – Anonymous – Charlie and Sam

Sexual abuse and sexual exploitation of a 12-year-old girl and her 11-year-old sister.
Learning: the importance of assessment to ensure that the needs of minority ethnic children are considered; there was a delay in moving the initial joint investigations forward which resulted in a delay to direct work; the importance of accurate assessment; and the use of professional interpreters within safeguarding practice.
Recommendations: are made around around management of CSE concerns, assessment and information sharing.
Keywords: child sexual exploitation, assessment, ethnic groups
> Read the overview report

2018 – Anonymous – Children F, G and H

Concerns about serious harm to three siblings due to suspected fabricated or induced illness (FII).
Learning: GPs should take a coordinating role when a child is attending a variety of clinics and hospitals for treatment; practitioners should be wary of relying solely on information provided by parents and ensure that the child's views are sought and listened to; practitioners should be alert to signs of disguised compliance by parents; practitioners need to maintain professional curiosity in cases where concerns emerge over a period of time.
Recommendations: request a review of the national Child Protection Procedures regarding FII; share learning from this review with NHS England; request that the Department for Education updates guidance on safeguarding and FII.
Keywords: fabricated or induced illness, disguised compliance, general practitioners, professional curiosity
> Read the overview report

2018 – Anonymous – Child G

Death of a teenage girl in spring 2015, by suicide.
Learning: the need for a coordinated approach to children and young people who self-harm; sufficiently robust safeguarding responses to self-harm and suicide ideation in teenagers; assessment as a dynamic process that should be updated as circumstances change; guidance around exclusion and vulnerable pupils in school.
Recommendations: to launch a campaign to raise awareness of self-harm and suicide ideation in children and young people; that agencies and CAMHS have sufficient tools, education and knowledge to assess risk and implement risk management plans for children and young people who self-harm; to ensure that the TAF/CAF model that supports early help for children is provided for families whose needs do not reach the threshold for statutory services; the LSCB should be assured that NHS England has informed all pharmacies in NHS England regarding selling of medication (Nytol) to children; to review processes for communicating available help to bereaved parents and their families.
Keywords: suicide, depression in childhood, exclusion from school, listening, self-harm, sibling relations
> Read the overview report

2018 – Anonymous – Child H1

Sexual abuse of a 15-year-old adolescent by her older brother in 2015.
Learning: when Early Help is delivered without holistic access to information and there is no plan with agreed outcomes, it is a challenge to monitor the impact of the intervention; it is important that efforts are made to understand why young people are engaged in behaviour described as “risk taking” and “challenging”.
Recommendations: to audit and monitor how the voices of children and young people inform assessments and interventions.
Keywords: sibling abuse, harmful sexual behaviour, listening
> Read the overview report

2018 – Anonymous – Child L and Child M

Severe neglect of twins aged 22 months in June 2016. Mother had three children removed from her care in March 2005 due to neglect and emotional abuse.
Learning: the need to remind key practitioners of national and local safeguarding policies and procedures; identification of concerns as to the function of the governance and supervision of child protection cases; the need to remind police investigating officers of agreed guidance on sharing information in parallel processes involving criminal proceedings and SCRs; the need to review case allocations and ensure that key practitioners have the necessary experience and supervision.
Recommendations: to remind all staff of the need to have knowledge and awareness of learning from SCRs when carrying out their child protection roles; to ensure there is compliance in place, for all staff, when there is a conflict of interest; to ensure record keeping is enhanced and expeditiously recorded onto the computer management system.
Model: mixed methodology.
Keywords: developmental disorders, family support services, fractures, home environment, non-attendance, optimistic behaviour
> Read the overview report

2018 – Anonymous – Child S

Non-accidental injuries to a 13-week-old infant in December 2015.
Learning: lack of adherence to child protection procedures regarding when to make a referral to children’s social care; ineffective communication between various health professionals; and optimism about parent’s ability to safeguard Child S despite evidence to the contrary.
Recommendations: GPs to be reminded of the importance of observing babies and documenting their interactions; the LSCB should review and ensure compliance with child protection procedures in respect of bruising to non-mobile babies, including clear guidance and training; the full Edinburgh Postnatal Depression Scale screening should be undertaken where there are clear risk factors identifiable during pregnancy; all community midwives to be aware when any type of injury is seen, it should be escalated to the Maternity Safeguarding Team.
Keywords: attachment behaviour, bereavement, disguised compliance, optimistic behaviour, postnatal depression
> Read the overview report

2018 – Anonymous – Child Z

Death of a 13-year-old boy from complications arising from his medical condition.
Learning: keeping the focus on the child whilst dealing with challenging parents; dealing with child protection concerns with professionals who are also colleagues; the need for decision making panels to have a safeguarding focus.
Recommendations: to oversee an audit of cases of children with complex needs to ensure each child has a multi-agency plan in place; ensure all children with plans have regular reviews; identify the lead professional for children with complex needs; provide training for staff where parents present a challenge to engage; conduct a review of home educated children; provide appropriate support available for parents of disabled children to help them come to terms with their child's condition or disability.
Keywords: children with physical disabilities, home education, medical care neglect
> Read the overview report

2018 – Anonymous – Darry

Attempted suicide of a 17-year-6-month-old young person in December 2016 resulting in significant and life changing injuries.
Learning: young people with deteriorating mental health require a holistic multi-agency response which takes account of all factors and does not focus on the young person as the problem; self-harm is a serious issue which needs robust multi-professional action; referrals to children’s social care need to make clear the concerns to enable a decision to be made on the best available information; there is professional confusion about the Mental Capacity Act as it relates to 16- and 17-year-olds, particularly in the context of parental decision making and professional advocacy.
Recommendations: There were no recommendations.
Model: a hybrid version of a systems process.
Keywords: anxiety, bullying, bereavement, child mental health, children with learning difficulties
> Read the overview report

2018 – Anonymous - Emily

Death of a 3-month-old girl in March 2015 as the result of Sudden Unexpected Death in Infancy (SUDI).
Learning: the risks associated with twins and prematurity are not routinely articulated across multi-agency partners; there may be a tolerance of sibling violence that would not be accepted for intimate partners, which does not acknowledge the risk for children; professionals overreliance on diagnosis fails to recognise the continuum of needs of parents who have learning or mental health difficulties; the lack of a multi-agency neglect framework and toolkit inhibits a shared professional understanding of neglect.
Recommendations: a number of recommendations in the form of questions to the LSCB around the additional needs of premature and twin babies; sibling domestic abuse; and professionals' understanding of neglect.
Keywords: infant deaths, child neglect, domestic abuse
> Read the overview report

2018 – Anonymous – Siblings A and B

Significant abuse, neglect and cruel parenting of two siblings aged 12 and 14 years by their relative carer over a period of ten years. The siblings had been removed from their parents’ care in their early years because of abuse and neglect.
Learning: all children and young people deserve to be effectively safeguarded from harm; the additional vulnerability of disabled children to abuse needs to be recognised and addressed; insufficient professional recognition or challenge of the blame of children by parents/parent figures as their defence against harsh, abusive and inconsistent parenting; poor assessments and ineffective Child in Need processes leave children and young people’s needs unaddressed and at risk of potential abuse and harm; fixed professional thinking which is not picked up through supervision and reflection has the capacity to undermine the ability of the safeguarding system to keep children and young people safe.
Recommendations: There were no recommendations.
Model: sets out key findings using a hybrid version of a systems process.
Keywords: children with learning difficulties, developmental disorders, emotional abuse, kinship foster care, professional curiosity
> Read the overview report

2018 – Anonymous – Young Person

Death by suicide of a 17-year-old young person in 2016. There were over 30 multi-agency contacts or events involving the young person and/or their close family in the ten-month period prior to the young person’s death.
Learning: the need to further develop the knowledge and skills in understanding and responding appropriately to adolescents and young people at risk of self-harm; to review how agencies fulfil their statutory obligations by recognising a 17-year-old as a child and ensure the child’s voice and views are key elements in the decision-making process; training to enable practitioners to be confident in recognising the impact of religious, ethnic and cultural influences; the need to actively promote support and advocacy services for young carers; to understand communication needs particularly in families whose first language is not English.
Recommendations: There were no recommendations in this learning summary.
Keywords: child deaths, culture, family violence, interpreters, voice of the child
> Read the overview report

2018 – Anonymous – Young Person F

Failure to thrive and lack of care of a young person in foster care over a number of years until November 2015.
Learning: health assessments should be holistic; every agency and foster carer need to understand the statutory requirement for children in care to be seen alone; the voice of the child and lived experiences were not sufficiently captured and considered; there was a lack of professional curiosity and generalisations were viewed as facts and not evidence-based; there needs to be appropriate challenge to the views and opinions of foster carers; both foster carers need to be effectively managed; safeguarding concerns raised by professionals were not given sufficient weight in decision making.
Recommendations: these are embedded in the learning points.
Keywords: child abuse, foster care, disguised compliance, deception
> Read the overview report

2018 – Barking and Dagenham – Child C

Death of a 3-month-old Black British/Caribbean girl September 2016 from cardiac arrest. After her death, Child C was found to have multiple fractures consistent with non-accidental injuries.
Learning: impact of poverty and homelessness on the child (including pre-birth) should always be considered; and investigations of fathers must be pursued even when resistance from mothers.
Recommendations: training for staff working with avoidant and hard to engage families should include identifying disguised compliance; and the relevant LSCBs must get assurance that agencies demonstrate how fathers or absent parents are included in any assessments.
Keywords: infant deaths, physical abuse, non-attendance, disguised compliance, homelessness, poverty
> Read the overview report

2018 - Barnet – Child E

Death of a 16-year-old boy in the care of the local authority in February 2016.
includes: the system for managing the health needs of children in care is not effective where young people in residential care have a complex range of needs; assumptions may have influenced practice which resulted in insufficient challenge where behaviours were unacceptable. 
Recommendations include: review commissioning arrangements for residential care to specify where a child/young person attends or is admitted to hospital, staff will accompany them with relevant health information; review policies in relation to children missing education and be clear about what action to take when young people are engaged in illegal work; arrangements for staff supervision to include opportunity to reflect on the emotional impact of work in complex cases and consider how assumptions and cognitive biases may be affecting practice.
Keywords: child deaths, children in care, drugs, health
> Read the overview report

2018 – Barnsley – Child R

Accidental death of a 7-year-old boy in July 2015.
unrealistic expectation by agencies for mother to address her substance misuse in a self-motivated manner; Child R not referred for specialist assessment or counselling as a result of the domestic abuse situation between his mother and father; at age six and a half, Child R was found to have considerable attachment and emotional issues but appears not to have benefited from psychological assessment or professional therapy.
Recommendations: to review, with South Yorkshire Police, the current design of the child protection incident form to ensure it captures essential data to discharge appropriate safeguarding responsibilities to a child; to ensure that children’s social care explores the need for specialist input into child protection conference proceedings, where the specialist is not currently engaged with the family and, therefore, not automatically invited.
Keywords: substance misuse, child deaths, emotional disorders, family violence, threshold criteria, aggressive behaviour
> Read the overview report

2018 – Bedford – Rosie

Life threatening and life changing neglect of a 3-year-6-month-old girl in September 2017.
Learning: children who are suffering from neglect (and other forms of child maltreatment) may be ‘hidden in plain sight’; pre-birth planning and assessments offer early help and support to vulnerable parents and ensure the future safety and wellbeing of the unborn child; more needs to be done to promote collegiate working, respect and mutual understanding of others’ roles and responsibilities, including the limitations in practice; all those delivering care to children, young people and their families must have the relevant competencies to do so.
Recommendations: seek assurances that practitioners are asking parents / carers why young children are not accessing early years provision; ensure that practitioners delivering care to children, young people and their families have achieved, as a minimum, the competencies set out in the relevant professional guidance, including oversight from an appropriately qualified professional.
Keywords: child neglect, failure to thrive, malnutrition, parents with a mental health problem, maternal health services, assessment of children
> Read the overview report

2018 – Bexley – John

Fractured skull to a 13-month-old boy in March 2017. Parents sought medical advice because of a swelling to John’s head but were not able to explain how the injury had occurred; they advised the paediatrician that he was a very active child with a habit of head banging.
the role of the father was largely absent in practitioner records; professional curiosity is especially important for unexplained injuries; the case mapping exercise undertaken by the social worker and team manager used the Signs of Safety model but focused too much on the present and did not take into account historical concerns.
Recommendations: ensure that practitioners are reminded about the effect of their intervention on families and importance of involving them in the formulation and delivery of plans; ensure that multi-agency safeguarding hub (MASH) workers are clear about whether parental consent has been given and for what purpose; advise MASH workers that formal feedback should be given to GPs who make a referral regarding a possible non-accidental injury.
Keywords: adults with learning difficulties, fractures, parents with a mental health problem, professional curiosity, referral procedures
> Read the overview report
> Read the executive summary 

2018 – Birmingham – in respect of the death of a woman and her child

Death of a 7-month-old baby as a result of pressure to the neck in June 2013. Both the woman and perpetrator had been in care with parental histories of violence and substance abuse; the perpetrator’s behaviour as a child was challenging and disruptive and he had convictions for assault. He was charged with the murders of the woman and the child and sentenced to life imprisonment.
Learning: information not consistently recorded in a timely manner; the high risk to children posed by the perpetrator was not identified at an early stage and the significance of serial domestic abuse not recognised; there was a culture amongst a group of young people who had been in the care system of acceptance and minimisation of violence, sexual offending and domestic violence.
Recommendations: to raise awareness of all children in care and those who care for them about what constitutes a safe and risky relationship, to ensure they enter into positive and healthy relationships; all police officers and staff recognise the importance of considering safeguarding children and young people identified with any reported incident; to review domestic violence training to ensure learning from this case in relation to control, coercion and risk by perpetrators is fully incorporated; to ensure a robust approach is in place to manage serial offenders of domestic abuse.
Keywords: adults physically abused as children, murder, unknown men, violence
> Read the overview report

2018 – Blackburn with Darwen – Child G

Death of Child G in October 2016 whilst in the care of a local authority children’s home. Death was later recorded as central nervous system and pulmonary depression and morphine use.
Learning: as Child G’s behaviour became more severe, more agencies became involved without considering which interventions were being effective; a multiplicity of protective and preventative actions does not necessarily lead to improved outcomes.
Recommendations: the LSCB should require that partner agencies are competent working with adolescents with challenging behaviours, learning difficulties and those who may be impacted by adverse childhood experiences; review the strategy meeting process for complex cases; ensure substance abuse training includes alerting workers to changes in substance use and indicators of when medical assistance is needed.
Model: uses the Significant Incident Learning Process (SILP) model.
Keywords: adverse childhood experiences, alcohol misuse, attention deficit disorder, child mental health, children at risk, children in care
> Read the overview report

2018 – Blackburn with Darwen – Child Y

Death of a 14-year-old girl (Child Y) by suicide at her home in February 2017.
Learning: single and multi-agency responses could have been improved in order to enhance suicide prevention efforts; the work to support Child Y after the sexual assault was characterised by incomplete multi-agency working, and a general lack of awareness of the potential impact of child sexual assault on the victim and their families.
Recommendations: children or young people who are victims of sexual assault should be offered a referral to a Child Independent Sexual Violence Advisor; to ensure the voice of the child is central to any contact; GP practices should review the service they provide to victims of child sexual abuse; widely disseminate learning from this case to enhance practitioner awareness of potential suicide risk factors.
Keywords: child sexual abuse, drug misuse, psychological effects, victim support
> Read the overview report

2018 – Blackpool – Baby BZ

Death of a 13-week-old baby in March 2017 as the result of acute traumatic brain injury due to abusive head trauma.
Learning: historical information and understanding its importance and relevance to ongoing work should be recognised to safeguard unborn and new-born babies; the practice of waiting until mothers are 30 weeks pregnant before a multi-agency approach is adopted in cases that meet the threshold for child protection may leave unborn babies and new-born babies at unnecessary risk.
Recommendations: review the arrangement around parenting assessments to ensure they are robust; seek assurance from Children’s Social Care that all assessments are scrutinised by managers; seek assurance from Children’s Social Care and adult mental health services that analysis of the effects of parents’ behaviours on their children forms part of the assessment and is evident within child protection plans.
Model: uses the Welsh concise model.
Keywords: child neglect, history, murder, non-accidental head injuries, professional collaboration, parents with a mental health problem, parenting capacity, risk assessment
> Read the overview report

2018 – Blackpool – Child BY

Serious head injuries which were potentially non-accidental to a 3-month-old child in January 2017. Child BY is a twin, born prematurely at 35-weeks’ gestation, discharged from hospital into a family with co-existing domestic abuse, mental illness and substance misuse.
Learning: the need to consider mother’s full history and understand the impact of trauma, loss and ongoing abuse and coercion; severe risk of harm is most likely where there is an absence of protective factors; the need to consider male perpetrators in assessments and address or recognise their behaviour and accountability for it.
Recommendations: to consider the approach to domestic abuse cases where the victim expresses a wish for the relationship to continue and how this impacts on the children; to ensure that practice and supervision are influenced by an understanding of the long-term impact of unresolved childhood trauma, loss and abuse and serious and chronic domestic abuse and coercion on parenting capacity; to consider how agencies currently respond to families where neglect may co-exist with domestic abuse and that neglect is responded to as a safeguarding issue and not solely as a symptom of domestic abuse.
Model: designed and led by reviewer to enable participants to consider the events and circumstances leading up to injuries to Child BY.
Keywords: abusive fathers, anxiety among professionals, emotional abuse, parenting capacity, parents with a mental health problem, premature infants
> Read the overview report

2018 – Blackpool – Child CA

Death of a 4-month-old infant in April 2017. The cause of death was unascertained.
Learning: learning points centred on information sharing; the application of pre-birth protocols; stronger leadership; and multi-agency arrangements to identify and support individuals and families with complex needs arriving to a new area with high levels of transience.
Recommendations: child protection assessment should be proportionate and plans should be specific, measurable, relevant and timely; frontline practitioners should receive regular and meaningful supervision; leaders should be able to demonstrate that they have a grip on cases assigned to their staff.
Model: the review followed the ‘Welsh Model’.
Keywords: infant death, information sharing, optimistic behaviour, risk assessment
> Read the overview report

2018 – Blackpool – Child CB

Death of a 17-year-old boy by suicide in December 2017. Child CB struggled with his identity and did not want others to know he was adopted.
Learning: to seek assurance that the preparation, training and ongoing development and support of foster carers enables them to offer long-term, stable and therapeutic placements to children who share Child CB’s vulnerabilities; to review what support and development arrangements are currently in place for adopted children and adoptive parents for children with adverse childhood experiences, attachment and identity issues.
Recommendations: to review existing arrangements for care leavers and ensure that the care plan considers the young person’s views; to review current suicide prevention strategies; to include known suicide risk factors for children and young people into ongoing staff development and training; focus on the impact of cannabis and other substances on mental health and other outcomes for children and young people, the potential interactions of cannabis with prescribed mental health (and other) medications and agency responses.
Keywords: adopted children, children with a mental health problem, coping behaviour, identity development, placement breakdown
> Read the overview report

2018 – Bolton – Baby D

Death of an infant aged under 3 months in December 2016.
Learning: NICE guidance in relation to management of mental health issues in pregnancy should be followed by practitioners in all settings; professionals require ongoing training in relation to the effects and impact of cannabis on mental health and parenting; professionals need support in making enquiries about existing and new relationships; professionals should have access to support to address any concerns regarding resistant parents and unwillingness to change risk behaviours.
Recommendations: ensure that GPs receive advice in relation to specific concerns regarding safe sleeping and that they take opportunities to reinforce safe sleeping advice; all relevant practitioners should have access to good-quality drug and alcohol training and be aware of the services provided by local drug and alcohol services.
Keywords: infant deaths, sleeping behaviour, risk taking
> Read the overview report

2018 – Bristol – Aya

Death of Aya, a 6-month-old baby who died after suffering non-accidental head injuries whilst in the care of her father on 25 December 2016. Aya’s father pleaded guilty to her murder and received a life sentence.
Learning: there is currently no specific universal programme of work with fathers either in the antenatal or postnatal period; the need to routinely question all mothers about domestic violence.
Recommendations: ensure that routine questioning about domestic abuse is embedded within all agencies working with women and children; that updated guidance will include within it that all members of the primary health care team who work with parents and children receive notification of any childhood injury; the need to implement aspects of the Healthy Child Programme that relate to fathers’ engagement.
Model: the methodology used was based on a broad systems approach.
Keywords: infant deaths, abusive fathers, single mothers, non-accidental head injuries, partner violence
> Read the overview report

2018 – Bristol – Becky

Death of a 16-year-old girl in 2015. Her step-brother and his partner were convicted of her murder and manslaughter respectively. A Domestic Homicide Review is addressing the circumstances in which Becky died.
Learning: the absence of an evidence-based understanding of the needs and circumstances of adolescents can lead to adolescents being seen as troublesome rather than troubled; the tendency of professionals to take parent/carer perspectives at face value without triangulating information from other sources can lead to a limited understanding of a young person’s needs; professionals are less challenging of the lack of engagement of fathers in child welfare practice.
Recommendations: Makes no recommendations but puts a number of questions for the Local Safeguarding Board to consider.
Keywords: child death, murder, adolescents, professional curiosity, fathers
> Read the overview report

2018 – Bristol – Child D

Death of a 17-year-old boy in February 2016.
Learning: the crucial importance of building relationships when working with families where there are both needs and challenges; the need to develop a constructive practice model with young men and boys who may not engage with services; the need for improved responses to domestic abuse in families in situations when it is not intimate partner abuse.
Recommendations: Children’s Social Care and Youth Offending Team to draw on the learning from this review to improve joint working; to consider working with adolescent boys as a thematic priority in its strategy.
Model: this is a joint Domestic Homicide Review (DCR) and Serious Case Review (SCR).
Keywords: adolescent boys, murder, sibling relations, substance misuse
> Read the overview report

2018 – Bromley - Elizabeth

Death of a 16-year-old girl in January 2014. Elizabeth was killed by a 16-year-old friend X at his home in Surrey. In October 2014 he was found guilty of murder and sentenced to life imprisonment with a minimum term of 25 years.
a report by Elizabeth concerning an incident within the family, set in the context of other difficulties, justified it being considered a safeguarding issue and should have been responded to accordingly; counselling services could have categorised her reports of sexual activity as exploitative and initiated a referral to children’s social care; no formal means existed in BSCB for unexpected child deaths to be reported to the LSCB on a case by case basis.
Recommendations: the named GP should circulate to practices the new Vulnerable Adolescents Strategy and associated protocols; training to include professional curiosity and safeguarding risk assessment when young people present with anxiety; to complete an audit on the quality of information sharing within and between partner agencies.
Keywords: murder, mother-child relationships, self harm, counselling, drug and alcohol services, gillick competency
> Read the overview report

2018 – Bury - Mario

Death of a 16-year-old boy by apparent suicide in February 2018.
practitioners viewed Mario in isolation from concerns about his wider family; advice provided to school by the multi-agency safeguarding hub (MASH) was not consistent with safeguarding policy and practice; Mario was not linked to domestic abuse incidents at his mother’s house; and the counselling service’s safeguarding policy and practice requires development.
Recommendations: increase awareness of the antecedents of suicide amongst children and young people; share learning with schools in the local authority; and ensure assessments consider the needs of siblings not living in the household.
Keywords: anxiety, divorce, interagency cooperation, self harm, siblings, suicide
> Read the overview report

2018 - Cambridgeshire and Peterborough - Case P

Sexual assault of a 14-year-old child. The young person reported the assault in November 2015, at the age of 18.
understanding of risk and how that can be managed needs to be better; agencies need to identify persons who present a risk to children and flag those persons within their agencies to enable them to be managed in a multi-agency fashion; parents and carers need to be equipped to identify grooming, especially when a risk is known or perceived.
Recommendations: ensure that organisations can effectively flag and monitor persons identified as presenting a danger to children; ensure that staff feel confident in identifying and referring persons who present a danger to children; review how effective disclosures can be achieved from children and young persons where there is a lack of verbal disclosure.
Keywords: child sexual abuse, disclosure, siblings, professional curiosity, information sharing
> Read the overview report

2018 – Camden – Baby C

Death of a 7-week-old infant from non-accidental injuries caused by shaking in February 2016. Father was convicted of manslaughter in March 2018.
Learning: there is no specific universal programme of work with fathers in the antenatal or postnatal period.
Recommendations: contact with fathers should be routinely recorded in midwifery and health visitor records; information about the link between crying babies and non-accidental head injury should be included in the core health promotion package offered to new parents.
Keywords: fathers, infant deaths, non-accidental head injuries, shaking
> Read the overview report

2018 - Cardiff and Vale of Glamorgan - CPR 03/2016

Neglect and possible sexual abuse of a 6-year-old child.
Learning:little evidence that the child’s views were gathered and supported; child protection conferences became focused on helping mother rather than the child; and delayed decisions can mean that children experience lengthy exposure to abuse and neglect.
Recommendations: update protocol on working with families who are not cooperating; ensure that training on information sharing for safeguarding children is available to staff in partner agencies; and ensure that there is meaningful engagement from schools across the region.
Keywords: addicted parents, child sexual abuse, disguised compliance, interagency cooperation, schools, voice of the child
> Read the overview report

2018 – Cardiff and Vale of Glamorgan – Extended Child Practice review

Death of an 18-month-old child due to non-accidental head injuries. The adoptive parent who had assumed the role of primary caregiver was convicted of murder of the child in November 2017 and received a life sentence.
Learning: adoption does not negate the need for safeguarding awareness; when children are seen at hospital, paediatricians are key professionals in recognising the possibility of injuries being caused deliberately; professional judgements should be based upon considerations of all the evidence available rather than individual events; professionals need to ensure the details of a child’s injuries are recorded as significant events; adoption reviews should provide opportunities for robust professional scrutiny and challenge; recording and retention of information received via text and other messaging services are increasingly important sources of information.
Recommendations: a child who has been placed for adoption and presents at hospital with an injury should be overseen by a paediatrician with safeguarding experience and training; develop a multi-agency set of professional standards for children who are placed for adoption, including expectations regarding the sharing of information which should be compliant with the All Wales Child Protection Procedures 2008; a child’s NHS number provided at birth should remain the same throughout a child’s life.
Keywords: infant deaths, non-accidental head injuries, adoptive parents
> Read the overview report

2018 – Cardiff and Vale of Glamorgan – Young Child

Review of the suspected sexual abuse and neglect of a 6-year-old girl in 2014.
Learning: assessments need to be timely and accurate; decision making meetings need to involve all the agencies that play a part in the child’s life.
Recommendations: implementing a consistent standardised multiagency timeline template for each child protection committee; medical evidence should form part of the evidence used in decision making; and ensuring that the police and paediatricians are involved in strategy discussions.’
Keywords: child sexual abuse, disguised compliance, harmful sexual behaviour
> Read the overview report

2018 – City of London and Hackney - Child M

Non-accidental injuries to a 13-month-old child of African-Caribbean ethnicity (Child M), including bruising to the face and transverse fractures to both femurs in June 2016. Father found not guilty of grievous bodily harm but both parents were found guilty of child cruelty.
Learning: examples of parental avoidant behaviour or disguised compliance which exacerbate risks to children; occasions where more robust professional curiosity or challenge would have been justified; professional responses appeared more positive than the available evidence would suggest particularly concerning the child’s injuries.
Recommendations: to enhance confidence within professional networks in the context of respectful certainty/cognitive dissonance to develop plans and interventions to respond to the possibility of deliberate harm even in the absence of conclusive evidence; support practitioners working with avoidant families, frequently fluctuating circumstance and disguised compliance.
Keywords: disguised compliance, emotional abuse, fractures, immigrant families, non-accidental head injuries, non attendance
> Read the overview report

2018 – City of London and Hackney - Child N and O

Death of a 16-month-old boy in March 2017 due to a non-accidental head injury.
Learning: practice should be sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family; communication, information sharing or service delivery should be fluid between those working normal office hours and others providing out of hours services.
Recommendations: promote the learning from this SCR, ensuring that issues relating to faith or culture do not dilute safeguarding responses for children exposed to domestic abuse; audit the use of interpreters at new birth/new contacts and the extent to which the health history of involved fathers (mental health, substance misuse, other impacts upon parenting) is being captured.
Keywords: child deaths, deception, emergency services, mental health, non-accidental head injury, wrongful accusation of child abuse
> Read the overview report

2018 – Coventry – Baby F

Serious and life threatening non-accidental head injury to a 4-week-old boy in September 2015.
Learning: poor quality and inconsistent record keeping within children’s social care; absence of the ‘voice of the child’ either in practice or in record keeping; a lack of professional curiosity about new male partners, their history as a father and the potential impact this may have on an existing family unit.
Recommendations: ensure that each GP practice holds multi-agency safeguarding meetings involving midwifery and health visiting teams so that timely, accurate information regarding vulnerable families is appropriately shared; reaffirm the importance of the voice of the child in the work of all services.
Keywords: parenting capacity, information sharing, mental health, non-accidental head injuries, record keeping, child mental health services
> Read the overview report

2018 – Croydon – Child J and Child K

Severe malnutrition of a 4-year-old child in 2015. Child J was admitted to hospital with severe acute malnutrition, diagnosed as a condition most usually found in developing countries, which could have been fatal if treatment had been delayed by 24 hours.
Learning: the impact of parental disputes, allegations of domestic abuse and conflict on children is not well understood; Child J did not reach the threshold for ongoing services from children’s social care and there was little focus on the impact of these issues on Child J or Child K; the child abuse investigation system in Croydon lacks effective joint planning between police and social workers particularly when there is another sibling in the home.
Recommendations: health visitor resources should be sufficient to carry out recommended checks to identify potentially vulnerable children; disseminate information on the importance of considering weight and height measurements to identify children with faltering growth; focus on identifying the best way to make sure placement planning focuses on all the child’s needs.
Keywords: child growth, family dynamics, malnutrition, parenting capacity, placement breakdown
> Read the overview report

2018 – Croydon – Joe

Serious injury of a 2-year-11-month-old boy in June 2016 from third-degree burns.
Learning: protection of children will be compromised if a child protection plan is not working and there is insufficient insight into safeguarding processes; lack of robust inter- and intra-agency decision making jeopardises children’s safety; family and Kinship are critical members of the safeguarding network and should be regarded as such.
Recommendations: to ensure a robust, timely multi-agency process that scrutinises child protection plans for children who are the subject of a child protection plan for 18+ months and evaluate impact; professionals to be supported in gathering evidence and triangulating evidence to improve risk assessments.
Model: methodology based on the Welsh Child Practice Reviews Guidance, taking a multi-agency approach, focussing on systemic strengths and weaknesses.
Keywords: burns, decision-making, drug misuse, neglect-identification, professional curiosity
> Read the overview report

2018 – Croydon and Lambeth – Child L

Cardiac arrest of 11-month-old child as a result of cocaine ingestion in July 2016. Child L survived the incident and was made subject to care proceedings. Criminal proceedings were brought against both parents in June 2018, and both were found not guilty.
Learning: keeping the child’s lived experience at the centre of safeguarding children practice; knowledge and skills in working with drug using parents; impact of homelessness and temporary accommodation on child protection; cross-borough working; getting the basics right, adherence to procedures and supporting frontline practitioners with guidance and reflective supervision.
Recommendations: ensure that safeguarding practice and supervisory system in place keeps the child’s lived experience at the core of all safeguarding work; the LSCBs and partner agencies should review practitioner knowledge and skills in understanding, assessing and responding to hidden substance misuse by parents where there is no sign of addiction or problematic lifestyle.
Model: Welsh model.
Keywords: child neglect, drugs, substance misuse
> Read the overview report

2018 – Derby – Child FD17

Serious injury of a 9-year-old child in October 2016 from burns caused by a scalding hot bath. Both parents were charged with neglect and were given suspended sentences.
Learning: the importance of obtaining a family history when a family moves to a new country and concerns are raised; importance of being able to communicate with families without sufficient interpreting services.
Recommendations: all agencies should ensure that their staff understand the impact of culture, race, and heritage when identifying neglect and they should not condone practices and beliefs that are not in accordance with practice in England.
Keywords: home environment, disguised compliance, child neglect, culture
> Read the overview report

2018 – Derbyshire – 9-week-old Child

Death of a 9-week-old infant in June 2013 due to a head injury. The cause of the injury and the circumstances in which it occurred were still under investigation at the time of the report.
Learning: importance of joint working and reciprocal information sharing between members of the primary health care team; to explore ways in which new fathers may be better engaged and supported by services; importance of providing health protection messages in relation to protecting infants’ heads, including the message that it is never safe to shake a baby.
Recommendations: health commissioners and providers of health visiting services should work together to ensure that the vulnerability of new fathers providing a primary care role to infants is considered in the assessment and provision of services.
Model: uses the Child Practice Review process that was introduced in Wales in 2013 to replace the serious case review process.
Keywords: infant death, non-accidental head injuries, shaking
> Read the overview report

2018 – Derbyshire - Young person

Death by suicide of a 16-year-old young person.
Learning: review format and information within the letter sent to young people and parents regarding children’s services, highlighting the importance of the family contacting the service if they have not been contacted within a set timeframe; professionals working with young people should complete an Early Help Assessment when there are signs of early vulnerability to ascertain the needs of the child and coordinate support for the young person and family.
Recommendations: audit early help processes to ensure that early help intervention is making a positive difference to children, young people and families; GP and school nurses should receive a copy of appointment confirmation and discharge letters from Child and Adolescent Mental Health Services (CAMHS); when a professional knows a young person or family outside their professional role, an alternative worker should be explored to offer the service to the young person.
Keywords: suicide, communication, general practitioners, child mental health services, internet, school nurses
> Read the overview report

2018 – Derbyshire – Young Person

Death of a 15-year-old young person.
practice and organisational issues identified include: Substance Misuse Services for Young People and CAMHS situated in different providers; importance of communication with fathers; importance of systems that enable communication of risk where more than one professional is involved in an organisation; professional awareness of patterns and sources of young people’s drug use; safety when experimenting with drugs. Areas of good practice identified include: support and commitment by Young Person's school and GP.
Recommendations include: development of an awareness raising and educational campaign about young people who use and supply drugs; guidelines to strengthen professional knowledge about referral thresholds and pathways for young people who abuse or procure drugs.
Keywords: child death, substance misuse, drugs, mental health
> Read the overview report

2018 – Devon – Child N

Sexual abuse of a girl between the ages of 10- to 16-years-old. Child N disclosed the abuse to a mental health worker in September 2015 when she was 19-years-old. Perpetrator convicted of multiple offences against her.
need to reduce thresholds for intervention in complex cases involving neglect; need for professional curiosity and challenge; using historical information, including timelines, can help build a true picture, especially in neglect cases; a multi-disciplinary and/or multi-agency approach is good practice; need to ‘think family’; need to consider sexual abuse when very young children self-harm or have injuries to intimate areas; perpetrator confession should be acted on.
Recommendations: no recommendations. Considerations for the board include ensuring: all practitioners understand the indicators for neglect and are trained to do this effectively; guidance for sexual abuse, including the threshold guidance, is robust and understood; child protection plans are outcome focused; all agencies escalate concerns and use a case resolution protocol appropriately.
Model: uses a hybrid Individual Agency Review and Learning Review methodology.
Keywords: child sexual abuse identification, disclosure, professional curiosity, voice of the child, grooming, information sharing
> Read the overview report

2018 – Dorset – Child M

Death of a 2 1/2–year-old child in 2016 following an assault by the mother’s partner, who was later found guilty of murder.
Learning: the importance for all agencies to notice patterns of behaviour, in particular considering the parenting capacity of a young parent with a complex history; effective safeguarding practice requires all professionals to consider their knowledge of domestic abuse, the predisposing factors and the impact on children; background checks on adults involved in domestic incidents are a vital part of safeguarding practice; when assessing an injury it is important that all professionals are thoughtful about the possibility of being misled by parents; asking the question “what is life like for a child in this family?” will help practitioners retain a child focus; the importance of involving non-resident fathers.
Recommendations: that agencies should be aware of the need to consider the parenting capacity of young people who have been known to services during their childhood and how this might impact on their care of children with whom they have significant relationships.
Keywords: child death, physical abuse, unknown men
> Read the overview report

2018 – Dorset – Child S

Death of a 3-year-old child in August 2017 as a result of injuries following a road traffic collision caused by the mother who was intoxicated by alcohol and drugs.
Learning: when predominantly working with adults, it is important to assess not only the presenting concern but to think wider and remain alert to how the adult’s behaviour might impact on children and family life; professionals do not always talk enough to other people involved in a child’s life, which can result in them missing crucial information and failing to spot inconsistencies in the mother’s account.
Recommendations: review training to ensure that there is sufficient focus on parental alcohol use, misuse and functioning alcoholics, how this can impact parenting capacity and children’s welfare and development; ensure that there is a focus on the need to involve and assess fathers and adult men connected to the children; to seek reassurance that information sharing protocols between midwifery services and primary care are robust and that information of relevance to safeguarding is shared.
Model: used a learning model based on a Soft Systems methodology.
Keywords: child death, alcohol misuse, information sharing, communication
> Read the overview report

2018 – Dudley – Child N

Serious injuries to an adolescent girl in supportive accommodation in September 2016 by her partner, who was arrested, charged and convicted.
: key themes for learning include: dealing with domestic abuse in teenage children; dealing with ‘missing’ episodes with looked after children; multi-agency working and working with a group of children who are engaging in abusive behaviour to one another; transition and accommodation issues for looked after children.
Recommendations: include Safeguarding Children Board include to review of the way in which children who are involved in domestically abusive relationships are assessed in terms of risk of harm.
Keywords: adolescents, partner violence, children in care, risk assessment, temporary accommodation
> Read the overview report

2018 – Dudley – in respect of Young Person F

Death of a 17-year-old boy in October 2016.
where children are placed in a long term placement with a Care Plan, which states their aim as adoption, any changes to this Plan should be managed with sensitivity; lack of urgency in responding to Young Person F when there were reports of drug running and gang involvement, with increasing missing episodes, with risks played down partly due to stereotypical notions of male adolescents; when decisions are made by Panels, the decisions must be informed not only by immediate costs but take into account projected costs if request is denied as this may incur greater costs overall.
Recommendations: to ensure that decision making about services can be made swiftly and be responsive to needs of the child or young person; to update current policies and procedures to include references to siblings when they have been placed together and one of them dies or becomes seriously ill; all looked after children should be provided with the option of an independent advisor or advocate.
Keywords: adoption, emotions, gangs, psychological effects, risk assessment, placement breakdown
> Read the overview report

2018 – Dudley – Peter 17 years; John 15 years; Tom 11 years; Christopher 9 years

Concerns sexually harmful behaviour between three adolescent males aged 17, 15 and 11 years and the sexual abuse of a 9-year-old boy placed together in local authority foster care.
Learning: none of the children, apart from Tom, received the necessary therapeutic support to enable them to adjust to foster care; there was a need to address their psychological and emotional problems not just physical needs; there was drift and delay in enacting decisions taken at Looked After Child reviews; the local authority did not have sufficient carers to provide suitable placements; the impact on the foster carers discovering sexual abuse should not be underestimated; important to understand barriers to using formal procedures for escalating concerns; social workers were under extreme pressure with an unstable workforce with high caseloads.
Recommendations: Children’s Services must ensure that the procedure on variations and exemptions to usual fostering limits is adhered to; ensure compliance with placement procedures with placement planning meetings taking place prior to placement; to review the current provision for young people who display sexually harmful behaviour.
Keywords: adolescent boys, child sexual abuse, communication, emotional disorders, placement breakdown, workload
> Read the overview report

2018 – Dudley – Young Person P

Murder of a 16-year-old girl in May 2017.
failure to instigate statutory child protection measures; a lack of assessment of the risks faced by P and a failure to listen to the voice of the child.
Recommendations: consider providing advice to adoptive parents on children contacting birth parents through social media and adolescent behaviour; professionals need to understand their responsibilities to homeless 16- and 17-year-olds; seek assurance that procedures and support for children reporting sexual offences is robust and properly resourced.
Keywords: adoption, homeless adolescents, murder, professional negligence, rape
> Read the overview report

2018 – Durham – Charlie and Charlotte

Severe neglect of two siblings aged 7 and 10. Both children suffered severe dental decay and permanent visual impairment.
Learning: the ‘start again’ approach taken when the mother became pregnant with Charlie led to an over optimistic assessment of parents’ capacity; how professionals recognise, assess and respond to risk when sexual abuse allegations are made by young people and recognition of child neglect.
Recommendations: current policy and practice should ensure when any parent becomes pregnant and there has been a history of care proceedings that a child protection conference is automatically convened; develop a working protocol to provide guidance.
Model: the Child Practice Review process that allows practitioners to reflect in an informed and supportive way; over prescriptive recommendations have limited impact and value in safeguarding children.
Keywords: adults with learning difficulties, alcoholic parents, child neglect, child sexual abuse, medical care neglect, non-attendance
> Read the overview report

2018 – East Sussex – Family S

Significant neglect of a 7-year-old child and 22-month-old sibling in 2015 because of parental substance misuse and alleged domestic abuse.
Learning: failure to register a child with a GP is a risk factor for neglect; babies discharged home after birth with no professional oversight of home conditions is a risk for children born to vulnerable mothers; lack of system for ‘late starters’ in schools means that children who start later in the term may not see the school nurse; perception that health visitors should not make unplanned visits.
Recommendations: consider the feasibility of a system for raising alerts on children not registered with a GP for longer than three months; guidance to midwifery staff requiring that all women receive a postnatal visit at their normal address; all agencies to provide assurance that their assessment processes enable the effective involvement of fathers, partners and other men within the household.
Keywords: child neglect, home visiting, substance misuse
> Read the overview report

2018 – Edinburgh – The Sexual abuse of children in care

The sexual abuse of children in two residential care homes over a number of years.
Learning: vulnerable victims’ needs were not acknowledged and victims did not trust adults in authority to protect them; child protection systems contributed to the harm that the victims experienced and agency practice was too dependent on procedures.
Recommendations: Makes no recommendations but agencies should consider the distance between the findings of the report, current practice and their own aspirations and take steps to bridge the gap.
Keywords: child sexual abuse, residential care, professional curiosity
> Read the overview report

2018 – Greenwich – Child V

Death of a 3-month-old girl in November 2016 due to non-accidental head injury.
Learning: lack of engagement with antenatal services poses a potential risk to the health and wellbeing of mothers and their babies; over-reliance on parental self-reporting can be susceptible to disguised compliance; professionals should be sufficiently curious about the father of the baby and extended family.
Recommendations: agencies to ensure that fathers are considered in assessments – this includes fathers, step-fathers and partners even when they do not reside with children; review the multi-agency pre-birth protocol to ensure it provides clarity on best practice in cases where women do not access antenatal care; review training programme to ensure that staff are aware of the risks associated with over reliance on self-reported information, lack of engagement and disguised compliance when working with families, including work with fathers.
Keywords: antenatal care, non-accidental head injuries, parental involvement, record keeping, pregnancy, parents with a mental health problem, non-attendance, mothers, disguised compliance
> Read the overview report

2018 – Greenwich – W Family

Deaths of a 9-year-old mixed heritage girl and her 3-year-old brother in January 2017 at the hands of their mother who used over the counter sleeping tablets, painkillers and methadone. The mother took her own life.
Learning: the need to understand the impact of a parent’s mental health on the children and how professionals should understand the possible wider impact and risk within the family.
Recommendations: the LSCB should implement a multi-agency ‘Think Family’ approach; to review arrangements in GP practices to ensure the welfare of children in assessing mental health of parents and carers.
Model: uses a hybrid systemic model.
Keywords: child deaths, maternal depression, post-natal depression, housing
> Read the overview report

2018 – Greenwich – Young Person X

Death of a 16-and-a-half-year-old boy by suicide in May 2017.
Learning: experience of violent relationships and emotional abuse can undermine a child’s self-worth and resiliency; lack of case records within children’s social care material renders work more difficult and time-consuming; differing levels of anonymisation and attribution of pseudonyms / abbreviations / roles by agencies submitting reports can complicate proceedings; involving extended family through a family group conference can identify relatives whose existence and interest may previously be unknown to agencies.
Recommendations: consider whether existing arrangements across the borough for a multi-agency approach are sufficient when the circumstances of especially vulnerable young people are changing frequently; GPs should include details of any adult accompanying a child / young person to a consultation in the child’s record; GPs should escalate safeguarding concerns if they do not receive a timely and reassuring response to a referral / notification made to another agency.
Keywords: suicide, family violence, foster parents, accident and emergency departments, anxiety, self-harm, emotionally disturbed children, information sharing, schools
> Read the overview report

2018 - Gwent  - Young Person

Death of an adolescent girl by suicide in January 2017.
CAMHS to review its use of "texting" contact and develop guidance on use to ensure it meets required governance standards; consider the development of a multi-agency locally agreed policy/protocol for the management of high risk cases of self-harm and potential suicide; signpost and make accessible information and guidance for young people and their families/carers experiencing difficulties in managing social media and the internet; CAMHS service to review how they communicate with families about the outcomes of their psychiatric assessments and ongoing formulation of the young person's mental health; explore opportunities for practitioners to gain broader experience and knowledge to promote and deliver collaborative and multi-agency approaches to the prevention of suicide and self-harm.
Recommendations: makes no recommendations except those included in the learning points.
Keywords: suicide, self harm, social media, child mental health services, communication, schools
> Read the overview report

2018 – Hampshire – Child U

Death of a 7-week-old infant from non-accidental head injuries in 2015.
Learning: promoting participation of parents in multi-agency meetings; information management and sharing; the need for assessments to be a continuous process including at times of increased vulnerability and awareness; understanding and implementation of key policies and procedures.
Recommendations: review key policies, procedures and protocols and update as needed; educate parents regarding the prevention of head injuries to babies; promote positive and safe parenting.
Keywords: infant deaths, non-accidental head injuries, information sharing
> Read the overview report

2018 - Hampshire - Child K

Death of an 11-week-4-day old boy after sharing a bed with his parents.
Learning: it is important to explore and confirm the exact circumstances of previous children’s services involvement and use that and other information to inform care planning; transferring information when children move to another area, especially if there has been statutory involvement with a child identified as a child in need or a child in need of protection, should be required.
Recommendations: review the guidance and information about ‘safe-sleeping’ arrangements provided to all prospective and new parents (including fathers or partners) and to the practitioners who may work with them, and consider promoting public awareness through a media campaign; share historic information about a child, young person or family with relevant practitioners and services (where appropriate) and include this in all assessments.
Keywords: sleeping behaviour, maternal depression, parental involvement, alcohol, family violence, injuries

> Read the overview report

2018 – Highland Child Protection Committee and North Tyneside Safeguarding Children Board- Child T

Life-threatening head injuries and other serious injury to 20-month-old boy in April 2016.
includes: the focus on processes in kinship care system to collect information rather than a full analysis of information gathered led to undue optimism about a potential kinship placement at the expense of critical thinking; the decision that Highland Council would retain management responsibilities when Child T moved to England was unrealistic.
Recommendations include: ensuring that guidance supports staff to lead and contribute to risk assessment generally and specifically in relation to kinship care; discussion at national level with chairs of child protection committees (CPCs) and Social Work Scotland about disclosure/vetting systems between Scotland and England; the need to value foster carers contributions in the assessment and planning of children moving to kinship care.
Model: uses the Social Care Institute of Excellence (SCIE) Learning Together model.
Keywords: non-accidental head injuries, kinship foster care, information sharing, child protection services, adolescent mothers, physically abused children
> Read the overview report

2018 – Hull – Baby D

Death of a baby boy in December 2014 aged 6 weeks. Cause of death was given as sudden death in infancy; the birth of a second child led to reinvestigation of the case. The pathologist felt the two fractures to the baby’s knee were more likely to be non-accidental injuries and not linked to vitamin D deficiency.
Learning: the importance of professional curiosity to ensure roles and remits are well understood; when a learning disabled woman becomes pregnant, the impact on her ability to care for her children should be considered; adult services practitioners require a deeper understanding of their safeguarding responsibilities and should work collaboratively with other agencies; importance of professionals communicating with each other to verify information given to them by family members; the need to communicate key information to the couple should have been informed by a formal assessment.
Recommendations: the LSCB to develop a local partnership-wide ‘think family’ strategy; to secure a better shared understanding of roles and responsibilities to enhance effective joint working; to cascade key learning from this SCR to front-line staff by means of bespoke briefings.
Keywords: adults with learning difficulties, communication, fractures, home environment, parenting capacity
> Read the overview report

2018 – Kent – Child D (Jamie)

Non-accidental injuries to a 5-month-old infant in April 2016, including a head injury and 28 fractures.
Learning: the need to keep an open mind in neglectful families that injuries may not be as a result of neglect but may result from physical abuse or mishandling; the importance of engaging parents and other adults, especially new adults who join households; importance of focusing on the child’s experience and life including their emotional experience; understanding implications for children missing health appointments as the term ‘Did Not Attend’ puts the focus on the child.
Recommendations: to review multi-agency and single agency guidance and training on understanding and working with drug and alcohol use; to strengthen the voice of the child in safeguarding assessments.
Keywords: adults abused as children, family violence, home environment, medical care neglect, substance misuse
> Read the overview report

2018 – Kent – Child G

Death of a 2-month-old girl in 2017 due to injuries consistent with being shaken.
it is important to assess and provide support and services to both parents, regardless of gender; when a parent is vulnerable, professionals may struggle to identify that they are not meaningfully engaging with services; there is a need for on-going communication and information sharing around, and following, transitions between services; supervision and clear processes for professionals to follow if they are not receiving supervision as required is vital.
Recommendations: request assurance and evidence from partner agencies that services for young parents include the expectation of appropriate engagement with father’s or mother’s partners; partner agencies to provide assurance that when vulnerable young parents transition between services, there is a robust and joined up plan to ensure their children’s needs and their own needs continue to be met.
Model: uses the Significant Incident Learning Process (SILP) methodology.
Keywords: infant deaths, shaking, mental health, parental involvement, transition to adulthood, drug misuse
> Read the overview report

2018 – Knowsley - Jane

Sexual abuse of a 4-year-old girl in May 2017 by a relative.
includes: with concerns that a child may have been sexually abused, the views of a specialist medical practitioner should be considered when deciding if a medical assessment is required; the conduct and record of child protection strategy meetings are fundamental to good safeguarding practice; when child protection medical assessments or police investigations are planned where children are witnesses, both parents should be given information about potential implications.
Recommendations include: oversee the development of a multi-agency referral pathway for children who require a paediatric forensic assessment; require agencies to conduct Achieving Best Evidence interviews consistent with Ministry of Justice guidance; agencies should be required to develop a communication plan to raise practitioners’ awareness of the KSCB’s dispute resolution and escalation process and to take any necessary steps to increase confidence in its use.
Keywords: child sexual abuse, siblings, grandparents, disclosure, general practitioners, assessment of children
> Read the overview report

2018 – Lancashire – Child LG

Serious head injuries to a 3-month-old infant in 2016.
Learning includes: all professionals should discuss with families at routine contacts about coping with an inconsolable crying baby and the dangers associated with 'shaking the baby; when it is known that a family receiving Early Help services have moved to a different area, professionals should ensure information is shared with their counter-parts in the new area particularly highlighting any risks or concerns; information should always be shared with partner agencies, and within agencies; when safeguarding concerns are evident, a pre-birth assessment should be considered, clear decisions and outcomes should be recorded.
Recommendations include: review relevant research alongside considerations of the local context in order to decide the most effective method to raise awareness with parents and families of shaking a baby and how to cope with inconsolable crying; ensure that there is sufficient awareness in education settings of information sharing protocols.
Keywords: crying, shaking, non-accidental head injuries, transient families
> Read the overview report

2018 – Lancashire – Child LI

Life threatening non-accidental injuries to a 4-month-old girl in August 2016 due to shaking.
multi-agency policy and practice should manage risk assessment of children who experience domestic abuse in the context of coercive controlling behaviour; coercive control should be included in local multi-agency guidance and strategy planning.
Recommendations: family courts should be given the outcomes of court ordered actions to inform decisions about children in accordance with the paramountcy principle; and records should be placed on information platforms by Police in a timely manner.
Model: Welsh model
Keywords: family violence, information sharing, non-accidental head injuries, physical abuse, unknown men
> Read the overview report

2018 – Leeds – Callum Garland

Death of a 14-year-old boy in August 2015.
to identify improvements in the assessment of risk and how this can be implemented through effective risk management plans; to identify whether there are improvements to supervision and management that would ensure better management of risky behaviours; to consider whether all aspects of Callum’s care and behaviour were brought together to comprehensively appreciate his needs and how to manage them.
Recommendations: for Local Authority children’s homes to design and implement processes in which risk assessments can be developed with relevant partners and family members where appropriate; for Emergency Services to establish a best practice approach to working at suicide incidents; for school nurses to document any knowledge of a child attending A&E and share that knowledge with other relevant health professionals.
Keywords: bullying, emergency services, professional curiosity, risk assessment, self harm, suicide
> Read the overview report

2018 – Leicestershire and Rutland – Child A

Death of a less than 1-year-old girl from a serious head injury. Child A was in the care of her paternal aunt when the incident took place. Aunt was found guilty of manslaughter and given a custodial sentence.
Learning: in cases of injury to a child, where the care givers do not speak English, an interpreter must be used once the immediate medical needs of the child have been attended to; if Children’s Social Care are notified of an incident for information only, the rationale for this and any expected response needs to be explicitly recorded; cases should not close to Children’s Social Care when there is agency feedback outstanding.
Recommendations: to consider a revision to procedures regarding injuries to mobile and non-mobile babies; to undertake work regarding accessibility of child health information in other languages; for agencies to be clear regarding recording of discussions held between agencies so professionals agree what is to be recorded, what action is to be completed, by whom and in what time frame; to raise awareness with parents and carers of how to seek emergency services.
Keywords: infant deaths, interpreters, non-accidental head injuries, record keeping
> Read the overview report

2018 – Lincolnshire – Child F

Death of a 15-week-old boy after feeding from a propped-up bottle sitting in a car seat in October 2015. Cause of death was unascertained.
Learning: recognition of underage sex; where the mother is a child, both her and the baby need to be treated as such; the quality of the Child in Need procedure and meetings needs improvement; professional curiosity was lacking and over optimism took place.
Recommendations: to ensure that the LSCB’s Child in Need process is operating effectively; to ensure that all agencies working with a child or family record full details of all adults within the household; carry out and complete appropriate and relevant CSE risk assessments; highlight the importance of record keeping; professionals need to be able to recognise disguised compliance and dis-engagements; professional curiosity and healthy scepticism should be included in all levels of safeguarding.
Keywords: adolescent mothers, child sexual abuse, disguised compliance, fractures, gillick competency, optimistic behaviour
> Read the overview report

2018 – Manchester – Child F1

Death of a 13-year-old child from a heart condition that was exacerbated by their morbid obesity.
Learning: there is a lack of clarity regarding childhood obesity as a child neglect concern; children’s help seeking behaviour needs to be recognised and responded to with support.
Recommendations: the need for the development of a strength-based psychosocial approach to the identification and management of childhood obesity; to look at the effectiveness of the current approach taken by partner agencies and staff in facilitating child-focused practice; to explore known barriers and build on this work to support future child-centred practice responses.
Keywords: obesity, non-attendance, hostile behaviour, mothers, help seeking behaviour
> Read the overview report

2018 – Manchester – Child G1

Non-accidental injuries sustained by a 4-year-old girl in June 2015. Her mother and partner were each given custodial sentences of six years.
Learning: the power of the adults’ narrative in drowning out the voice of the child; high caseloads leading to superficial assessments; approaches to domestic abuse that did not allow for the possibility of malicious allegations.
Recommendations: disclosure by children must be given priority and investigated; information gathering on all members of the household should be a basic requirement of practice; the development of a culture of challenge and reflection to enable practitioners to question what they are told.
Keywords: abused children, family violence, social work practice, non-accidental head injuries, voice of the child
> Read the overview report

2018 – Manchester – Child L1

Non-accidental head injury to an infant just under 8-weeks-old in September 2016 due to violent shaking.
Learning: good practice by the GP practice nurse; information elicited from mother by practice nurse became diluted during recording; implications for sharing safeguarding information in the case of out of area births.
Recommendations: to develop practitioner guidance on available options when a victim decides to retract allegations of domestic violence; to develop an abusive head trauma strategy to ensure effective prevention of abusive head injury in babies; to obtain assurance that partner agencies fulfil their statutory obligations to ensure strategy meetings take place when necessary and include all necessary partner agencies.
Keywords: abusive fathers, crying, emotional abuse, immigrant families, language
> Read the overview report

2018 – Manchester – Child M1 and M2

Non-accidental injury of 1-month-old infant M1 in August 2016 which led to M1 and older sibling M2 being placed in foster care.
Learning: professionals were generally over optimistic about mother’s ability to protect her children; M2’s verbal and non-verbal messages to adults (the ‘voice of the child’) were not given the weight they should have been; where there is conflicting information professionals need to seek independent sources and escalate concerns when they have evidence based doubts on decisions pertaining to safeguarding children.
Recommendations: taking account of and thoroughly understanding any previous serious case reviews in relation to a family.
Model: uses a variant of the systems approach developed by Social Care Institute for Excellence (SCIE).
Keywords: family violence, child neglect, voice of the child, disguised compliance, physical violence
> Read the overview report

2018 – Manchester – Child N1

Death of a 3-year-old child in March 2017. Child N1 was found unresponsive in the bath; cause of death unascertained.
Learning: importance of ensuring that communication has been received and is being acted on and timely transfer of records, particularly in cases where families are moving between areas; ensure the perspective and the daily lived experience of the children is the primary focus of professional intervention; importance of gaining the involvement and perspective of fathers to inform assessment and intervention; importance of routinely recording that there has been consideration of the need to make a safeguarding referral; importance of communication and information sharing between agencies and across areas when working with mobile families.
Recommendations: to ensure that where enquiries are being made under section 47 of the Children Act 1989, all relevant agencies are involved in strategy meetings or discussions to share and evaluate information, and plan the work.
Keywords: child death, child neglect, information sharing, voice of the child
> Read the overview report

2018 – Medway – Dawn

Death of a 16-year-old girl due to diabetic ketoacidosis in 2015. Review focuses on the concerns around the management of her illnesses both in the home and by professionals and services.
Learning: safeguarding needs were not assessed by any of the agencies involved; there was a lack of professional curiosity around siblings and parental neglect; child’s voice not sought or heard; lack of understanding of how the family’s cultural beliefs impacted on their attitudes; comprehensiveness of assessments, including risk; information sharing between health agencies.
Recommendations: health providers should provide assurance about how they manage and coordinate the care of children and adolescents with complex health needs to ensure that safeguarding issues are not missed; develop flagging systems across agencies which identify children and adolescents where other children or young people in the family are looked after; develop a system for regular liaison between children’s services in different areas, where children in families of concern live between parents and across areas.
Keywords: adolescents, child deaths, medical care neglect, professional curiosity
> Read the overview report

2018 – Medway – Ellie

Death of Ellie, a 2-year-7-month-old girl and her mother found in a flat in Medway in March 2016. Post-mortem examinations proved inconclusive and police ruled out the involvement of others in the deaths.
Learning: the majority of contacts with agencies were unremarkable given Ellie’s mother’s status as an over-stayer; frequent moves reduced the possibility of any continuity of agencies’ monitoring or support; mother’s apparent rejection of her family in the UK and limited network of friends compounded her fear of being detected and removed from the UK; lawful and efficient responses to extremely marginalised groups are not always enough to compensate for the very particular vulnerabilities represented by those who have no recourse to public funds.
Recommendations: that the Immigration and Support Service should be sufficiently informed of obligations and expectations arising from section 11 Children Act 2004; GP registration protocols should be reviewed and a robust reporting system to the health visiting/school nursing service for all under 18s should be established.
Keywords: asylum seekers, homelessness, immigrant families, social exclusion
> Read the overview report

2018 – Mid and West Wales – Child A

Death of a 17-year-9-month-old young person by suicide. He had been placed in care at the age of 2 years as a result of severe physical and emotional abuse and neglect; his foster carers subsequently adopted him.
Learning: effective communication and planning between professionals is an essential component of good multi-agency working; a professional resolution process would avoid drift and delay in care planning; professionals need to feel confident when working with parents who are perceived as challenging and be more empathetic in working with families; pathway planning for young people in care to consider their holistic needs, emotional resilience and learning ability; enabling young people to communicate what is important to them is not the same as repeating what they say.
Recommendations: local authority training for practitioners on the legal framework for children in care, particularly where disruption is evident or does not share parental responsibility; produce good practice guidance to ensure focused supervision of practitioners based on high challenge and high support; all agencies to assure the LSCB on how the child’s voice influences their ability to ensure good outcomes for children in care taking into account the child’s lived experience.
Keywords: anxiety, assessment of children, attention deficit disorder, emotional abuse, placement breakdown, professional collaboration
> Read the overview report

2018 – Middlesbrough - Billy

Serious injuries to a 6-year-old boy following a road traffic collision in April 2017. Police had recorded incidents of Billy and other children playing unsupervised on a busy dual carriageway in 2015 and referrals were made to Children’s Social Care.
all children within a family need to be considered in assessments and plans; professionals need to identify when parental cooperation with a plan is superficial; the need to be curious about information held by other agencies and be proactive in sharing information that may improve the understanding of the child’s lived experience; consider the daily life of all the family through the child’s eyes when working with parents who misuse substances; view with respectful caution a parent’s self-report of their drug taking; good quality plans and reflective supervision is key to effectively recognising and challenging neglect.
Recommendations: to consistently capture the voice of the child and lived experience with meaningful analysis; to request assurance from partner agencies providing early help about arrangements for reflective supervision for their practitioners; and how can the LSCB ensure that the impact on children of parental substance misuse is appropriately considered in multi-agency assessments and plans.
Model: uses the Significant Incident Learning Process (SILP) methodology.
Keywords: attachment behaviour, disguised compliance, neglected children, parenting capacity, substance misuse
> Read the overview report

2018 – Newcastle – Baby K

Death of 13-week-old infant due to non-accidental traumatic head injury in March 2017. Father was charged with manslaughter and was subsequently acquitted.
includes: the intrinsic vulnerability of babies; risk assessments to have a reflective review by supervisors; the benefits of having an open, non-incident based approach to all forms of abuse within the family, supported by structured enquiry, professional practice and awareness that a victim may not disclose or even identify the existence of abuse.
Recommendations: there are no recommendations.
Keywords: infants, physical abuse, non-accidental head injuries, fathers
> Read the overview report

2018 – Newcastle – Sexual exploitation of children and adults with needs for care and support

Joint serious case review concerning sexual exploitation of children and adults with needs for care and support in Newcastle between 2007 and 2015.
Learning: understanding the prevalence of sexual exploitation requires assuming it is taking place and adopting a pro-active approach to look for it, recognising that the most reliable source of information is from victims and those targeted; the most effective way to address sexual exploitation and safeguard and promote the welfare of victims is to resource multi-agency teams, co-located in the areas in which sexual exploitation takes place; effective safeguarding is a collective responsibility and requires a culture of robust inter-agency and professional challenge of practice and strategy; sexual exploitation is not restricted to child victims.
Recommendations: for the government to consider which community services not routinely involved with local safeguarding frameworks have a contribution to make to early identification and prevention of sexual exploitation and make arrangements to ensure that their contribution is made and monitored through regulatory functions or otherwise.
Keywords: child sexual exploitation, child sexual abuse, organised abuse
> Read the overview report

2018 – Newham – Chris

Death of a 14-year-old boy in September 2017 as the result of a bullet wound to his head.
Learning: lack of analysis and professional curiosity in assessment can negatively affect understanding of a child’s development and vulnerabilities; not sharing information between agencies can leave practitioners with an incomplete oversight of the presenting issues.
Recommendations: increase cross-agency awareness of the role social media plays in gang tensions and violence; review processes for the relocation of young people and families out of Newham; where multiple risk indicators exist, consider additional transitional support between primary and secondary education with a focus on child criminal exploitation and gang affiliation.
Model: uses a mixed methodology aligned with the SCIE Learning Together approach.
Keywords: child behaviour problems, crime, drugs, gangs, harmful sexual behaviour, race, violence
> Read the overview report

2018 – Norfolk – Case Y

Physical and sexual abuse of six children, aged between 4 and 16 years, by their father, who was sentenced to life imprisonment.
Learning: professionals often fail to pick up signs of child sexual abuse, placing responsibility on victims to make sure their abuse is identified; the need to build a platform for disclosure and a trusting relationship; further develop understanding the behaviour of perpetrators; the importance of multi-agency meetings.
Recommendations: use family history to identify risk and likelihood of sexual abuse; practitioners should be equipped with the skills, language and tools to facilitate appropriate curiosity; to consider listening to children in each recommendation especially when developing a practice model.
Keywords: abusive fathers, alcoholic parents, children with physical disabilities, disguised compliance, sexually abusive parents, transient families
> Read the overview report

2018 – Norfolk – Child V

Death of a 6-month-old baby girl from serious head injuries in March 2016. Evidence of previous head trauma and a fracture to her arm. Child V’s father was convicted of manslaughter in December 2017.
Learning: victims of domestic abuse often withdraw police statements, which complicates the prosecution process; professionals must question and challenge decisions and concerns directly with colleagues, irrespective of their professional background or status; the matter of language difficulties and consistent use of interpreters is an area for improvement.
Recommendations: Norfolk LSCB and partner agencies need to develop a system to support non-engaging parents in domestic abuse offences and rape criminal cases; to have robust and easily accessible systems in place to support team functioning and staff wellbeing; ensure that the children’s services workforce understands the limitations of solution focused interventions for relationship counselling where domestic abuse is suspected; neonatal and maternity services should implement systems to routinely gather and share safeguarding / domestic abuse information.
Model: uses the NSCB Thematic Learning Framework model.
Keywords: abusive fathers, emotional neglect, premature infants, fractures, family violence, language
> Read the overview report

2018 – Norfolk – Child Z

Sexual assault of a 14-year-old male by a 20-year-old male care leaver in June 2016. The assault took place whilst the two males were being housed in temporary accommodation by the local District Council who were unaware of YPA’s harmful sexual behaviour.
Learning: Children’s Services should ensure its leaving care service is fit for purpose; the need to put in place effective early intervention services for young people, including care leavers, who exhibit HSB; unaccompanied children under 16 years of age must not be placed in temporary accommodation; police child sexual exploitation perpetrators’ risk assessments must result in effective and timely multi-agency planning of suspected individuals.
Recommendations: that HSB procedures are fit for purpose and up to date; to disseminate and embed HSB policies and procedures; to widely disseminate and implement findings and learning from this SCR; for the Sexual Abuse Referral Centre (SARC) to report to the LSCB on the feasibility of expanding the service remit to include children and young people who have suffered non-penetrative sexual abuse.
Keywords: harmful sexual behaviour, communication, data protection, risk assessment, sexually abused boys, transition to adulthood
> Read the overview report
> Read the executive summary

2018 – Norfolk – Family U

Sexual abuse of four children under the age of 13 by their father over a number of years. Father subsequently received a life sentence and mother sentenced to two years imprisonment.
Learning: understanding and mapping family history; difficulty in recognising or naming sexual abuse prior to ‘disclosure’; implications of limited focus on relationship building, especially with adolescents; impact and causes of drift.
Recommendations: to continue developing a multi-agency approach to child sexual abuse so as to ensure it is not reliant on disclosure by victims, but on proactive and supported practitioners; review the support provided to frontline staff regarding the impact of the emotional content of child safeguarding on frontline; to develop a shared approach by which partners report on, or seek information about, any significant changes to an agency’s function, resources or practice which could impact on multi-agency safeguarding.
Keywords: child sexual abuse, incest, listening, voice of the child
> Read the overview report
> Read the executive summary

2018 - North Ayrshire - J Family

Significant harm of a sibling group whilst in the care of their parents. All children were taken into care.
Learning: five priority findings emerged including: loss of clarity about the appointment of a Lead Professional resulted in lack of coordinated overview of children's needs; assumption that giving and receiving information equates to communicating which can lead to misunderstandings about the current assessment of children's situations; tendency to restrict evidence of children's experience to what they say, which results in missed cues and the privileging of the voices and views of adults; some services for adults take insufficient account of children connected to their clients and thereby fail to identify risks to their wellbeing and safety.
Recommendations: There are no recommendations but the review raises a number of questions for the Child Protection Committee relating to each learning point.
Methodology used: SCIE's Learning Together model.
Keywords: voice of the child, child protection, assessment, child neglect
> Read the overview report

2018 – Northumberland – Olivia

Sexual abuse of a 12-year-old girl in 2015 by her mother’s partner.
Learning: intrafamilial abuse is still likely to be the most common form of sexual abuse that professionals will encounter; the verbal disclosure of a child is one aspect of the investigation of sexual abuse and lack of further disclosures or supporting forensic evidence should not negate the belief that the child may have been abused; practitioners should be aware of disguised compliance; describing the results of medical examinations as ‘inconclusive’ or ‘neutral’ in the context of sexual abuse may bring a risk that the absence of a definite finding could be taken as ‘evidence’ that alleged abuse did not occur.
Recommendations: face-to-face, multi-agency strategy meetings should be held in cases of suspected child sexual abuse; all agencies must ensure that listening to, and hearing what children say is important.
Keywords: child sexual abuse, disguised compliance, listening
> Read the overview report

2018 – Nottinghamshire – Madison

Disclosure of abuse and asking to be taken into care by 16-year-old female child, who had been living with her mother, step-father and half siblings in March 2016.
Learning: the need to distinguish between behaviour that might indicate cruel rather than neglectful care; children more readily disclose information to adults such as teachers or health practitioners whom they can trust; professionals must be aware and sceptical about how parents may seek to influence how information is processed; recognition and response to self-harm.
Recommendations: to ensure the voice of the child is sought by professionals to appropriately inform judgements and decision making during enquiries and assessments; to ensure that chronologies are appropriately collated and analysed to inform judgements and decision making when concerns are raised in regard to child abuse.
Model: investigatory model for collating information with analysis using elements of a learning review model.
Keywords: assessment [social work], bereavement, bruises, emotional abuse, failure to thrive
> Read the overview report

2018 – Nottinghamshire – Peter

Death of a 16-year-old boy by suicide in June 2017.
Learning: professionals should make notes of disclosures made by children as soon as possible after the conversation, which must not include leading questions; notes must be suitable for disclosure to any future enquiry or investigation.
Recommendations: ensure that staff understand, in line with the school’s updated policy, that it is not the role of staff to investigate disclosures by interviewing the child or others involved, unless asked to do so by police, CSC or NSPCC; review the inter-agency CSE procedures to ensure that when there are sufficient concerns to support a section 47 enquiry that the appropriate multi-agency response is triggered; undertake an audit of CSE meetings; promote the increased use of the Early Help Assessment Framework by agencies and explore the barriers which prevent professionals from completing them.
Keywords: suicide, body image, child sexual exploitation, disclosure, deception, anxiety, self-harm, eating disorders, sexuality, schools
> Read the overview report

2018 – Oldham – Baby H

Injury of an 11-week-old boy in September 2015 as a result of shaking.
Learning: improved understanding by neonatal staff about the triggers which can lead to abusive head trauma in young babies; help with the support and guidance that neonatal staff offer to all parents, particularly those whose babies are considered vulnerable; more professional awareness of pre-birth assessment procedures would be beneficial in mitigating potential future safeguarding risks.
Recommendations: criteria and procedures for starting pre-discharge meetings should be robust and understood by all professionals involved; consideration should be made to cooperating with other LSCBs to explore how learning can be shared to develop policy and practice.
Keywords: non-accidental head injuries, shaking, antenatal care, nurses and nursing, midwives, information sharing
> Read the overview report

2018 – Oldham – Child G

Inflicted abdominal trauma to a 6-year-old child in June 2014 while in the care of mother’s partner.
Learning: professionals engaged in multi-agency working must be attuned to non-verbal methods of communication and advocate for a child that is not being heard.
Recommendations: LCSBs must ensure GPs are part of multi-agency safeguarding arrangements; working directly with men in families must be embedded in professional thinking.
Keywords: voice of the child, unknown men, risk assessment, injuries, health care, abused women
> Read the overview report

2018 – Portsmouth – Child E

Death of Child E aged 18-days-old, cause of death recorded as ‘head injury’. Child E was born at home following a concealed pregnancy. Mother was charged and found guilty of murder and Grievous Bodily Harm; the father was charged, tried and acquitted of causing death of a child.
Learning: better use of early help and intervention; the necessity of good reflective supervision and management scrutiny in all agencies; the assessment of the impact of specific parental issues of domestic abuse, alcohol misuse and parental mental health; and risks associated with concealed pregnancies.
Recommendations: to ensure that partner agencies have an agreed step-up/step-down protocol concerning the use of the Common Assessment Framework; to oversee the strengthening of multi-agency procedures in relation to the identification, referral and assessment of concealed pregnancy; to seek assurances from GP practices that health visitor/GP meetings are in place and are effective in identifying vulnerable families at an early stage; to review guidance on assessing domestic violence.
Keywords: adults in care as children, family violence, infant deaths, non-accidental head injuries, parenting capacity, parents with a mental health problem
> Read the overview report

2018 – Rochdale – Child E

Death of a 3-month-old boy in September 2017 attributed to being left in an unsafe sleeping environment.
the rationale for closure of Common Assessment Framework (CAF) should identify trigger points to review necessity for further multi-agency sharing of information; understanding multi-agency referral pathways is crucial to professionals’ sharing information with purposeful intent; specialist midwives are best placed to support the pregnancy of women with a known drug history; health agencies need to work together in order to ensure that new born babies are registered with a GP practice.
Recommendations include: review guidance ascribed to cessation of CAF to include a risk indicator to support single agency identification of risk to initiate further multi-agency consultation; ensure that the role of specialist midwifes is developed and promoted amongst the wider health economy; use this review as an instructive case scenario to support early help services to understand barriers to best practice.
Keywords: drug misuse, infant deaths, common assessment framework (CAF), parenting education, optimistic behaviour, antenatal education
> Read the overview report

2018 – Rotherham – Child R

Concerns about non-accidental injury to an infant aged just under 3 weeks admitted to hospital in December 2013, and further injuries sustained whilst in hospital and in the care of his father in January 2014.
key findings are analysed by theme: conducting a child protection investigation; agencies’ responses when there is uncertainty about the causes of an injury to a child; perception of hospitals as a place of safety; balance between a child’s need for protection versus the need to attachment; maintaining momentum, ownership and management oversight over time periods which include weekends and Bank Holidays; information sharing and recording; and engagement with family.
Recommendations include: to consider a review of the Child Protection Procedures and Practice guidance due to the concerns of the review that they are incompatible with Working Together 2013; to consider the need to develop practice guidance and training to assist staff in cases where there is uncertainty about a child’s medical condition; to request an audit of section 47 investigations focusing on cases where no subsequent initial child protection conference has been held to establish where there is a systemic barrier to the convening of such conferences. 
Model: used the Significant Incident Learning Process (SILP) methodology.
Keywords: physical abuse, infants, hospitals, child protection
> Read the overview report

2018 – Salford - Child T

Abduction from the United Kingdom of an almost 3-year-old girl in December 2016. Child T was subject to a Full Care Order with Looked After Child (LAC) placed at home status. She was abducted by her birth parents which is a crime as the Care Order meant the Local Authority shared parental responsibility for Child T.
effective information sharing and communication are vital if children are to be safeguarded when their parents are involved in serious crime; practitioners working with LAC placed at home should be alert to their vulnerability and ensure they understand their responsibilities towards safeguarding them and meeting their needs; multi-agency practitioners need to ensure they are clear about the content of parental written agreements; always be alert to the possibility of disguised compliance even when parents present as fully engaged and working well with agencies.
Recommendations include: Greater Manchester Police and Children’s Services should assure the LSCB that strategy meetings or discussions are always held when a child has been subject to a Police Protection Order; partner agencies to assure the LSCB that the learning from this review has been implemented and embedded into practice.
Model: multi-agency concise review (MACR). 
Keywords: child abduction, communication, disguised compliance, immigrant families, parenting capacity, threshold criteria
> Read the overview report

2018 - Sefton - Martha, Mary and Ben

Neglect of three siblings, a 2-year-old and 5-year-old twins, in August 2017.
child protection enquiries should not be ended without considering the actions agreed at strategy meetings; there were shortcomings in the early recognition and identification of neglect and a subsequent delay in providing the family with the right help at the right time; where neglect is an issue, Child in Need assessments and plans can be enhanced by the use of the Graded Care Profile.
Recommendations: require an audit of decisions to end Child in Need plans with an accompanying action plan, if necessary, to secure improvement; practitioners and managers must use the Graded Care Profile where there are issues of neglect in early intervention or working with children who may be in need; ensure that there are specific actions in respect of the identification and assessment of dental neglect as a safeguarding issue.
child neglect, children of incest, drug misuse, parents with a mental health problem, home environment, crime
> Read the overview report

2018 – Shropshire – Child E

Murder of a 7-year-old boy by his mother in September 2017. Mother was sentenced to life imprisonment.
focuses on the following themes: lack of clarity about the safeguarding referral pathway across the professional network; managing allegations and concerns in respect of children of separated parents; lack of engagement with and unconscious bias against fathers.
Recommendations: clarify the decision-making process for referrals to early help and children's social care; review the notification process for section 37 reports; and create learning opportunities for reflecting on the approach to providing a whole family focus.
Keywords: abusive mothers, divorce, partner violence, parents with a mental health problem, partner relations
> Read the overview report

2018 – St Helens – Baby A

Death of a 6-week-6-day-old girl found unresponsive on the couch next to her mother in November 2016. Baby A was born prematurely at 36-weeks’ gestation. At the time of her death, both parents had been drinking alcohol and were significantly intoxicated.
Learning: practitioners should be aware that pregnancy and post-delivery is a critical time for women to experience deterioration in their mental health; monitoring and assessing growth of new-born, premature infants should be in line with expected practice standards; all relevant multi-agency professionals should be contacted for a core assessment; all agencies should contribute to effective information sharing.
Recommendations: to ensure all early-help guidance addresses the issues identified in this review; to seek assurance that ‘Did Not Attend’ policies contain clear guidance on the actions to be taken when adults with caring responsibilities fail to engage with services dealing with health issues that can adversely impact on parenting capacity.
Keywords: alcoholic parents, non-attendance, parents with a mental health problem, premature infants, sleeping behaviour
> Read the overview report

2018 – Shropshire – Child C

Death of 17-year-old male child from Vietnam in December 2016 by drug misuse.
Learning: a number of issues concerning agencies’ awareness of the indicators of trafficking and associated risks, their assessment of young people who present as unaccompanied asylum seekers, the management of risk in cases where children remain missing for a long time and the impact of a child’s status on how they are managed and reviewed.
Recommendations: inter-agency guidance on children who present as unaccompanied asylum seekers and trafficked children should have a dedicated referral pathway that outlines the role of each agency; national guidance should be issued to clarify how police and local authorities work together and agree on who takes primacy in the identification and confirmation of age of a person who presents as an unaccompanied asylum-seeking child.
Keywords: unaccompanied asylum seeking children, drug misuse, refugee children, child trafficking
> Read the overview report

2018 – Somerset – Family A

Significant neglect and sexual abuse of three children over a 15-year period.
Learning: focuses on the long-term impact of chronic neglect; vulnerabilities of children with additional needs; safeguarding practice in the schools; school attendance; engagement of parents presenting as hostile; and professional differences.
Recommendations: frontline practitioners working with children and families from all agencies should be trained to work with families who display aggressive and evasive behaviour; child protection supervision for all cases where children are the subjects of child protection plans or child in need plans must be a priority for all agencies; family support advisors should keep professional records of their involvement with families.
Keywords: child neglect, child sexual abuse, hostile behaviour, children with learning difficulties, voice of the child
> Read the overview report

2018 – Sunderland – Baby A

Death of a 20-day-old baby following an assault by the family dog.
Learning: professionals need to help families think about risks that may be posed by family pets to children and the need to educate both parents about the risks of alcohol to the safe care of their children.
Recommendations: delivering a public awareness campaign around the risk to babies and children as a result of parental use of alcohol and unsupervised dogs.
Keywords: infant deaths, alcohol, substance misuse, unknown men
> Read the overview report

2018 – Sunderland – Young Person Mark

Circumstances leading to a 15-year-old boy being placed in a secure setting in September 2015.
Learning: the need to improve understanding of adolescent choice and risk, especially in terms of substance misuse; the importance of shared assessment processes to pull out indicators of need or vulnerability; a lack of professional curiosity to investigate what the underlying reasons were for Mark’s behaviour and drug misuse; the need for a clear chronology of events to show where risks lie.
Recommendations: to the LSCB, develop a multi-agency framework to support the development of resilience and improve outcomes for vulnerable adolescents; support staff to engage effectively with young people and better understand issues of risk such as child sexual exploitation and substance misuse.
Keywords: behaviour disorders, drug misuse, listening, optimistic behaviour, professional behaviour
> Read the overview report

2018 -  Telford and Wrekin – Family Q

Neglect of five siblings aged between 6-weeks and 9-years-old from June 2015 to December 2016.
limited information sharing about indicators of neglect when children moved within and between local authorities; indicators of neglect were normalised by professionals working in areas of high deprivation; lack of professional curiosity about information shared by the mother.
Recommendations: information sharing processes for children moving between local authorities should be reviewed; barriers to effective use of tools to support the early identification of neglect should be identified; learning, including the recognition of dental health as an indicator of neglect, should be shared across the workforce.
Model: uses the Significant Incident Learning Process (SILP) methodology.
Keywords: disguised compliance, health visitors, professional curiosity, schools, neglect, social deprivation
> Read the overview report

2018 – Wakefield - `Madison’

Death of a 6-day-old baby girl in July 2017. Father was sentenced to life imprisonment for murder.
includes: in cases of concerns about long-term neglect it is important to understand the child’s lived experience, and assess the totality of the child’s care; importance of reflective and challenging supervision in cases where there are concerns about long-term neglect to guard against the rule of optimism; importance of recognising a lack of engagement/disguised compliance. Good practice identified includes: early recognition of the family’s need for enhance support by the health visitor.
Recommendations include: use a standardised, objective approach to the assessment of neglect; need for a shared understanding and common language of levels of needs/thresholds, particularly following a referral to Children’s Social care.
Model: uses the Significant Incident Learning Process (SILP) methodology.
Keywords: infant deaths, physical abuse, child neglect, voice of the child
> Read the overview report

2018 – Wakefield – Ollie

Serious and life-threatening injuries of a 5-week-old infant girl in August 2017 due to shaking.
Learning: understanding parental history and vulnerability is important in assessing actual or potential risk to children; sharing information between health professionals should be seen as standard practice, especially during pregnancy and early childhood; the practical use of information, rather than just recording it, is critical to effective safeguarding arrangements; knowledge of controlling and coercive control in adult relationships can help practitioners make informed decisions about risk to children.
Recommendations: for the LSCB to ensure that there is ongoing scrutiny to evaluate how effective improvement action has become embedded into routine practice; to seek reassurance that the decision making at the point of contact and referral are appropriate and based on appropriate information sharing.
Model: used the Significant Incident Learning Process (SILP) methodology.
Keywords: physical abuse, shaking, crying, infants, family violence
> Read the overview report

2018 – Walsall – Child A

Death of a 6-month-old infant due to a non-accidental head injury in June 2016.
Learning: not all professionals have the same level of expertise in all areas of practice, so use of those with expert knowledge (e.g. mental health) can provide a more in-depth understanding of the client; robust communication is key in understanding concerns across all agencies particularly where there is cross border working; NICE guidance indicates that routine enquiry into domestic abuse should be undertaken during pregnancy.
Recommendations: hearing the voice of the child, particularly for younger children, where parental issues may be the more obvious focal point; understanding of coercive control; to formulate guidance on the importance of engaging with fathers; to reconsider the effectiveness of prescriptive thresholds guidance; robust systems in place to share information relating to safeguarding concerns; to implement a communication model across partner agencies.
Model: uses a mixed methods approach based on systems methodology.
Keywords: fathers, information sharing, parenting capacity, parents with a mental health problem, professional curiosity, threshold criteria
> Read the overview report

2018 – Walsall – Child W8

Death of an 8-year-old child in January 2018. Child W8 was stabbed to death by her father.
Learning: sometimes very serious harm to children is not predictable; agencies made aware of domestic abuse incidents should proactively enquire about mother’s and children’s safety; mothers and children are better protected if midwives consistently use Routine Enquiry during pregnancy and the immediate postnatal period; entering a new relationship can be a risky time for families who have experienced domestic abuse.
Recommendations: evidence that practitioners show professional curiosity and are competent in working with families where domestic abuse is a feature; consider how to best raise awareness about the increased risks of violence at the point of leaving an abusive relationship and on discovery of a new relationship.
Keywords: child death, murder, partner violence, separation, antenatal care
> Read the overview report

2018 – Waltham Forest – Kesandu

Neglect of a 9-year-old girl in March 2017.
includes: current investment in school nursing means their contribution to child safeguarding is significantly curtailed; no agreed universal structure to how school staff present cases to Local Authority Early Help increases the risk that information will be missed; gaps in the process of joint dissemination within CEOP increase the risk of a fragmented response.
Recommendations include: consideration of a statutory requirement nationally for school nursing; seek reassurance from CEOP that their organisation has reliable systems in place for joint dissemination including the collating of data; seek reassurance from CEOP that all staff have sufficient knowledge of relevant and necessary procedures, regardless of their role, without making assumptions.
Model: uses the Social Care Institute for Excellence (SCIE) Learning Together (LT) methodology.
Keywords: child abuse images, child abuse reporting, child neglect, communication media, home environment, neglecting parents.
> Read the overview report

2018 – Western Bay - WB N 25 2016

Death of a child in a house fire in July 2016.
important to ensure, particularly during times of disruption and change, that adequate support is in place for professionals; professionals should ensure that clear descriptive language is always used when completing assessments, particularly during cases of neglect; multi-agency, independent supervision would be beneficial with long standing ‘stuck’ cases; when parental relationships are identified as presenting a risk to children, professionals should consider ways to empower parents to make the right decisions, for example, healthy relationship work; any professional that worked with a child who has died needs to have access to support and debrief session within a short time frame following the event.
Recommendations: there are no recommendations in the Review.
Keywords: disguised compliance, drug misuse, fire service, home environment, optimistic behaviour, parental capacity
> Read the overview report

2018 - Western Bay - WB S36 2017

Death of an 8-month-old baby boy in the spring of 2017.
develop guidance to help Children's Social Care staff work better with colleagues from other Local Authority areas, particularly where members of the same family reside in more than one area; co-sleeping advice should be further reinforced after baby reaches 6 months, particularly with respect to risk factors; practitioners should be clear about family structure and seek information about all adults involved with a child and to consider the type, level and quality of contact and care; all conversations held with Children's Services should be documented in the child's records, even if the outcome of the conversation is no further action.
Recommendations: makes no further recommendations other than those included in learning points.
Keywords: sleeping behaviour, parents with a mental health problem, siblings, infant deaths, alcohol misuse, disguised compliance
> Read the overview report

2018 – Wigan – Child M

Death of a 10-week-old infant in July 2016, found unresponsive in a car baby seat by father. Child M was a second twin, born at 28-weeks’ gestation, discharged from hospital at age 8 weeks.
Learning: assessment of parental capacity should include all adults that undertake a parenting / caregiver role with children; infants should never be left to sleep in a car travel seat except for the recommended time span; opportunity to refer mother to Specialist Midwifery Drug and Alcohol Services during first twin pregnancy was missed; inconsistent provision of bereavement support.
Recommendations: partner agencies should have in place a robust Early Help offer, to include the unborn child; threshold guidance should have clear step-up and step-down escalation processes when working with Early Help; participation of adult services to support assessment of risk, planning and intervention when working with adults with parental responsibilities; improved focus on the hidden male.
Model: a hybrid methodology was used to complete the review, combining several theoretical models and techniques.
Keywords: alcoholic parents, parenting capacity, parents with a mental health problem, sudden infant death, twins, unknown men
> Read the overview report

2018 – Wiltshire – Family M

Concerns regarding five children aged between 4 and 12 years in February 2016. Mr W, father of the two youngest children, had watched Category A, B and C child abuse images and uploaded them for others to watch.
Learning: the huge increase in the number of men viewing online child sexual abuse images has not been matched by professional knowledge; the absence of a clear framework for interviewing children outside the established process; insufficient appropriate professional challenge and the use of escalation processes; a tendency for professionals to uncritically accept what parents tell them about their children; professionals are deskilled in their response and inconsistent in how they name child and adolescent neglect; and evidence of lack of rigour and focus in child protection processes.
Recommendations: there are no recommendations presented as such, but under each finding are questions for the Board. Concludes by raising concerns regarding the collective and cumulative impact that resource pressures can have on delivery of services.
Model: review was undertaken using the Learning Together systems model developed by the Social Care Institute for Excellence.
Keywords: child sexual abuse, communication, optimistic behaviour, pornography, record keeping, step-parents
> Read the overview report

2018 – Wirral – Child H

Sexual exploitation of girls over a number of years by the Rajenthiram brothers.
includes: alcohol and domestic violence are frequently evident in families where neglect is a factor and can be common features in the parents of children vulnerable to child sexual exploitation (CSE); children who are experiencing CSE do not always recognise themselves as victims; avoid using phrases such as ‘putting themselves at risk’ and ‘lifestyle choices’ as this makes the child responsible for their abuse.
Recommendations include: ensure the thresholds of need are understood so children receive the right service at the right time; ensure robust management oversight of cases is in place and supported by regular reflective supervision of staff; review the response to children who frequently attend A&E.
Keywords: child sexual exploitation, grooming, sexual offences, sexually abused girls, sexually abusive people, siblings
> Read the overview report

2018 – Wirral – Child I and Child J

Death of a 2-year-1-month-old child and non-accidental injuries to their twin.
when health visitors encounter unknown individuals during home visits, they will, as a matter of routine, seek to establish their details and record them; to check that the home address linked to electronic out-patient appointment letters has been updated, where necessary.
Recommendation: to ensure robust, ethical and effective sharing of information when professionals make enquiries to children’s social care about named children, to maximise the likelihood that potential indicators of harm are identified and acted on where no safeguarding risk exists.
Model: uses a systemic approach based on the model developed in Wales for undertaking Child Practice Reviews. 
Keywords: drowning, fractures, murder, non-attendance, step-parents, unknown men
> Read the overview report

2018 – Wolverhampton – Child G

Death of a 2-year-9-month-old boy of Caribbean and African heritage (Child G) on 22 November 2016 from cardiac arrest. After his death Child G was found to have peritonitis and a complex fracture of the skull along with other injuries. His mother's partner was convicted of murder and sentenced to life imprisonment; his mother was convicted of allowing the death of a child.
Learning: ways in which professionals assess the risk of domestic violence, and the implications that having no right to remain and no recourse to public funds have on the lives of the families they work with; professionals need to understand what parents' faith means to them during the assessment process and find out about other individuals who may be involved with them.
Recommendations: to consider how the LSCB can draw to national attention the inconsistent application of duties for authorities to safeguard and promote the welfare of children of families with no recourse to public funds.
Keywords: immigrant families, non-accidental head injuries, non-attendance, single mothers, religion, unknown men
> Read the overview report

Case reviews published in 2017

Case reviews published in 2017

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 2017. To find all published case reviews search the national repository.

Case reviews describe children 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

2017 – Anonymous – Alex

Death of 11-year-old child with complex medical needs requiring a high level of input from a variety of practitioners and putting a high level of demand on those caring for the child, making it difficult to define the threshold for neglect.
Key issues: Alex was diagnosed with cystic fibrosis (CF) at a year old. The parents separated when Alex was 5. There was evidence that the mother had experienced domestic abuse, coercion and control which continued with a partner who became Alex’s stepfather. The stepfather had considerable influence in decision making and gave the impression of having parental responsibility. Alex’s health deteriorated from age 6 and hospital admissions increased due to CF. Clinical staff were concerned about carers’ capability to deliver the care needed.
Learning: the importance of the child’s wishes and feelings to influence their care; practitioners had varying levels of knowledge in relation to the child’s clinical needs; the cumulative nature and clinical implications of his illness were not fully understood by those working with the child; the formal escalation procedure in place at the time was not used.
Recommendations: the importance of the voice of the child; the importance of supervision in social work; the need for formal processes and procedures to be in place to share information about children who meet the LSCB threshold level 3 criteria; decision making in practice should include the history of the family dating back at least one year.
Keywords: cystic fibrosis, emotional neglect, optimistic behaviour, parenting capacity
> Read the overview report

2017 – Anonymous – Child AB

Life threatening attempted strangulation and suffocation of child by mother, followed by mother's suicide attempt, in 2014 and 2015. Child AB became subject to child protection investigation and child in need plan.
Background: no indication of child abuse prior to the first event. Maternal history of mental illness, self-harm, disclosed attempts to harm husband and attempted suicide.
Key issues: include: management of screening for maternal mental health and domestic abuse not fully embedded in practice; lack of direct questioning regarding thoughts to harm others; professional decision-making impacted by affluence and status of family.
Recommendations: include: strengthen professionals' understanding of the negative impact of professional biases and beliefs in safeguarding practice; review procedures to improve understanding of the child as a protective factor, risk of filicide and harm to others in cases of parent mental illness.
Keywords: parents with mental health problems, filicide
> Read the overview report

2017 – Anonymous – Child F and Family

Harmful sexual behaviour and death of 17-year-old boy in 2015 as the result of stab wounds.
Background: Child F was assessed as a Child in Need in 2011. Behaviour and attendance at school erratic, and several incidences of involvement with others in minor and serious offences, including rape of a 12-year-old and 14-year old. Decision made that prosecution relating to first rape was not in public interest.
Key issues: when cases are not pursued in the public interest it is still necessary for the young person to be given a full understanding of the implications of their actions; lack of support for mental health needs due to referrals to and from between agencies; good chronologies of key events would help spot risks; agencies should take great care when describing sex as consensual when in law it cannot be; young teenagers are often unclear about consent.
Recommendations: review safeguarding approach to young people with harmful sexual behaviour; encourage education providers to ensure law around consent is explained clearly; ensure that a young person’s concern about violent risks to them is taken seriously by agencies.
Keywords: harmful sexual behaviour, adolescents, consent
> Read the overview report

2017 – Anonymous – Child Y

Serious health and developmental impairment of a teenage boy due to fabricated or induced illness (FII) over a number of years.
Learning: the difficulties faced by professionals in working with a family when FII is suspected.
Recommendations: development and implementation of pathways for the early identification and management of perplexing presentations, including suspected cases of FII, and for the management of identified cases of FII, including those who are subject to child protection plans; the Department of Health and the Department for Education should be asked to commission national research to establish the prevalence, incidence and case characteristics and outcomes for children who have perplexing presentations or FII.
Keywords: fabricated or induced illness, emotional abuse, adolescent boys
> Read the overview report

2017 – Anonymous – Considering child sexual exploitation

Child sexual exploitation of 3 girls by a young adult female who was involved in sexual activity with them and recruited them in abusive sexual behaviours by a number of older adult males between January 2013 and August 2015.
Key issues: all girls had complex needs and missing from home episodes. The alleged perpetrator was part of a wider network of predominantly male operatives.
Learning: difficulty in identifying the alleged perpetrator as a risk to children; the need for services to work with parents to strengthen parental confidence as perpetrators set out to deliberately drive a wedge between child and family; importance of early intervention in responding to sexual exploitation; the need to understand children as victims without choice or informed consent.
Recommendations: introduce a process for responding to vulnerable children/young people which incorporates child sexual exploitation and: identifies and minimises the risk from a non-familial source; builds on factors that increase resilience; facilitates a multi-agency team around the child; and facilitates partnership with key people in the life of the young person.
Keywords: alcohol misuse, child sexual exploitation, grooming, harmful sexual behaviour, runaway adolescents
> Read the overview report

2017 – Anonymous – Martin

Death of a 14-year-old boy in February 2016 initially thought to be due to suicide but, before the review was completed, an inquest determined the cause to be misadventure.
Key issues: Martin was an adolescent with mental health needs. His parents separated following domestic abuse by the father. Although there were concerns about his emotional wellbeing at home and school in December 2015, a referral to children’s social care was not made.
Learning: the challenge for professionals working with families where members have a range of complex needs; need for coordination in provision of services across local authority boundaries; specific practice issues were found which highlight the dilemmas faced by front-line practitioners when exercising professional judgement in their safeguarding practice.
Recommendations: to strengthen the sharing of information to ensure a whole family approach when working with children in blended families; to re-launch the CAMHS pathways within the borough; for the London Safeguarding Children Board to work with organisations across London to mitigate the risk to children where there is a lack of clarity associated with localised commissioning arrangements; partner agencies should be asked that contracts with service providers include an expectation that they should fully participate in any serious case review process.
Keywords: child deaths, child mental health services, disguised compliance, emotional disorders, parents with a mental health problem, self harm
> Read the overview report

2017 – Bedford – Baby Sama

Death of a baby girl under 2 months old of white British/Pakistan origin, in October 2015 as a result of fatal injuries received after falling from her car seat. The Coroner’s Inquiry found her death was a tragic accident that could not have been predicted.
Key issues: mother was 20 and father 28 when Sama was born. Mother spent time in foster care and had had witnessed domestic abuse against her mother when she was a child. Mother was looked after for 4 months when she was 15 when concerns were raised that she was involved with a 23 year old male (Sama’s father) who was known to be violent. Father had convictions for domestic violence, assault, drug dealing and breeding dogs for fighting. Concerns identified about father being involved in the sexual exploitation of two looked after children. In July 2015 Salma was made subject to a Child Protection Plan under the category of neglect.
Learning: issues identified include: recognising and addressing the impact of child sexual exploitation (CSE) in assessments and plans to safeguard children; understanding the dynamics of domestic abuse including perpetrator behaviour; recognising the links between animal abuse and child abuse/domestic abuse.
Recommendations: makes recommendations relating to the safeguarding of babies from domestic abuse.
Keywords: child sexual exploitation, grooming, infant deaths, children in violent families, official inquiries, partner violence, drug misuse
> Read the overview report

2017 – Birmingham – Child D

Death of a 5-month-old child of Lithuanian parentage from a brain injury in March 2015. Father was found guilty of murder of Child D in February 2016 and also found guilty of injuries caused to siblings DD and LD.
Key issues: Child D was a twin who was born prematurely and spent 2 months in hospital after their birth. Child D's sibling had further health complications that required hospital appointments. The family were not known to children’s social services until the death of Child D. The family were under financial pressures and away from the main support system of their extended families. There was contact with health visitors, GPs and hospitals before the birth of the twins.
Learning: considering all children in a family, fathers must be included in assessments and plans for children, highlights the importance of interpreters.
Recommendations: improved arrangements would not have prevented the death of Child D but there are opportunities for services to make some changes to develop their services.
Keywords: physical abuse, family violence, non-accidental head injuries
> Read the overview report

2017 – Birmingham – Child S

Death of a 15-month-old child in January 2015 as a result of multiple non-accidental injuries.
Key issues: Child S had been brought to live in the UK by his mother from the Czech Republic who left him in the care of his adult half-sister and her partner. He was not known to any services. During the 3 months that he was in their care he sustained significant injuries that led to his death. A number of friends and relatives were aware of the injuries to Child S but did not report it.
Learning: the importance of using interpreters when working with families whose first language is not English, need for information in a number of languages, challenges of international migration for safeguarding children, work needed to address the lack of knowledge or trust of professionals and services within migrant communities.
Recommendations: makes a number of recommendations related to working with migrant families.
Keywords: abandoned children, child death, physical abuse, migrants
> Read the overview report

2017 – Birmingham – Isobel

Sexual abuse by Isobel’s mother’s partner from a young age; she was assaulted by him when she threatened to disclose the abuse.
Learning: professionals did not always recognise when they needed to ask questions, share information or follow up with colleagues about a child’s wellbeing and struggled to address Isobel’s thoughts “I just wanted someone to ask me”; lack of professional curiosity when faced with adults who misused drugs and alcohol; organisational systems were not in place to enable practitioners to see children and young people on their own.
Recommendations: Isobel did not want the report published in its entirety, so this review sets out emerging themes and highlights the learning points. There are no recommendations included.
Keywords: child sexual abuse, enuresis, listening, parents with a mental health problem
> Read the overview report

2017 – Birmingham – Shi-Anne Downer [birth name]: AKA Keegan Downer

Death of an 18 month-old-girl from a white British and black African background in September 2015. The post mortem revealed over 150 internal and external injuries that had been caused over a number of months. Shi-Anne’s guardian was subsequently convicted of murder.
Background: mother had a history of drug abuse, mental health issues, reluctance to engage with services and time in prison; father was in prison at the time of her birth; 5 older siblings had previously been taken into care. Shi-Anne was made the subject of a child protection plan before her birth and was placed in foster care after birth. In January 2015, Shi-Anne became the subject of a special guardianship order (SGO).
Key issues: the pre-birth decisions made about Shi-Anne’s care followed the same approach as decisions made for her older sibling, without considering whether this was also appropriate for Shi-Anne 5 years later; the assessments for the special guardianship order (SGO) were flawed and incomplete; professionals had little or no contact with Shi-Anne after the SGO; risk factors for the guardian’s reduced parental capacity, such as becoming pregnant and the breakdown of her relationship, were not recognised and acted upon.
Learning: all relevant checks should be carried out and the need for a period of monitoring should be considered before a special guardianship order is finalised.
Model: blended methodology.
Keywords: infant deaths, physical abuse, selection procedures, special guardianship orders
> Read the overview report

2017 – Blackpool – Child BW

Death of 3-month-old child in 2015 due to medical causes.
Background: Child BW lived with mother and two siblings. A child protection plan had been in place for all children 1 year before the death due to concerns of neglect.
Key issues: include: views on a good enough home environment can be subjective and complicated by working in a deprived area; mother’s disguised compliance may have added to the optimistic view of her intentions and capacity to change. Good practice identified: robust information sharing processes and good local professional relationships.
Recommendations: include: wider promotion and clarification for staff of neglect assessment tool; audit on how expected outcomes are recorded on Children’s Services’ documentation; audit of pre-birth child protection processes to ensure that when siblings are on a child protection plan the needs of an unborn baby in the family are considered separately; review progress of earlier recommendations of safe sleep assessment.
Keywords: infant death, neglect, disguised compliance, sleeping behaviour
> Read the overview report

2017 – Bournemouth and Poole – Child O

A potentially life threatening injury of Child O carried out by the resident parent.
Learning: joint working to assess risk and plan; recognising the risks to children of parental mental illness; listening to family concerns; overreliance on specialist consultant's diagnosis; reliance on partners to care for patients and ensure safety of dependent children.
Recommendations: were made for Bournemouth and Poole Safeguarding Children Board relating to multi-agency working, listening to families, Think Family messages being translated into practice and tracking risk assessments.
Model: the review followed the Partnership Learning Model.
Keywords: assessment, child abuse, identification, children at risk, parents with a mental problem
> Read the overview report

2017 – Bradford – Jack

A teenage boy, Jack, was sexually abused over several years from the age of 13, by multiple adult males. He was visiting adult chat rooms, being groomed and meeting individuals who posed a severe risk to him.
Key issues: there was significant multi-agency support for Jack but services were not effective in keeping him safe from abuse. Good practice identified by the school and GPs.
Learning: lack of understanding of technology-assisted abuse and its effects; restricting a young person’s access to technology will not keep them safe, we must educate children, young people, carers and parents in how to keep safe whilst online; child protection procedures were inconsistently applied; a lack of coordinated support for families and young people; absence of leadership and planning.
Recommendations: the need to investigate technology-assisted abuse and consider local responses to protect children and young people; to seek assurance from police and children’s social care that child protection processes are fit for purpose and that issues relating to practice identified by this case are being dealt with.
Model: Partnership Learning Review. 
Keywords: child sexual exploitation, Childline, online grooming, sex offenders
> Read the overview report

2017 – Brighton and Hove – 'A'

Death by suicide of a 17-year-old boy in January 2016. 'A's' mother had mental health problems and 'A' had been exposed to physical and emotional abuse and witnessed domestic violence from an early age.
Learning: identifies learning under three headings: choice and initiation of placement; issues arising during placement, such as identifying the need for additional therapeutic support; and transition towards greater independence including help with coping with change and his move from therapeutic care.
Recommendations: the need for training around the vulnerability of care leavers for Brighton and Hove Children's Social Care; all care and placement plans should include a contingency position; and the therapeutic unit should review organisational capacity to challenge care plans if they deem it necessary.
Keywords: child mental health, children in violent families, family violence, harmful sexual behaviour, parents with a mental health problem, suicide
> Read the overview report

2017 – Brighton and Hove – Siblings W and X

Reported deaths of 2 brothers in Syria in 2014; it is understood they went with a friend to join their elder brother fighting for the Al-Nusra Front. Child W died soon after his 18th birthday (but travelled when he was under 18) and Child X died aged 17.
Background: the children had several siblings and grew up in Brighton but spent considerable periods in their parents’ North African/Middle Eastern country of origin. It is understood that the family came to the UK because they opposed the regime in their country and at least 1 family member was killed for his political beliefs. The family left the UK for several years and experienced racism when they returned. The children disclosed physical and domestic abuse by their father and became subject to child protection plans; the mother separated from the father who spent long periods overseas. Child W and his sibling Q began behaving antisocially and became involved with Youth Offending Services. Siblings W and X left the UK in January 2014.
Learning: professionals do not have effective ways to intervene in families who have suffered long standing trauma: this can increase the risk of young people being vulnerable to exploitation; efforts to support children so they are less likely to become vulnerable to radicalisation do not seem to address all the core issues.
Recommendations: practitioners need to have a greater understanding of, and curiosity about, the role and potential impact of culture, identity, gender, religion and beliefs on children.
Model: SCIE (Social Care Institute for Excellence) Learning Together methodology.
Keywords: muslim people, racism, radicalisation, runaway adolescents
> Read the overview report

2017 – Bristol – ZBM

Death of a 4-day-old girl in December 2014.
Learning: the complexity and range of services that work with pregnant women with mental health problems makes it difficult to coordinate multi-organisational working; the positive strategy of long-term engagement with service users in mental health services can create difficulties when balancing the needs of a pregnant service user against the needs of the unborn child; the practice of service users being asked to relay complex information about their treatment or condition verbally to other agencies makes it more likely that this information will be incorrectly relayed or not shared at all, placing the unborn child and service user at increased risk of vulnerability.
Recommendations: This report does not make recommendations to the Bristol Safeguarding Children’s Board about what actions should be taken in response to the findings of this review.
Keywords: pregnancy, parents with a mental health problem, infanticide, family support services, antenatal care, children’s services
> Read the overview report

2017 – Buckinghamshire – Child sexual exploitation 1998-2016

Discusses all the cases of child sexual exploitation (CSE) in Buckinghamshire from 1998-2016. Since 1998 there have been more than 10 Thames Valley Police operations across the county involving up to 100 children and young people. In 2013 a serious case review was undertaken to examine the response to 1 young person (J), but the impact of CSE on the other young people has not been reviewed.
Key findings: looks at the chronology of events starting in 1998 and the operations and reviews since then. Outlines reviews carried out by Thames Valley Police, Children’s Social Care and Buckinghamshire Safeguarding Children Board and the Misunderstood audit of peer-on-peer sexual exploitation. Explores the voice of those affected including interviews with 16 young people and 2 parents.
Learning: identifies what needs to change in order to improve agencies’ response to children, young people and adults facing CSE.
Recommendations: makes 14 recommendations including Buckinghamshire Safeguarding Children Board and Children’s Social Care should facilitate discussions with organisations such as Young Carers, Youth Clubs and the Youth Service to ascertain how they can better engage with statutory agencies to safeguard young people at risk of CSE; Buckinghamshire Safeguarding Adults Board should bring agencies together to ensure there is an appropriate, effective and coordinated response available to victims of CSE as they become adults.
Model: draws on information from agencies about past performance and assesses this against their current performance. Points out where practice has improved and identifies gaps and learning that still need addressing.
Keywords: local safeguarding children board, case studies, child protection, child sexual abuse, child sexual exploitation, children’s services, local authorities, sex offenders, england
> Read the overview report

2017 – Central Bedfordshire – Nolan

Death of a 1-year-old boy, Nolan, in 2015 as a result of serious head injuries with the explanation inconsistent with the injuries sustained.
Background: Mother's childhood included exposure to domestic abuse and neglectful care and she was on the Special Educational Needs register at school. She lived with her mother and partner. Her first child was born when she was 16 and Nolan was born when she was 17. Both infants were born prematurely and had medical problems. Nolan’s father had mental health issues, a permanent movement disorder and lived in supported housing. Reluctance by mother to engage with services, including late booking for pregnancies and missed medical appointments for the children. 5 referrals were made to Children’s Social Care, the last 8 days before Nolan’s injuries.
Key issues: lack of curiosity about late booked pregnancy; no recognition of the impact of prematurity, unexpected home birth and illness on the parents’ ability to cope and implications of any rejection of help; challenges to parenting capacity should be communicated; the need to follow up referrals with checks and a visit.
Recommendations: make the reporting of bruising to non-mobile babies mandatory; ask member agencies to report on how they ensure the role of fathers and wider family members in the household are properly assessed; ask the police to review its internal handover processes; the LSCB should demonstrate the essential value of professional curiosity.
Methodology: follows a systems-based methodology which maximised staff involvement and kept the depth of the inquiry proportionate to the complexity of the case.
Keywords: infant deaths, non-accidental head injuries, non-attendance, parenting capacity
> Read the overview report

2017 – Croydon – Claire

Review of the responses of agencies between 1 January 2012 and 31 January 2014 to a young girl who was found to have contracted two sexually transmitted infections whilst in local authority foster care.
Background: Claire was known to multi-agency services from the age of 5 months and had previously been the subject of a child protection plan. At 6-years-old she was sexually abused by a member of the household and became a looked after child in the care of her paternal grandmother. This placement broke down and Claire was placed in foster care. Claire was removed from the placement after 15 months when she was diagnosed with chlamydia and gonorrhoea.
Key issues: lack of assessment, support and guidance for kinship foster carers; absence of scrutiny and challenge when assessing and approving new foster carers; lack of collaboration between social workers representing different teams within the looked after child service; the importance placed on performance indicators compromised the role of the Independent Reviewing Officer.
Recommendations: strengthen the contribution of family members in looked after child reviews and child protection conferences; review how agencies are kept informed of planned changes for a child and consider adapting processes to facilitate the involvement of partner agencies; put processes in place to embed challenge as an accepted responsibility in safeguarding children.
Model: uses the Social Care Institute for Excellence (SCIE) methodology.
Keywords: child sexual abuse, children in care, foster parents, placement breakdown, professional collaboration, sexually transmitted infections
> Read the overview report

2017 – Croydon and Lewisham – Children R, S and W

Life-threatening injuries of a 6-month-old girl, Child W, in April 2015. The injuries remain unexplained but were suspected to be non-accidental. Mother and her partner were arrested on suspicion of grievous bodily harm but not charged. Child W and her siblings, aged 1 and 4, were placed in foster care.
Background: all 3 siblings were subject to child protection plans for neglect. During this process they moved from one local authority area to another. The case transferred between local authorities but the family were reported as missing. Mother was vulnerable, her own mother had suffered serious mental illness and she had spent much of her childhood in the care of her grandmother. There were concerns about domestic abuse, lack of engagement with services, mother’s young age and her mental health problems associated with childhood trauma.
Learning: responses from children’s social care were incident-led. Opportunities were missed to assess the children’s needs over time to assist in measuring the impact of the help already offered. Local authorities needed to have clear ‘step up / step down’ procedures for families who reject Early Help services.
Recommendations: make sure multi-agency training ensures the voice of the child is central to any contact or assessment. Develop a range of resources for practitioners to use when assessing children’s needs, including very young, pre-verbal children.
Keywords: child neglect, non-accidental head injuries, family violence, parents with a mental health problem, non-attendance, early intervention
> Read the overview report

2017 – Derbyshire – Polly

Death of a 21-month-old girl, Polly, in May 2014 after attempts of resuscitation in hospital failed. Polly’s mother was convicted of murder and child cruelty, and her boyfriend of allowing the death of a child.
Key issues: Polly was subject to a child protection plan at birth due to pre-birth concerns about possible neglect. Polly was in foster care for a period in 2013 following a reported incident of domestic violence at home. Polly was returned to her mother’s care in October 2013 with a supervision order which included regular contact with her birth father. Between January and April 2014 Polly was involved in a number of medical incidents. Reports of domestic abuse referred to agencies and the family moved from supported living arrangements to rented accommodation in a neighbouring county.
Learning: the child protection plan did not assess the implications of the mothers mental health needs on her capacity to parent; lack of authoritative professional practice that saw Polly as the primary client; lack of understanding by some professionals about their role and responsibility when Polly was subject to a supervision order; little recognition of the role the boyfriend and father were playing in Polly’s life; and medical staff did not consider the possibility of child abuse or neglect when Polly presented with medical issues.
Keywords: family violence, child death, foster care, neglect incidence, mental health, medical practitioners
> Read the overview report
> Read the executive summary

2017 – Dudley – Child P and Child H

Death of a 2-year-4-month-old child (Child P) and a 7-month-old child (Child H) at home in unrelated incidents, with no specific cause of death identified.
Key issues: agencies had been involved with their families because of concerns about neglect and welfare of the children.
Learning: inadequate and adult focussed assessments, failure to incorporate males in assessments, lack of professional curiosity and an over-optimistic view of parental ability to effect change, effects of substance misuse overlooked and poor information sharing.
Recommendations: requiring the preparation and consideration of an up to date genogram for all inter-agency meetings concerning a child’s welfare. Carry out an audit of cases to form a judgement on the impact of the Neglect Strategy. Review arrangements for the timely completion of serious case reviews. Ensure more effective consideration of mental health issue within assessments of the needs of children.
Model: Significant Incident Learning Process.
Keywords: child deaths, disguised compliance, parenting capacity, parents with a mental health problem, sleeping behaviour, unknown men
> Read the overview report

2017 – Durham – Baby Bailey

Death of a 7-week-old boy in November 2015. Baby Bailey had been co-sleeping on the couch before being found in the Moses basket. The post-mortem gave the cause of death as “unascertained”.
Key issues: parents were known to police due to the supply and use of drugs and related offences; the family was known to multiple agencies due to concerns about the neglect of 2 older siblings. Parents were arrested and interviewed but there was insufficient evidence to substantiate criminal neglect. Mother declined support from the Education Welfare Officer and Parent Support Adviser. She didn’t present for antenatal care until she was over 26 weeks pregnant with Bailey and did not attend several medical appointments for herself and her children. Home conditions throughout the period under review fluctuated from “just good enough” to “unsafe”.
Learning: drug use and related offending were not recognised or responded to as a child safeguarding issue; there was no multi-agency strategy meeting following the parents’ arrest for alleged neglect; the implications of denied or concealed pregnancy were not understood; the day-to-day lived experiences of Bailey’s older siblings were not sought.
Recommendations: implement a protocol for concealed and denied pregnancy; provide guidance for instances when children are not brought to medical appointments; ensure there is a standardised approach to strategy meetings.
Model: uses the Child Practice Review process to identify how agencies worked together.
Keywords: antenatal care, child neglect, infant deaths, newborn babies, non-attendance, substance misuse
> Read the overview report

2017 – Enfield – Child YT

Death of 17-year-old boy after his arrest for illegal entry into the UK and subsequent placement in foster care the day before.
Recommendations: reviewing out of hours emergency child protection to record all aspects of vulnerability; ensure the voice of the child is heard.
Keywords: suicide, adolescent boys, unaccompanied asylum seeking children
> Read the overview report

2017 – Halton – Young Person

Life-threatening asthma attack experienced by a teenaged boy in December 2014; at the time he was visiting relatives who did not seek medical help for around 18 hours. After being treated in hospital he was taken into care due to concerns about his health and the cumulative effects of neglect.
Key issues: Young Person lived with his mother and her partner, and did not know his father. He suffered from long-term asthma and severe eczema which was being treated at a satellite dermatology clinic. He and his mother had Common Assessment Framework (CAF) support between 2009-2012.
Learning: from early age, professionals held information about Young Person which was not shared; professionals had limited understanding of the young person’s lived experiences; treatment for the young person’s eczema was provided by a medical team that primarily worked with adults, and had limited knowledge of how chronic conditions can affect a child’s life and age appropriate pathways for support.
Recommendations: identifies findings for the local safeguarding children board (LSCB), which can be used as a basis to make the local safeguarding system safer. These include: professionals need to be confident to raise questions about family or household members who could pose a risk of harm to a child.
Model: Social Care Institute for Excellence (SCIE) Learning Together model.
Keywords: child neglect, children with a chronic illness, disguised compliance, health services
> Read the overview report

2017 – Hertfordshire – Child G

Death of a boy aged less than 1 year from unknown causes. A post mortem examination identified seven fractures which predated the death.
Learning: reluctance to name neglect by professionals involved with the family; the crucial importance of the assessment process to ensure appropriate intervention; the need to review the types of cases that are discussed in supervision.
Recommendations: the need to challenge agencies to demonstrate they are working in line with its strategic approach to neglect; to ensure that those families and children managed under Children in Need are the correct ones and are properly reviewed; the need to deliver safe and effective services for children within its traveller communities and to use this learning to enhance services to other minority communities.
Model: uses a systems approach.
Keywords: child assessment orders, student social workers, substance misuse, travellers, unknown men, violence towards professionals
> Read the overview report

2017 – Hertfordshire – Family H

Alleged sexual abuse of three siblings by their older brother in July 2015.
Learning: agencies should develop a pathway for the management of children with complex social and emotional needs, linked to aggressive behavioural difficulties or risk to others to address the needs of a small number of children, who do not easily match any diagnostic criteria and may not therefore meet the thresholds for any specific service.
Recommendations: more effective input by paediatricians and CAMHS staff to Child in Need meetings; multi-agency aspects need to be considered to ensure all relevant professionals are identified and invited to contribute and Child in Need meetings.
Keywords: siblings, harmful sexual behaviour, attention deficit disorder
> Read the overview report

2017 – Hull – Baby J

Death of Baby J aged 4 weeks in summer 2014 owing to head injuries associated with being shaken. Baby J's father, FJ, was later convicted of manslaughter.
Key issues: Baby J's parents had both received support from mental health services prior to and after Baby J's birth. FJ had a history of domestic abuse with a previous partner and increasingly with Baby J's mother. Both parents were homeless and living in separate hostels throughout the pregnancy although Baby J's mother moved to her parents after the birth. An initial assessment was carried out in November 2012. Although recommended, a pre-birth risk assessment was not carried out.
Learning: no single agency had a full picture of the parent's history of mental health issues and drug and alcohol misuse; the risks posed by domestic abuse and coercive control by perpetrators were not understood; written agreements with families need to be monitored.
Recommendations: improving information sharing, communication and record keeping in relation to domestic abuse and mental health issues and involving fathers in risk assessments.
Keywords: family violence, homelessness, non-accidental head injury, parents with a mental health problem
> Read the overview report

2017 – Isle of Wight – Child G

Death of a 6-year-old girl, Child G, in summer 2016. It appears that her father killed her and her 2 dogs before killing himself.
Key issues: Child G had never had any direct contact with children’s social care. Some professionals described the father as having a learning disability although this was not formally diagnosed. He had regular periods of depression and had been referred for psychotherapy following 3 bereavements and the loss of his job. Child G and her mother were also referred for mental health support. The parents separated and mother had twice reported to the police that the father had gone missing because she was concerned about the risk of suicide. He was assessed by a psychological therapist as being at moderate risk of causing himself harm.
Learning: professionals working with the father needed to consider how his mental health problems might affect Child G and what her needs might be. Risk assessments need to be continually updated as circumstances change. Having a child should not in itself be seen as a factor which can reduce a parent’s risk level.
Recommendations: the safeguarding adults board and the safeguarding children board should develop a shared strategic approach to “Think Family”. The joint working protocol for safeguarding children and young people whose parents/carers have problems with mental health, substance misuse, learning disability and emotional or psychological distress should be reviewed and made more accessible to practitioners from the multi-agency partnership.
Keywords: child deaths, fathers, filicide, parents with a mental health problem, suicide
> Read the overview report

2017 – Kent – Child C

Death of a girl aged 2 years-and-four-months in June 2015 caused by accidental ingestion of her mother's methadone.
Learning: no documentary evidence about the views of the children or the ability of the mother to prioritise her children; potential neglect not identified; not every agency had a full picture of the children's needs and their reactive working was not conducive to identifying long term neglect; there was lack of clarity about the safeguarding risk assessment process.
Recommendations: update training on resistant and hostile parents; all agencies should use chronologies when carrying out risk assessments; KSCB to review and update the training programme for working with substance misusing parents.
Keywords: addicted parents, assessment of children, children of addicted parents, parenting capacity, substance misuse

2017 – Liverpool – Chris

Subdural haematoma suffered by Chris, a baby under 6-months-old, in September 2015. Further examination revealed recent and old injuries including rib and leg fractures. Chris’s injuries will have a life-long impact.
Background: Chris’s mother is a migrant to the UK. Her husband, MH, is also a migrant. MF is the birth father of Chris and sibling CS. Both MH and MF had access to the children. Family had contact with services including the GP, health visitors, midwifery and maternity services and the police. Police attended incidents involving the family on 5 separate occasions and notified children’s services each time. Referrals were also made by maternity services and the health visitor following Chris’s birth. Concerns included domestic abuse, the family being victims of anti-social behaviour and mother’s rough handling of CS during a medical appointment.
Key issues: safeguarding children in migrant families could be improved by addressing cultural competence in understanding family dynamics and more effective use of interpreters; services are too reliant on self-report information from migrants due to a lack of robust historical health, social care and criminal records.
Recommendations: the LSCB should ensure that professional interpreter services are always used by agencies - the use of family members or others is not acceptable; LSCB should contact the relevant government department to highlight poor availability of historic health and social care records for migrants to the UK.
Model: systems methodology developed by the Social Care Institute for Excellence.
Keywords: infants, non-accidental head injuries, physical abuse, family violence, immigrant families
> Read the overview report

2017 – Luton – Child J

Death of a 13-month-old boy in November 2015 from non-accidental head injuries inflicted on the day of his death.
Key issues: Child J lived with his parents for the first weeks of his life. Parents had a history of domestic abuse and separated in Spring 2015. They were known to children’s social care services. Mother became involved with a new partner and moved to a new area where children’s social services were informed about the family. Child J died of non-accidental head injuries and a post-mortem found several fractures. Mother and her partner were imprisoned for offences connected with his death.
Learning: transfer arrangements within health visiting and between Family Nurse Partnership and health visiting assume a degree of cooperation from families, which may leave children of avoidant parents at risk of harm when families move; professionals may underestimate the risk of physical harm to children in domestic abuse situations involving physical violence.
Recommendations: effective transfer arrangements between local authorities to avoid losing sight of vulnerable children when families move; and transfer of information between health visitors where families are transient.
Model: SCIE Learning Together systems model.
Keywords: physical abuse, family violence, head injuries
> Read the overview report

2017 – Manchester – Child H1

Alleged rape of a 14-year-old girl (Child H1) by her stepfather in July 2015. The stepfather was found not guilty of rape at his trial. Child H1 was the eldest of five children, born shortly after her mother arrived in the UK from Rwanda seeking asylum.
Learning: a danger that neglect is left unaddressed when the provision of practical support is prioritised; insufficient attention within a CPP of how a service which might benefit the individual needs of children may result in the wrong service provision; professionals feeling uncomfortable asking about a person’s background, culture and belief systems; over-concern about the risks rather than the benefits of information sharing.
Recommendations: to review how communication can be improved between primary and community care to strengthen safeguarding; review learning and development plans within multi-agency services to recognise, assess and respond to risk with particular reference to males in households, mobile isolated families, immigration status and black and minority ethnic communities.
Model: SCIE’s Learning Together methodology, a systems approach which seeks to understand professional practice in context.
Keywords: abusive men, child sexual abuse, child protection services, children in care, maternal depression, neglected children
> Read the overview report

2017 – Manchester – Child I1

Neglect of three siblings aged 0-1, 5 and 3 years, who were removed from mother and mother's partner in December 2015.
Learning: there was a fixed and overly optimistic view of the case by some of the professionals; at times the parents' needs received more professional attention than those of the children; professionals did not always feel confident in their responses to some of the issues, particularly around gender roles and transgender issues.
Recommendations: the voice and daily lived experience of the child should be the primary focus of all agency interventions; agencies should work closely together in cases of long term neglect, especially if there is concern about disguised compliance.
Model: systems methodology approach focusing on multi-agency professional practice.
Keywords: child neglect, disguised compliance, listening, optimistic behaviour
> Read the overview report

2017 – Manchester – Child K1

Death of a 3-year-old child from an asthma attack.
Learning: professionals need to take into account safeguarding concerns such as the impact of smoking and home environment; health professionals need to ensure they have a good understanding around the concept of good enough care for a child with a chronic illness; consider the father’s role in caring for a child; involving the housing provider in child protection meetings where there are rent arrears and neglect.
Recommendations: lead health professionals to be identified for all children with a chronic health problem with clear communication systems in place for information sharing.
Model: uses a systems approach based on the Manchester methodology.
Keywords: child neglect, childhood illness, low income families, smoking
> Read the overview report

2017 – Merton – Child B

Serious physical assault in September 2015 of a 16-year-old girl whilst she slept. B's mother pleaded guilty to grievous bodily harm and was sentenced to a Hospital Treatment Order under the Mental Health Act, 1983. Child B became a looked after child.
Background: long history of mother's poor mental health, reports of excessive alcohol consumption and tensions in the parental relationship resulting in disputes which sometimes escalated to possible domestic abuse. B was subject to a child protection plan for emotional abuse, later becoming a child in need and finally a vulnerable child, supported by universal services. She was also a young carer for her mother.
Learning: a holistic 'Think family' approach had not been embedded across multi-agency children's and adults' services; young carers were not always recognised as such and their needs were not always understood or attended to by the whole multi-agency system; recognition of trends or patterns of risk, or changes in risk and when to 'step up' or 'step down' a case were not robust with a lack of confidence in escalating concern.
Model: Multi-Agency Child Practice Review methodology
Recommendations: review how the principles of the holistic 'Think Child, Think Parents, Think Family' approach are operating and how they are embedded in commissioning and leadership of frontline practice and its management, with joint working and understanding of mental ill-health and parenting.
Keywords: mental health problems, alcohol abuse, domestic abuse, physical abuse, emotional abuse, risk assessment, interagency cooperation, holistic approach
> Read the overview report

2017 - Middlesborough - Jenny, Molly and Emily

Concerns about a 10-month-old girl having ingested methadone and her two siblings aged 4- and 10-years-old being exposed to drugs in January 2014.
includes:professionals must assess the impact on parenting of mental health or drug and alcohol misuse; It is important to work directly with children ensuring their voices are heard; professionals should consider the possibility that parents in a drug treatment programme may be tempted to use their medication on their children.
Recommendations include: social workers should consider the risk of drug using parents actively giving drugs to their children; training for social workers in order to gain confidence in working with parents who show disguised compliance and manipulative behaviour; extended family who are relied upon should be included in key child protection meetings. 
Model: Uses the Significant Incident Learning Process (SILP) model.
Keywords: disguised compliance, drug misuse, hostile behaviour, voice of the child, alcohol misuse
> Read the report overview

2017 – North East Lincolnshire – Child T

Death of a 4-year-1-month-old girl as a result of non-accidental head injuries and ingestion of a range of illegal drugs.
Background: Child T was subject to a Child in Need plan for 13 months following her birth. For at least 6 months before her death, she was exposed to and ingested heroin, methadone, ketamine and various benzodiazepines. Mother and partner were charged with neglect, child cruelty and drugs offences. First child was taken into care before the birth of Child T as a result of domestic abuse and drug misuse by both parents; father was in prison at the time of death.
Key issues: the need for robust assessment to understand family functioning and assessing parental capacity to change; where siblings are born to children subject to a Child Protection Plan, a proactive decision is needed about the unborn or newborn baby; all contacts from family members raising concerns about the welfare of a child should automatically be treated as a referral; the need for multi-agency professionals to develop tools and skills to combat disguised compliance, particularly where parental substance misuse or domestic abuse are key causes of concern.
Recommendations: all children identified as a Child in Need should have a multi-agency plan with a level of management oversight equal to children subject to a Child Protection Plan; multi-agency professional meetings should ensure attendees understand the status and range of kinship care arrangements and their implications for the child; practitioners should develop increased skills in analytical thinking to apply at points of assessment and decision making.
Keywords: drug misuse, family functioning, parenting capacity, partner violence
> Read the overview report

2017 – Nottingham – Child J

Death of a 7-year-old girl in July 2014. Her aunt, who she lived with under Special Guardianship Order (SGO), and paternal grandmother were both sentenced to imprisonment for child cruelty.
Key issues: Child J was born with mild learning disabilities and a kidney condition. Her mother was a single parent and had poor mental wellbeing; her father had several other children and had spent time in prison. Mother disclosed having thoughts of harming Child J and made allegations of abuse against the paternal grandmother, father and father’s new partner. Child J became a Child in Need. She was placed with a foster family at 4-years-old and received support from child and adolescent mental health services (CAMHS) after showing signs of having experienced significant early trauma. She was placed permanently with her aunt (her father’s sister) under an SGO, with support under a Family Assistance Order (FAO). During this time the aunt stated Child J was self-harming and deliberately misbehaving. Several concerns were raised about the aunt’s punitive parenting style, including a referral to the NSPCC helpline.
Learning: includes: there was a lack of understanding about the impact of early emotional abuse and neglect on young children and the likely manifestation of this in their behaviour; a full assessment which brought together all the available information on Child J in the context of possible physical abuse was needed; the importance placed on engagement with parents/carers can mistakenly leave children at risk.
Recommendations: professionals should not accept the term self-harm in children under 10 without a consideration of potential wellbeing or safeguarding concerns.
Model: uses a hybrid systems methodology
Keywords: child deaths, physical abuse, punishment, special guardianship orders
> Read the overview report link

2017 – Nottingham – Baby ON16

Non-accidental injuries of 16-week-old baby which resulted in admission to accident and emergency.
Learning: the need for practitioners to be aware of the significance of early life experiences, drug use and mental health problems in parents and their impact on the children; the need to understand normal child development which would have improved the quality of decision making; inter-agency cooperation; the need for effective supervision and managerial oversight. Examples of good practice were noted by the GP, the housing support worker and the health visiting service.
Recommendations: reviewing procedures for children cared for by extended family members and undertaking a learning exercise to improve responses to injuries and bruises in young babies.
Keywords: siblings, family Violence, physical abuse
> Read the overview report

2017 – Nottinghamshire – LN15

Death of an 8-year-old boy in October 2014 as a result of a normally treatable kidney infection.
Key issues: LN15 was known to paediatric services from the age of 14 months for developmental delay, chronic constipation and floppiness. Attendance at physiotherapy, neurology and occupational therapy appointments was sporadic; he was not registered with a GP for two years before his death; correspondence was not received due to frequent house moves; evidence of the mother making decisions about treatment and medication.
Learning: the need to record address, telephone number and GP details at every appointment; updating inter-agency cross authority procedures to provide more detail of medical neglect; changes to practices at the Trust including an end to the partial booking system for children and provision of a key worker to link between services.
Recommendations: to strengthen cooperation between hospital services and general practitioners; to have policies in place to change ‘Did not attend’ records to ‘Was not brought’ to emphasise the child’s vulnerability.
Keywords: absenteeism, child advocacy, children with physical disabilities, developmental disorders, disguised compliance, housing, multidisciplinary approach
> Read the overview report

2017 – Rochdale – Child K

Death of a baby girl, Child K, who drowned in a bath in the presence of her older brother and sister. The 3 young children were left alone in the bath while in the care of their mother. Child K was taken to hospital by ambulance where her death was confirmed.
Background: history of domestic violence between Child K's parents, her brother was subject to a child protection plan in Bury because of this. The family had professional involvement from specialist services in Bury. Following their move to Rochdale the family lived in separate households with extensive contact and shared care. Child K was born in Rochdale where family accessed universal services. An offer of family support services was declined as Child K's mother was suspicious of social workers.
Learning: the police decision to interview Child K's brother shortly after the incident reflected poor communication between the police and children's services and poor judgement on the part of officers involved; engagement with families who have additional need but who don't reach the threshold for extra help or reject it.
Recommendations: the LSCB to conduct a multi-agency practice and service review on how agencies meet the needs of families who are reluctant to engage with services.
Model: Rochdale Borough Safeguarding Children Board Systems Model.
Keywords: sudden infant death, drowning, infant death, partner violence, maternal depression
> Read the overview report

2017 – Rochdale – Child L

Death of Child L aged 14 in 2016. A coroner's verdict found the cause of death to be 'death by misadventure'.
Background: Child L was found hanging in her home in February 2016. Child L had attempted suicide in the previous 2 years by overdose and had a history of self-harming from the age of 7. She had witnessed persistent domestic abuse from an early age. Child L had contact with Child and Adolescent Mental Health Services (CAMHS) and Children's Social Care (CSC). A common assessment framework (CAF) and a Child in Need assessment were completed.
Learning: keeping the focus on the child at risk when dealing with resistant parents or assessing parental capacity; critical thinking skills are necessary when assessing families with complex dysfunction; remaining attuned to the presence of unknown men.
Recommendations: all children assessed as medium to high risk through self-harm or suicide are referred directly to CSC to coordinate multi-agency working.
Keywords: alcohol misuse, parenting capacity, self-harm, suicide
> Read the overview report

2017 – Somerset – Child L and Child J

Non-accidental injuries to 6-week-old Child J, sustained on at least two separate occasions. Child L, aged 5 months, half-sister to Child J, had a mouth injury and bruising 10 months earlier and had been subject to a Child Protection enquiry but after a Child and Family assessment the case was closed.
Learning: the need for practitioners to be aware of the significance of early life experiences, drug use and mental health problems in parents and their impact on the children; the need to understand normal child development which would have improved the quality of decision making; inter-agency cooperation; the need for effective supervision and managerial oversight. Examples of good practice were noted by the GP, the housing support worker and the health visiting service.
Recommendations: the strengthening of inter-agency procedures for the police, children’s social care, housing providers and the NHS Foundation Trust.
Keywords: disguised compliance, fractures, parenting capacity, teenage pregnancy
> Read the overview report

2017 – Somerset – Child Sam

Severe and irreversible brain damage caused to a 6-month-old boy as a result of non-accidental injury.
Learning: importance of professionals working with families to recognise the increasing risk factors within the family and the impact these might have on the parents' ability to care; importance of information sharing.
Recommendations: ensuring that agencies identify and respond to risks and vulnerabilities within families where domestic abuse is a concern; appropriate training given about the importance of measuring and recording growth measurements; and training for health care professionals to highlight the signs and symptoms of brain injuries in young babies.
Keywords: infants, physical abuse, non-accidental head injury
> Read the overview report

2017 – Somerset – Fenestra

The child sexual exploitation (CSE) of Child C and Child Q by Perpetrators A and B between 2010 and 2014. Police Operation Fenestra led to their convictions for sexual offences against 6 children (including Child C and Child Q) in 2016.
Learning: professionals' difficulties in recognising 'inappropriate relationships'; not recognising parents' concerns; safeguarding risks for children in relation to piercing and tattoo salons.
Recommendations: uses 'considerations' for the LSCB as opposed to recommendations: are the police sufficiently resourced to support complex CSE investigations and take the lead in multi-agency working; is the LSCB satisfied with mental health services to support CSE victims; how can safeguarding be improved locally; do practitioners understand the need for persistence and curiosity when developing trusting relationships with children.
Model: uses the Social Care Institute for Excellence (SCIE) Learning Together methodology.
Keywords: child sexual exploitation, children’s attitudes, parent-professional relationships, pregnancy, police
> Read the overview report

2017 – Staffordshire – Child B

Death of a 14-month-old girl in July 2014. Cause of death was not ascertained but there were concerns she had died while co-sleeping with her mother and maternal grandmother who were both believed to have been under the influence of alcohol.
Key issues: Child B and her siblings were on a child protection plan under the category of neglect. There were 5 critical incidents related to the mother’s alcohol misuse.
Key findings: there were a number of missed opportunities to safeguard Child B and her siblings; there was a tendency to parent-centred practice; professionals did not listen to the views of Child B’s siblings; birth fathers were not involved in assessment and planning.
Recommendations: involving fathers and other significant men connected to a child in child protection cases; listening to the voice of the child; inter-agency communication.
Model: Uses the Social Care Institute for Excellence (SCIE) Learning Together systems methodology.
Keywords: child neglect, alcohol misuse, optimistic behaviour, children’s views
> Read the overview report

2017 – Stockport – Pip

Death of a 15-year-old girl as a result of a collision with a train in December 2015. The coroner’s inquest concluded that her death was suicide.
Learning: the need to understand that anorexia places strain not only on the child, but also on the family and professionals working with them; recognition that anorexia has safeguarding issues for multi-agency advice, not just health professionals; the need for all assessments carried out to be coordinated into one record of evidence.
Recommendations: the development of eating disorder pathways; ensure that the views and feelings of young people and their families are considered; the use of national guidance to support medical practice.
Keywords: anorexia nervosa, adolescent girls, child deaths, depression in childhood, eating disorders, family therapy
> Read the overview report

2017 – Sunderland – Family X

In 2014 a large sibling group were removed from parental care because there were concerns they had been exposed to and were suffering from chronic neglect.
Learning: better outcomes would be achievable for children at risk from neglect if multi-agency activity was underpinned by a common assessment tool; to focus on parental capacity for change to avoid drift in achieving positive outcomes for children; where children are at risk of harm, a multi-agency approach is best delivered through a child protection plan that adopts SMART planning techniques; when working with chaotic families it is important for professionals to remain focused on the children and their voice.
Recommendations: to develop a clear neglect framework, assessment tools, processes and practice models; to work with the Children’s Strategic Partnership to develop and implement a model for assessing capacity to change; to oversee the introduction of quality assurance processes which ensure that children subject to child protection plans remain categorised to the most appropriate source of risk; and in order to maintain a focus on the voice of the child in practice around neglect, findings of recently completed audits on the Voice of the Child and Section 11 must be acted on.
Keywords: child sexual abuse, disguised compliance, listening, neglecting parents, optimistic behaviour, parenting capacity
> Read the overview report

2017 – Sunderland – Young Person Rachel

Circumstances leading to a 15-year-old girl being placed in a secure setting in summer 2015.
Learning: better understanding by professionals and practitioners of the interplay between adolescent choice and risk, especially in relation to sexual behaviour and sexual exploitation; importance of multi-agency assessments which focus on the child’s care and experiences; child sexual abuse in the family will often come to the attention of services as a result of a secondary presenting factor; the range and nature of adolescent risks are different to those facing younger children and the traditional response to such risks does not necessarily fit with young people’s lived experience.
Recommendations: strengthen skills and knowledge base of the children’s workforce so that professionals are better equipped to recognise and respond to sexual abuse within the wider family; ensure that services to young children with harmful sexual behaviour are proportionate and timely; improve the effectiveness of multi-agency practice with adolescents who are at risk due to substance misuse and other risk taking behaviours and/or abuse and exploitation.
Keywords: adolescents, child sexual exploitation, risk taking
> Read the overview report link

2017 – Surrey – Adult S and Child CC

Death of a 14-year-old girl and her mother, who were both killed by the girl’s father, who subsequently committed suicide.
Learning: provided in the form of analytical observations, which include: private health services have been reluctant to share information; police did not enquire about the presence of children when called to the domestic abuse incident; some missed opportunities were noted in dealing with the same incident.
Recommendations: police to analyse their response to domestic abuse incidents; community interventions using the concept of co-production to be trialled; the independent school to integrate domestic awareness in safeguarding domestic abuse; HM Government to develop statutory guidance to include private medical care and oblige them to take part in DHR process.
Model: this is a joint Domestic Homicide Review and Serious Case Review.
Keywords: family violence, filicide, homicide, police, suicide
> Read the overview report

2017 – Surrey – Child BB

Death of a 23-month-old child in May 2014 due to non-accidental injuries.
Key issues: Child BB was taken to hospital in a state of extreme physical collapse, with bruises and burn marks, and died the following day. Criminal charges were brought against the mother and her partner in March 2015, but the partner committed suicide before the trial. Mother was found not guilty.
Learning: better inter-agency work and closer communication between police, probation services and children’s services could have resulted in a better understanding of the behaviour of the mother’s partner; safety messages on dating websites focus on the users’ personal safety but not on potential risks after a relationship is established.
Recommendations: include: police, probation service and children’s services to review processes for liaison about incidents and call-outs in relation to domestic violence; national consideration be given to how mothers can be alerted to the need for caution when engaging in new relationships with previously unknown men, potentially with an emphasis on relationships made through internet dating sites and social media.
Keywords: child deaths, physical abuse, online safety, domestic abuse
> Read the overview report

2017 – Surrey – Child GG

Concerns about child sexual exploitation (CSE) of a 16-year-old girl.
Learning: lack of recognition among professionals of the risk of CSE as well as 'drift'; lack of coordination of services; the importance of relationship-based practice with children who have been involved in CSE; the need to avoid blaming or holding children responsible for the abuse and CSE; the importance of information sharing.
Recommendations: audit the extent to which children involved in or at risk of CSE are no longer blamed or held responsible and that records are respectful about the child and their family; raise awareness of CSE with taxi drivers, hotels, after school clubs, youth groups, park wardens and sports clubs.
Keywords: adolescents girls, behaviour, child sexual exploitation
> Read the overview report link

2017 – Swindon - Child S

Death of an 8-week-old girl in October 2015 whilst sleeping with her mother on the sofa. Child S was taken to hospital following a cardiac arrest and life support was withdrawn after three days.
Background: Child S was subject to an interim supervision order and a child protection plan at the time of her death. The family was known to Swindon Borough Council Children, Families and Health; Great Western Hospitals NHS Foundation Trust; CAFCASS.
Key issues: neglect, the impact of time spent in hospital on ability to care for children, communication gaps between organisations, health visit delays.
Learning: The impact of time spent in hospital on ability to care for children.
Recommendations: include: make training available to Children and Families staff regarding the effects of long term drug use on the brain and to consider the impacts on patient’s ability to care for their family after a discharge from intensive care.
Keywords: sleeping behaviour, child neglect, depression
> Read the overview report

2017 – Thurrock – Harry

Death of a 16-year-old Black British boy of West African parentage in a young offender institution (YOI). He had a history of epilepsy and a post-mortem examination confirmed death from natural causes.
Key issues: a formal diagnosis of epilepsy was made at age 7. The diagnosis was not recorded by either primary or secondary school and prescribed medication may not have always been ingested. His aggressive behaviour caused concern from age 13; he was excluded from school on several occasions and 2 separate assaults of railway ticket inspectors led to his detention in the YOI.
Learning: possible side effects of medication (aggression, impulsivity, violence) should have been explored; annual reviews by the GP practice of medication should follow practice policy; response times to medical emergencies in the YOI should be reviewed; internal information sharing within the YOI should be improved.
Recommendations: the YOI should strengthen procedures around medical risk factors of under-18-year-olds; the health provider at the YOI should undertake an audit of the ordering of medical tests to ensure procedural compliance; school nurses should alert teaching staff if a pupil has a diagnosis of epilepsy; NHS England should ensure that GP practices have policies in place with respect to regular medication reviews for children with epilepsy.
Keywords: aggressive behaviour, detention centres, exclusion from school, information sharing
> Read the overview report

2017 – Trafford – Child N

Circumstances around Child N becoming a looked after child at the age of 7. Following placement in foster care after the father’s physical assault of an older sibling, Child N and siblings disclosed physical, sexual, emotional and psychological abuse.
Learning: identifies learning lessons in relation to multi agency working maintaining the child as the focus.
Recommendations: focused outcomes and plans for children; the value of multi-agency working; undertaking a thematic audit on working with violence and aggression; and developing a strategy to hear the voice of a child for children subject to multi agency procedures.
Keywords: physical abuse, disguised compliance, listening
> Read the overview report

2017 – Trafford – Child PB

Alleged sexual abuse of an adolescent boy by foster carers in two separate placements between 2013 and 2015. A criminal investigation was initiated but neither foster carer was charged with criminal offences.
Key issues: Child PB became looked after aged 12 due to behavioural problems. His first long-term foster carer (FC1) requested that the placement be ended, citing ill health. PB was placed in a residential educational setting, living with a second foster carer (FC2) during weekends and holidays. His behaviour deteriorated and he was moved to a permanent residential placement. PB went missing several times, returning to FC2 although this was not always reported. On one occasion FC2 told police he hadn’t seen PB, but PB was found hiding undressed at FC2’s home. Despite FC2 being suspended as a foster carer, PB was persistently found at FC2’s home. Weeks later, following therapeutic support, PB disclosed sexual abuse by both foster carers.
Learning: although these disclosures have not led to prosecutions, the actions and behaviours of both foster carers should have led professionals to consider at a much earlier stage whether they could keep children in their care safe and whether they posed a risk to children placed with them.
Recommendations: ensure foster carer assessments and reviews are robust, thorough and appropriately challenging; ensure supervision files have carefully maintained chronologies to support supervision and review so that any emerging concerns or issues can be addressed; ensure all practitioners have a sound understanding of the range of characteristics, motivations and behaviours of people who seek to sexually abuse children.
Keywords: child sexual abuse, foster carers, placement breakdown, runaway adolescents
> Read the overview report

2017 – Waltham Forest – Child S

Death of 3-year-old Child S, cause unknown, in summer 2014, 6 months after moving to a London borough.
Background: Child S’s mother had a history of long term substance misuse. Child S, a sibling Child Y and the mother were known to Children’s Social Care, universal and specialist health and disability services, pre-school support services and drug support services in both local authorities. Child S had been the subject of a Child Protection Plan in 2013 but removed from the plan in the same year. Child S had serious health concerns from birth, eventually identified as cerebral palsy. Contact with all agencies featured many missed appointments. The family moved to a London borough soon before Child S’s death.
Learning: escalation of concerns; core and follow up assessments; continuity in social work practice; healthy scepticism about long term drug use; reporting and sharing information in drug services; experience of the child; transferring information between areas; hidden men; safeguarding children with disabilities; police sharing information.
Recommendations: pre-birth planning and assessment appropriate with drug using parents; Children in Need meetings properly recorded and CSC assessments up to date; compliance with 2009 guidance on safeguarding children with disabilities; review compliance on transferring cases; embedding healthy scepticism about long term drug using parents.
Keywords: cerebral palsy, addicted parents, non-attendance
> Read the overview report

2017 – Warrington – Child 1

Child 1 witnessed mother’s death in the family home in 2014 from multiple stab wounds caused by father. Child 1 sustained stab wounds including the partial amputation of finger during the incident.
Key issues: Child 1 was the eldest of 3 siblings, one of whom was also present in the home at the time of the incident. The children were not known to child protection agencies. They attended school and had no additional health needs. Father and mother were married for 16 years prior to the incident but were experiencing marriage difficulties and attending marriage counselling. Mother experienced domestic abuse and disclosed that she thought father bugged the house, her phone and computer and that she was frightened for her safety and that of her children. Both parents had been in contact with police with issues around domestic difficulties. The criminal investigation revealed that the family home was dominated by father’s controlling behaviour.
Learning: a point of separation represents increased risk of harm to a victim of domestic abuse as well as children within the relationship; stalking behaviour in the context of domestic abuse is an indicator of high risk and is significantly associate with dangerous acts; the sharing of information between professional agencies is critical.
Recommendations: development of early help initiatives to help children talk about domestic abuse; publicising and promoting the role for independent domestic violence advocates; the use of public information notices to maximise the impact of warnings in cases of stalking.
Keywords: partner violence, emotional abuse, family conflict, murder
> Read the overview report

2017 – Warwickshire – Child J

Non-accidental leg fracture of a 7-month-old baby who had been on a child protection plan since birth and had been living in a mother and baby foster placement with her mother until aged 5-and-a-half-months.
Key issues: Family were known to agencies for about 6 years due to concerns about the care of 2 older children where a number of probable non-accidental injuries occurred and family violence and substance misuse were present in the household. These children were subsequently taken into care and adopted. After the placement in foster care ended, the mother was housed in her home town some distance from the foster carer.
Learning: importance of assessing the accuracy of current or historical concerns reported by others; the need to respond flexibly to requests to house families in other local authority areas; to consider what formalised support is required following a move out of a baby and mother foster placement.
Recommendations: to make arrangements for appropriate medical and health advice to be available at strategy meetings; to consider how new professionals working with a family are made aware of the case history and reasons for decision making.
Keywords: adverse childhood experiences, family violence, housing, parenting capacity, unknown men
> Read the overview report

2017 – Warwickshire – Child T

Death of a 23-month-old infant due to non-accidental injuries whilst in foster care in June 2013.
Key issues: Child T was a looked after child who was placed with foster carers in March 2013 as a result of injuries sustained whilst in his mother's care. In June 2013 Child T died following admission to hospital with non-accidental injuries.
Learning: fostering social workers should consider the needs and wellbeing of the children in foster care from a safeguarding perspective, regular and consistent supervision of foster placements is crucial, unrealistic expectations and views of foster carers due to lack of knowledge of child development must be challenged and addressed through training.
Recommendations: social workers should be made aware of the need to formally register any concerns about the care offered by foster carers as complaints to be investigated.
Keywords: child death, physical abuse, foster care
> Read the overview report