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 help@nspcc.org.uk.
2022 – Anonymous – Adam
Death of a child in a road traffic collision in 2020. Adam was believed to have been at risk of criminal exploitation at the time of his death.
Learning includes: always follow safeguarding procedures to assess and manage the risk of harm to a child in parallel with any criminal investigation; practitioners should professionally challenge and escalate any decisions that they do not agree with; ensure the risks and the impact of non-engagement to the child have been assessed before closing a case and consider escalating the concerns if those risks are still prevalent.
Recommendations include: practitioners need to be able to distinguish between factual information and hearsay evidence that needs to be utilised to inform a risk assessment; consider adverse childhood experiences (ACEs) and trauma informed practice as a strategic priority together with the need to provide training on the impact of ACEs on children, including where there has been a history of criminality; adopt the Child Safeguarding Practice Review Panel's recommendation that all safeguarding partnerships have an understanding of the nature and scale of the problem of child criminal exploitation, and are able to identify children engaged with and at risk from criminal exploitation; strategic partners to agree and implement a contextual safeguarding response that will engage and empower members of the community.
Keywords: child deaths, child criminal exploitation
> Read the overview report
2022 – Anonymous – Anya, Rosa, Whitney and Lena
Intrafamilial sexual abuse and neglect of four girls in an extended family over a number of years.
Learning focuses on: identification of intrafamilial child sexual abuse; harmful sexual behaviours and siblings; intrafamilial sexual abuse by women; enabling children to talk about child sexual abuse and responding appropriately; understanding help seeking behaviour; the sexual abuse of disabled children; recognising the importance of safe adults and the non-abusive parent and family; understanding the motivations and behaviours of adults who pose a sexual risk to children; responding to adult disclosures of sexual abuse in childhood; responding to the needs of parents with learning disabilities; assessment of the connection between parental learning disability and neglectful parenting; the importance of understanding family history.
Recommendations include: consider the appropriate commissioning of services for children who have experienced child sexual abuse and for families who are supporting children in the aftermath of child sexual abuse; reinforce the importance of children's access to appropriate therapy while police investigations are continuing; develop guidance regarding complex and historic abuse investigations; remind police of the importance of considering a range of risk management measures including sexual risk orders; local and regional safeguarding procedures regarding child sexual abuse need to include the requirement to undertake criminal injuries compensation processes and raise with children and their parents the Victims Right to Review scheme.
Keywords: child sexual abuse, child neglect, incest, harmful sexual behaviour, parents with learning disabilities
> Read the overview report
2022 – Anonymous – Babies with injuries
Two cases of non-accidental head injuries and bruising of 14-week-old infants. A bruise was observed on Baby 1 two months prior to injuries. Baby 2 was in the care of their father at the time of the incident.
Learning includes: advice on safe sleeping and safe handling needs to be provided to both parents; professionals need to consider how they can meaningfully engage with fathers, including those who do not live with the child; awareness of the impact of having a new baby on fathers as well as mothers; if information about a new baby is not shared directly with a health visitor, it cannot be guaranteed with current systems that all important information will be known by them; even a small bruise on an infant needs to be recognised as a potential warning injury by professionals; family members should not have unsupervised contact with their child in hospital if a non-accidental injury may be the reason for attendance.
Recommendations include: use learning from the next national child safeguarding practice review to explore what can be done to improve the involvement of fathers in work with families with new babies; undertake work to provide a better understanding of the role of fathers and the need to engage with fathers, and consider projects in other parts of the country; seek assurance from partner agencies regarding knowledge and use of the injuries in non-mobile babies policy.
Keywords: infants, physical abuse, non-accidental had injuries, bruises
> Read the overview report
2022 – Anonymous – Charley
Murder of a young child by their mother's partner.
Learning includes: investing time both strategically and operationally in improving work with fathers will contribute significantly to the welfare of children, their families and communities; practitioners would be helped and supported in responding to the complexities of domestic abuse through the introduction of a practice model that systemically helps the whole partnership and external stakeholder to work to a holistic domestic abuse informed approach; a decision to cease multi-agency planning in totality without the necessary consideration of threshold step down risks children being exposed to escalating harm without adequate review mechanisms; no assessment that considers risk of domestic abuse should be accepted as complete without exhausting all options to include the alleged perpetrator of the abuse.
Recommendations include: strengthen the multi-agency approach to domestic abuse by exploring and adopting a specific practice model that provides a perpetrator based, child centred, and survivor strengths approach; ensure that robust step-down and transfer processes that promotes independence at a pace that supports embedding of change are in place; develop a plan to publicise and generate the use of Clare's Law by educating both professionals and the community; ensure that step down and maintenance support is built into the commissioning of domestic abuse services to support sustained change for both victims and perpetrators.
Keywords: child deaths, family violence
> Read the overview report
2022 - Anonymous - Child 9
Child sexual abuse in the context of child sexual exploitation and trafficking of a 14-year-old child over a significant period of time. The abuse was perpetrated by males ranging from older adolescents to adult men, who were known either to Child 9's mother or some of her relatives.
Learning includes: frequent local movement around education providers is an indicator of risk; the use of victim blaming language is careless and should be avoided to ensure the presenting behaviour is seen as a representation of the child's distress; there should be no delay in monitoring and information sharing when vulnerable children who live in a cross boundary area are subject to elective home education or are missing education; practitioners in urgent care centres should always be prepared to "think the unthinkable", and finding the time to secure communication with a child alone should be a central focus; the use of hypothesis in safeguarding assessment and planning is crucial; attendance and active participation in child protection meetings should be a priority for services to ensure effective information sharing.
Recommendations include: highlights the ongoing development needs of the multi-agency workforce when working with children who have escalating and complex safeguarding needs, working with troubled children, hypothesis in safeguarding work, reflective supervision and the use of victim blaming language in safeguarding work; ensure that responsive restorative services are available for children who are victims of rape and sexual assault; examine issues and demonstrate improvements around children missing education and children subject to elective home education.
Keywords: child sexual abuse, child sexual exploitation, child trafficking
> Read the overview report
2022 – Anonymous – Child A
Death of a 12-year-old child by suicide in 2020.
Learning includes: wider consideration of issues relating to children electively home educated (EHE), children from the Jehovah's Witness faith, child and adolescent mental health services (CAMHS) and triage arrangements and information sharing in tertiary hospitals.
Recommendations include: consider how to engage local faith communities to undertake a proportionate Section 11 process to provide assurance to the safeguarding children partnership on the effectiveness of those arrangements; the local authority EHE team continue to lead the work on improving the identification and assessment of children who are electively home educated and ensure the voice of the child is included; engage with the Department for Education in the development of local guidance for schools on children electively home educated; request the National Safeguarding Practice Review Panel considers the recommendations from the Independent Inquiry into Child Sexual Abuse (IICSA) report and its final report on the safeguarding arrangements within religious faiths to ensure they are addressed and implemented at a national level; alert the National Child Safeguarding Practice Review Panel, and contact all child death review leads, to raise awareness of the need for child death review processes requiring referrals to the coronial process to be explicit about any potential safeguarding concerns.
Keywords: suicide, home education, religion
> Read the overview report
2022 – Anonymous – Child G
Attempted suicide by a 7-year-old child at the family home. Sixteen months prior to this event, Child G had disclosed that they had been sexually abused on two occasions by their stepfather.
Learning includes: it is important to continue to communicate with children about their world; professionals need to be reflective in the context of what may be a change in the child's priorities rather than adhere exclusively to an adult assumption of what the child requires; consider a more judicious use of care planning forums when there is lack of clarity about what the options are in reducing risk within families; there should be more effective planning, assessment and recording at all stages of the achieve best evidence (ABE) process.
Recommendations include: for agencies to consider the importance of not making assumptions about the source of a child's distress in the absence of speaking to the child directly, and the clarity about a plan to work together concerning how the child's needs are met while awaiting specialist assessment; ensure that procedures for convening multi-agency meetings are followed, to allow for clearer planning and communication between agencies; ABE interviews should be carefully planned and appropriately documented, in line with expected good practice and guidance, and there should always be consideration as to whether a further strategy meeting is required following the ABE interview.
Keywords: suicide, child sexual abuse, disclosure, interviewing
> Read the overview report
2022 – Anonymous – Child N
Life-threatening injuries to a boy in August 2020. Child N fell from a second-floor window and sustained serious injuries
Learning includes: work with families should demonstrate an understanding of the impact race, culture and religion can have on parents' behaviour; agencies should obtain contact details of a parent not living in the household and should engage them in important decisions regarding their child, unless there is a reason not to do so; practitioners require the knowledge and skills to promote engagement with families who are resistant to co-operating with services offered; for children experiencing neglect there can be a range of factors which mean that incidents have some element of forewarning; the category of harm should reflect the risks to the child, which should be articulated in the child protection plan; statements for family court proceedings should articulate all the risks of harm to a child.
Recommendations include: consider how agencies can develop practitioners' knowledge and skills in working with resistant families; when a section 47 enquiry is initiated all circumstances should be reviewed to ascertain if the threshold is met for a joint agency investigation; undertake a review of safeguarding training to ensure that cultural awareness and sensitivity is promoted; the child protection service should undertake an audit of the categories of harm identified for children who are subject to child protection plans to ascertain if the categories reflect the identified risks.
Keywords: child neglect, injuries, autism
> Read the overview report
2022 – Anonymous - Children O, P and Q
Three siblings aged between 6-15-years-old who experienced a significant domestic abuse incident in August 2021. The abuse was perpetrated by their father against their mother and lasted over 11 hours in the family home.
Learning includes: agencies should be cognisant of the assessment, chronology, and history of families, before making judgements about risk based upon the decisions of others; children’s case closure should highlight ongoing support offered to the family and identify risk factors which would result in the case being escalated and re-assessed; agencies need to follow up and follow through when parents are tasked with self-referring for agency support or services; significant low attendance at school should at least prompt an early help assessment; supervision should consider gender bias and ensure that discussions focus on the risks presented by both parents; agencies working with children and young people would benefit from hearing from domestic abuse survivors and their experiences of statutory interventions.
Recommendations include: agencies should alert the multi-agency safeguarding hub (MASH) if it is known or becomes apparent that children have been the subject of care proceedings or child protection planning in another local authority; safeguarding partners should consider how learning from the Covid-19 pandemic is embedded into organisational forward plans; raise practitioner awareness of young carers and their routes for support, and the link between the young carer role and neglect; child protection plans, child in need plans and early help plans need to reflect the actions that safeguarding agencies take if parental relationships and contact is resumed without formal agreement.
Keywords: family violence, physical abuse, abusive fathers, substance misuse
> Read the overview report
2022 – Anonymous – Daisy
Life-threatening injuries to a 4-year-old girl who was struck by a road vehicle in June 2021. Police commenced an investigation into possible neglect following reports of mother being intoxicated at the time.
Learning includes: disproportionate/issues of professional optimism in the context of substance abuse addiction and domestic abuse; the voice of the child and the child's journey was not understood by all professionals; engagement and communication with the family was not always/could have been more robust and concerns raised by relatives were not given/could have been given adequate weight; the family's history, including an older sibling being subject to a Special Guardianship Order, should have been considered more when assessing parenting capacity; engagement and service delivery were impacted by COVID-19.
Recommendations include: ensure families are systematically used to inform decision-making, information sharing and managing risk, with extended families able to contribute to the plan for a child; ensure a full understanding of a family's history is collated and this is considered in all assessments; children placed on Special Guardianship Orders with family members must be comprehensively included in assessments and planning; police should ensure that incidents of domestic abuse are linked to the same family network so that the cumulative impact is understood and risks can be assessed; partner agencies working with adults must share information with relevant children's professionals where there are concerns which could impact on parenting capacity.
Keywords: accidents, injuries, child neglect, family violence, alcohol misuse, information sharing
> Read the overview report
2022 – Anonymous – Family M
Death of a 5-year-old child in November 2018 due to injuries sustained in a serious and reckless incident at the family home.
Learning includes: gathering and analysing family history, which includes history of contact with services, is a core task when working with children and families; it is important that appropriate empathy towards the parents does not cloud professional judgement or challenge; supervisors and managers should consider how busy frontline workers make trade-offs in order to resolve goal conflicts and cope with uncertainty and system pressures, and ensure this does not compromise children's welfare and safety; the language used to describe services, forms, tasks and activities carries weight and can create expectations; exploring and reconciling differing perspectives about the risks a child or family is experiencing is a necessary task when operating in a multidisciplinary context; when working with parents who are, or become, resistant it is important that expectations are transparent about the professional response to such resistance and that these are clearly stated from the outset; when new, and potentially serious information emerges about risk to children the response should be measured and match the level of seriousness; when undertaking assessment work, professionals should be alert to all risks that children may face, and not make assumptions about mothers naturally being protective.
Recommendations include: to ensure the learning is disseminated across the multi-agency safeguarding partnership.
Keywords: child deaths, children at risk, mothers, maternal behaviour, language
> Read the overview report
2022 – Anonymous – Joshua
Neglect and sexual abuse of an 8-year-old boy by two associates of his mother. The abuse took place prior to and during the time he was subject to a child protection plan.
Learning includes: the need to assess and understand parental ability to protect when making decisions around supervised contact; limitations of an evidence-based response to child sexual abuse (CSA); importance of requesting and sharing police intelligence at the earliest opportunity; the need for the development of a strong and robust response to CSA that is not a purely evidence-based approach and includes the provision of appropriate tools and training; recognising when the Graded Care Profile 2 (GCP2) tool should be used to help identify and address neglect; understanding the purpose and effectiveness of written agreements and assessing whether they should be used within current practice; the importance of perpetrator disruption.
Recommendations include: develop an overarching multi-agency strategy for responding to CSA; develop a CSA training programme for practitioners across the multi-agency partnership; review the way in which multi-agency meetings facilitate the discussions and recording of confidential information and how that information is shared with families to facilitate an increased understanding of the risks; explore and understand rationale for not sharing information with parents and carers, and ensure that the information not shared is kept to a minimum.
Keywords: child neglect, child sexual abuse, police, neglect identification, information sharing
> Read the overview report
2022 – Anonymous – Marie
Death of a 16-year-old girl in January 2020 by suicide.
Learning includes: the need for a clear model for managing high risk self-harming young people; ensure clarity between professionals about responsibilities to coordinate, and ensure timely information gathering and effective intervention; the importance of a family assessment to provide background context and allow opportunities to assess parenting capacity; ensure concerns and worries raised by a child are considered and investigated; ensure professionals exercise professional curiosity to ask more questions and understand what a child has experienced, and to learn what other agencies know; and ensure initial early interventions are appropriate for meeting the child’s needs.
Recommendations include: update the local documentation on self-harm and suicidal thoughts to develop an interagency “team around the child model and procedure” to assess and intervene with young people where moderate and high risks have been identified, ensuring that there is clarity about coordinated multi-agency care with clear plans and timely reviews; for young people where moderate and high risk of suicide has been identified, there should be a dedicated range of preventive and treatment resources available without long waits; and consider whether a new local response should be developed to prevent further deaths when a young person has died by suicide, considering new models for enhanced joint working and integrated provision emerging nationally.
Keywords: suicide, adolescent girls, child sexual abuse, professional curiosity, voice of the child, information sharing
> Read the overview report
2022 – Anonymous – Pippa
Death of a 15-year-old girl in September 2018 by suicide. Pippa was subject to a care order and lived in a care home at the time of her death.
Learning includes: the importance of considering how childhood experiences can impact the behaviour and vulnerabilities of troubled adolescents; child sexual abuse in the family will often come to the attention of agencies because of a secondary presenting factor, which then becomes the focus of intervention; practitioners need to proactively assess and engage with all significant men in a child's life; where child sexual exploitation is suspected, risk assessments need to consider risks which emerge from vulnerabilities arising from past abuse, loss and trauma; professionals need to maintain a questioning and curious response to what they are told or what they see; a lack of knowledge among professionals about the evidence base related to risk indicators for adolescent suicide could leave them ill-equipped to discuss or recognise signs and respond accordingly.
Recommendations include: support the development and implementation of a multi-agency framework for work with vulnerable at-risk adolescents; ensure that agencies have systems which can evidence robust managerial oversight of actions, decisions and plans relating to work with adolescents; ensure that practitioners have regular supervision from a senior manager, safeguarding lead or an appropriate external source; provide learning and development opportunities about adverse childhood experiences, trauma and familial child sexual abuse; audit the effectiveness of meetings to ensure that they lead to improved and timely outcomes for children and young people.
Keywords: suicide, adolescents, children in care, child sexual abuse, professional curiosity
> Read the overview report
2022 – Anonymous – Riley
Life-threatening injuries to a 17-year-old boy. Riley was hit by a car and assaulted by the driver.
Learning includes: recognise and reflect on cumulative risk, including parenting history and adverse childhood experiences; the need for active communication between agencies involved in assessing need; undertake joint assessments to ensure all needs are identified; see a child's behaviour as their way of communicating and be reflective about what the behaviour could be telling us; use language that recognises a child's behaviour as a means of communication; recognise the impacts of neglect and trauma, understanding how this can manifest in adolescence; not overloading a child with referrals/workers but considering what needs to be prioritised and who is the best person to deliver; understanding a child's needs, and being needs led rather than service led; practitioners work together to respond to multiple needs such as underlying learning needs and child protection concerns; creativity about where and how appointments take place to maximise engagement and attendance.
Recommendations include: a review of children who have disengaged with school/ learning to ensure that robust multi-agency plans are in place to meet their needs; explore the use of a communication passport which can be reviewed at key stages in a child's life, so all agencies understand the strategies needed to engage with a child with additional needs; consider the partnership's approach to adolescents receiving hospital treatment.
Keywords: injuries, adolescent boys, contextual safeguarding, family violence, crime
> Read the overview report
2022 – Anonymous – Ruby
Death of an infant girl in 2020 found to be an accident, linked to an unplanned unsafe sleeping environment. Ruby was on a child protection plan due to risk of neglect when she died.
Learning focuses on: awareness of a parent's history; considering and involving fathers; assessing wider family members who play a key role in supporting or safeguarding a child; sharing concerns about the impact on a child of changes of circumstances; the impact of alcohol and substance misuse on children and unborn babies; safer sleeping advice; using virtual technology for key meetings; strengths-based models of assessment and planning; avoiding over-optimism and losing focus on the child; knowledge of multi-agency safeguarding procedures and professional confidence in challenging when they are not followed.
Recommendations include: promote the involvement of fathers; ensure that the implementation of sleep assessments includes bespoke explicit and detailed safer sleep advice, including an explanation of why vulnerable babies are more at risk of sudden unexpected death in infancy (SUDI); ensure that key meetings such as child protection conferences being held by video conference or telephone have the optimum involvement of parents; ensure that professionals have the knowledge and confidence to challenge other agencies, including the use of escalation policies; consider how to ensure that accurate information about medication being prescribed to a pregnant woman is available to all health professionals working with the family.
Keywords: infant deaths, sleeping behaviour, substance misuse, fathers, optimistic behaviour
> Read the overview report
2022 – Anonymous - Young Person Joe
Fatal stabbing of a 15-year-old boy while intervening to protect another young person during a robbery in 2019. Concern about the family had escalated throughout 2018 particularly in relation to Joe and his sister being at risk from criminal and sexual exploitation.
Learning themes include: the family context; understanding and managing risk; partnership working; and management oversight.
Recommendations include: agree, implement and monitor the impact of a relationship-based, trauma-informed practice model across all agencies which includes an approach to working with fathers; review the current training and development opportunities regarding disabled children, to ensure professionals are clear about the threshold for access to services and the impact on parents of caring for a disabled child; review its approach to the provision of services which create diversionary activities and resources to mitigate the ‘pull’ of exploitation; engage the council in a review of and relaunch of the Young People at Risk Strategy to specifically incorporate a review of existing child protection systems in relation to extra familial harm and a transitions protocol for children moving from primary to secondary school; reinforce the early help and social work practitioners’ understanding of their ‘key worker’ role through training, development, and supervision; agree a model approach to supervision and training across all agencies that supports the development of professional curiosity in all practitioners to ensure a greater understanding of the lived experiences of children; and children’s social care should develop a protocol with housing providers which clarifies processes and thresholds for housing transfers on safeguarding grounds.
Keywords: child criminal exploitation, child deaths, contextual safeguarding, exclusion from school, housing, pupil referral units
> Read the overview report
2022 – Argyll and Bute – Child A
Explores the circumstance around the suicide of a 17-year-old boy in February 2021.
Learning includes: ensure that communication between CAMHS and partner agencies is robust and that the needs of the child/young person (YP) are fully understood by all partners involved in the child/YP’s care, for those YP at risk the CAMHS manager should consider agreeing a process for a child’s planning meeting prior to discharge from the service with partners to ensure information is being shared and plans are being regularly updated to reflect changes in circumstances; the initial work undertaken by both the Child and Adult Protection Committee’s in the development of the Young Person Support and Protection Procedures needs to be built upon and discussion between Children and Adult Heads of Service should take place to progress this joint work; review and refresh local practice guidance and ensure that practitioners are trained in the model in the Getting it right for every child (GIRFEC) practice guidance and are confident in its use; review current IRD thresholds and satisfy themselves that professionals understand the threshold and that situations are being appropriately assessed and managed when concerns are raised by any partner; and review existing Early and Effective Intervention (EEI) guidance with a view to amending practice guidance to include the gathering of information about all children within a family home where there are concerns about the impact of an individual’s behaviour on other children within the family home.
Recommendations are embedded in the learning.
Keywords: child deaths, child mental health, education, family functioning, suicide
> Read the overview report
2022 – Barnet - Leo
Large number of unexplained injuries to a 3-year-old boy in April 2021. Leo was assessed to be showing signs of neglect of his physical care. Children's social care and universal services had been provided across two local authority areas.
Learning themes include: assessment of injuries to young children and the need for child protection medicals; holding the child and their experience in mind; consideration of child protection processes while a child is subject of a supervision order and the role of the lead professional at step down to universal services; supporting parents who experience mental health problems; information sharing with busy GP Practices; case supervision and multi-agency management across two local authorities; maintaining significant relationships for care leavers being rehoused; the need for a wider perspective in domestic abuse work; work with care leavers as parents; and the impact of Covid-19 on service provision and identifying vulnerable families.
Recommendations include: seek assurances that the role and skills of the lead professional are understood and embedded within any team around the family arrangements, especially when a case is being closed to social care and the lead professional role is not held by a dedicated early help specialist; a standard child protection data sharing form is sent to GPs for completion and that this is a form based on the template developed by the National Named GP Group; to develop best multidisciplinary practice guidance where services are provided across more than one local authority, to ensure that the needs of children and their parents who are care leavers are met; and to review the skills of frontline practitioners in supporting the emotional attachment between carers and children.
Keywords: child neglect, injuries, parents with a mental health problem, termination of care, children’s services, information sharing
> Read the overview report
2022 – Bedford - Thematic review of serious youth violence
Thematic review commissioned following two cases of serious youth violence (SYV) which led to the death of one adolescent boy and the serious injury of another adolescent boy in 2018. For both the young people involved there were concerns about the misuse and selling of drugs and potential involvement in gangs. The cases are considered in relation to service responses, informing a wider case audit of young people identified as vulnerable or at risk of SYV.
Learning themes include: home life and family backgrounds characterised by extreme levels of violence and physical abuse; peer groups and gang involvement; school histories with exclusions and school moves; neighbourhoods as key contexts of harm; and harmful online contexts.
Recommendations include: the local safeguarding children board should ensure that early risk indicators arising from adverse childhood experiences (ACEs) are identified and responded to through early help assessments; schools and alternative education providers should carry out assessments where there are concerns about peer groups or harmful behaviours and develop intervention plans; the board should seek assurance that schools are preventing exclusions at the earliest opportunity and when young people are permanently excluded from school and being placed in alternative education provision they are provided with immediate wrap-around support for the transition; interventions with young people and families to address the impact of SYV and CCE should be evidence based, sensitive to ACES and the experience of trauma, and characterised by flexible, persistent and relational working.
Keywords: adolescent boys, adverse childhood experiences, child criminal exploitation, child deaths, child mental health, children in violent families
> Read the overview report
2022 – Berkshire West – Aiden
Severe burns and injuries to a 1-year-6-month-old boy in December 2019. Medical opinion was that the injuries were non-accidental, and were likely to have been inflicted or were due to a significant lack of supervision and neglect.
Learning includes: experiencing significant trauma, adversity or loss as a child may contribute to parenting capacity being compromised; where there are multiple risk factors, the importance of thoroughly assessing each one to understand which needs might be associated with which risks; practitioners should link and analyse facts about parental issues which may have an impact on a child’s safety, with records reflecting thinking processes; the importance of consistency and continuity of social workers, to build trust and to monitor any developments that may negatively impact a child; the importance of revising initial assessments about a child’s circumstances, as failing to review these may result in risk to the child; chronologies can be key for understanding needs and risks, and can support assessment and risk management.
Recommendations include: consider an audit of open cases where anonymous referrals are made, to ascertain the quality and effectiveness of the assessment and response; consider a multi-agency audit on how thresholds are applied by children’s services in cases where there are concerns about unborn children; raise the profile about the need for practitioners to be professionally curious about male associations with vulnerable women.
Keywords: burns, injuries, parents with a mental health problem
> Read the overview report
2022 - Berkshire West - Serious Youth Violence
Serious incidents in early 2021, including the fatal stabbing of a teenage boy and an adult. One adult and six young people were convicted of offences including murder and manslaughter.
Learning includes: difficulties identified in school attendance and behaviour, and the professional response; the involvement of boys in criminal behaviour in early adolescence and the response of services; patterns of social care and early help service involvement, team allocation, assessment, and thresholds; child and adolescent mental health (CAMHS) and other specialist health services; and incidents of violence against girls and women.
Recommendations include: services should jointly develop a ‘problem profile’ of serious youth violence and child exploitation; services should evaluate the profile of children at risk of exploitation to provide a better understanding of any disparities in service provision and outcomes associated with race, ethnicity, and disability; there should be improved information sharing with schools about pupils who may be at risk of exploitation; the time taken for cases involving young people to be investigated and resolved should be reduced; the role that the Pupil Referral Unit can play in combatting child exploitation should be reviewed; the number of professionals who are involved with children and young people should be reduced; there should be earlier referral and engagement with CAMHS for children who are at risk of school exclusion; and the role of speech and language services in relation to young people at risk of entering the youth justice system should be reviewed.
Keywords: adolescent boys, adverse childhood experiences, child criminal exploitation, children missing education, gangs, young offenders
> Read the overview report
2022 – Birmingham – Hakeem
Death of a 7-year-old boy from asthma in November 2017. Hakeem’s mother was convicted of gross negligence and manslaughter.
Learning includes: confusion by professionals around significant harm thresholds for neglect where a child has a chronic medical condition that is being poorly managed by a parent; a lack of communication between those responsible for non-school attendance and children’s social care which resulted in the two processes not taking account of the neglect that Hakeem was experiencing; little professional understanding of the daily lived experience of the child, resulting in a lack of assessment of what Hakeem’s reality was like and the level of neglect experienced; failure by agencies to consult and inform the birth father of the growing concerns for the child, resulted in professionals not adequately taking account of his ethnicity and background, alongside the potential for extended family support.
Recommendations include: where children have had hospital admissions for chronic conditions there is a robust discharge plan that includes identifying if any other agencies are involved; improvement work on engaging fathers includes those who may be on remand or serving prison sentences and makes appropriate reference to their ethnicity and family support networks; need for pharmacists to have specific safeguarding training that makes links between parental drug misuse, prescription medical equipment and childhood asthma.
Keywords: child deaths, child neglect, children with a chronic illness, drug misuse, father-child relationships, manslaughter
> Read the overview report
2022 - Blackburn Darwen Blackpool Lancashire - Child AB
Two siblings, aged 15 and 6-years-old, removed from their mother’s care in May 2020. There was an investigation concerning sexual offences against the children involving an unrelated male who had been sent images of Child B by his father. The father was at the time a convicted sexual offender having been found guilty of downloading indecent images of children in 2014.
Learning themes include: the child protection plan; the team around the family plan; effectiveness of universal health services; the voices of the children and their lived experience; disguised compliance; assessment and management of the father’s risks to the children; and elective home education (EHE).
Recommendations include: GP practices should be fully compliant with all relevant safeguarding procedures, including information sharing, knowledge of a child’s safeguarding status and when to refer to children’s social care; the EHE service should provide guidance, including an integrated decision and action pathway, that enables professionals to assess that children are receiving a suitable education, that also meets any safeguarding needs and which is subject to the prevailing statutory provisions; the Department for Education should produce practitioner guidance that seeks to integrate EHE and safeguarding policy and practice, including a decision-making flowchart; National Probation Services and the local constabulary should take steps to ensure that offender manager practice of sex offenders is informed by a more holistic approach to assessment and risk management planning; and the College of Policing should review the active risk management system tool and consider including wider family dynamics and additional corroborative evidence beyond offender self-reporting.
Keywords: child abuse images, disguised compliance, fathers, home education, probation service, sex offenders
> Read the overview report
2022 - Blackburn with Darwen, Blackpool and Lancashire – Child C, D and E
Deaths of Child D aged 24-days-old and Child C aged 21-months-old seven months apart in 2013 following breathing difficulties at home. Several years later Child E was admitted to hospital with breathing difficulties. In 2018 Child C and D’s father was arrested and found guilty of murder and attempted murder.
Learning themes include: perplexing presentations (PP)/fabricated or induced illness (FII) and physical abuse in children; medically unexplained deaths in children including sudden unexpected death of children (SUDC) arrangements, child death overview panel (CDOP) arrangements and criminal investigation; and coercive control and domestic abuse.
Recommendations include: review the implementation plan developed in support of the new local arrangements for perplexing presentations or fabricated or induced illness in children and consider the inclusion of the proposals for learning identified in this review; request paediatricians consider a review of using an assessment tool such as the Brief Resolved Unexplained Event (BRUE) model to support their clinical practice and to improve the risk assessment of children attending with brief resolved unexplained events; conduct a partnership wide audit with their acute hospital trusts to review the effectiveness of the arrangements for facilitating strategy discussions/meetings in the hospital setting; request that the integrated care systems across the partnership review their child death arrangements and provide assurance that the proposals for learning have been addressed; consider how the local in-school programme on coercive control and healthy relationships can be expanded and delivered to young people not in education.
Keywords: child deaths, fabricated or induced Illness (FII), sudden infant death, family violence, abusive fathers, risk assessment
> Read the overview report
2022 - Blackburn with Darwen, Blackpool and Lancashire - Child LS (Thomas)
Significant head injuries to a 2-week-old boy in Autumn 2018. The injuries were suspected to be non-accidental. Thomas was alone in a room with his brother when the injury occurred.
Learning themes include: early help; supporting adults with experience of adverse childhood experiences (ACES) and trauma; the impact of domestic abuse on children; abusive head trauma; safer sleep for infants; and identifying and supporting learning difficulties of parents and carers.
Recommendations include: the safeguarding children partnership should require all partners to evidence their organisational focus and response in relation to the Domestic Abuse Act 2021's requirement to recognise children who see, hear or experience the effects of domestic abuse as victims in their own right; the partnership should re-promote the local area's pre-birth protocol across all partners including the examples of pre-birth strengths and concerns to ensure all practitioners have a sound awareness of when and how to consider its use; the partnership should consider how professionals across the partnership are supporting parents and carers with learning disabilities and learning difficulties, what resources are available and whether further awareness raising and promotion regarding responding well to people with learning disabilities and difficulties is required; and the partnership should request assurance from members and subgroups that housing related challenges for families remain a focus across the partnership, including all professionals becoming more aware of the cumulative risks to children which housing issues can bring.
Keywords: family violence, early intervention, homeless families, non-accidental head injuries, adverse childhood experiences, adults with learning difficulties
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2022 – Blackburn with Darwen, Blackpool and Lancashire – Millie
Suicide of an 11-year-old-girl in March 2019.
Learning includes: be less risk adverse and more risk sensible around working together; demonstrate professional curiosity around the effect an absent parent or role model may have on the well-being of a child; think about the bigger picture and adopt a single, whole system approach to needs and risk of a child; be alert to the impact that an increase in the number of underlying risk indicators can have on a child and to be able to spot them, and then respond to them collectively, as early as possible, even in the absence of any obvious high risk factors; have clear management intervention and involvement at critical moments.
Recommendations include: staff should be professionally curious when a pupil has not attended a drop-in session and record the reason for the non-attendance; staff training around the importance of when to share information, what information to share and who they need to share the information with; schools that have a manual paper-based safeguarding system should be encouraged to move to an online system; all designated safeguarding leads in schools should be aware of the importance of the accurate recording, cataloguing, and storing of safeguarding material; safeguarding practitioners should escalate and de-escalate cases up and down the continuum of need scale to ensure that children are receiving the proper level of safeguarding support.
Keywords: suicide, schools, professional curiosity, children at risk
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2022 – Blackburn with Darwen, Blackpool, Lancashire – Sarah
Death of an 8-day-old baby in Summer 2017 following head trauma caused by shaking.
Learning includes: maternity services should ensure written records reflect the needs of the mother and baby; support plans should be clearly documented to ensure links with early help teams; when significant support is in place for a family it is good practice to hold a professionals' meeting before that support network is closed; maternity services must ensure that there is a full transfer of information in cases where a pregnant mother moves from one area to another; where appointments are missed there should be an effective follow up mechanism; health visitors should follow standard operating procedures when a patient is transferred from one area to another; when a pregnant patient fails to attend appointments, it is critical that these failures are correctly recorded and that a follow up is carried out according to procedures; the need for professionals to have a robust discharge plan for mothers to provide protection and support, including who is responsible; professionals in health and social care need to better understand structures and processes to improve information sharing and joint working.
Recommends that the local children's safeguarding assurance partnership should ensure that the learning points raised are subject to a SMART action plan.
Keywords: infant deaths, shaking, maternal health services, antenatal care
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2022 – Bradford – Harry
Hospitalisation of 12-year-old boy with a complex range of physical and learning needs admitted with severe weight loss and numerous severe pressure sores in May 2021.
Learning includes: a shared digital system is not always a guarantee of effective communication; exercise professional curiosity when there are a high number of absences from school; when domestic violence is known to occur, there should be an assessment of the impact this might have had on the children; there should be robust attempts to engage fathers when they are involved in the child's life.
Recommendations include: heads of service/senior managers of education, health and care services working with disabled children with complex needs should ensure that the recommendations in NICE NG213 relevant to their service are implemented; safeguarding training for all professionals who work directly with children with disabilities and complex needs takes into account the research and learning from safeguarding reviews on how and why disabled children are more vulnerable to abuse; promote the importance of 'thinking family' via a campaign aimed at all professionals involved in assessments and/or with designated safeguarding responsibilities in their setting; agencies should review their existing training programmes to ensure that it is clear to practitioners that all children should have a voice, including those who are pre- or non-verbal; review the CSPR arrangements to ensure all relevant services are included in scope even if they were not initially involved in the rapid review; undertake a systems review to ensure a robust approach to child in need arrangements.
Keywords: cerebral palsy, disguised compliance, medical care neglect, professional curiosity, voice of the child
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2022 – Brighton and Hove - Child Delta
Death of a 20-month-old girl in December 2019, caused by a combination of starvation and influenza, after being left alone for six days.
Learning themes include: decisions about assessment of risk and safety planning; the child’s lived experience; the impact of housing need within assessments; the impact of a young parent being not in education, employment or training (NEET); significance of family history and the impact of trauma and exploitation on an adolescent parent; adultification of an adolescent parent; and issues around facilitating a child focused service for children of parents who are looked after children or care leavers.
Recommendations include: review assessment guidance so that holistic multi-agency assessments take place prior to making significant changes to a child’s plan, except when emergency action is required, and include an explicit section to address risks and any necessary risk management plan; assessments of adolescent parents should always include a specific focus on the child’s vulnerable child, especially if they do not have their own social worker; assessments should include all family members who will be involved with child-care; ensure staff are aware of the allocations policy enabling senior managers within children’s social care to nominate a family for housing transfers when there is a need to keep a family together; consider practitioners training needs on the long-term impacts of trauma for children; clarify which social worker is the lead professional when there are different social workers in a family; consider what systems need to be in place to meet the needs of children NEET; and the local authority should address the range of potential accommodation needs for young parents to be able to provide a range of support provision.
Keywords: adolescent mothers, child deaths, child sexual exploitation, child neglect, children in care, housing
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2022 - Buckinghamshire - Child AA
Death of a child in 2019. At the time of death Child AA was known to several agencies.
Learning: concludes that the death could not have been predicted prior to or at the point of the mother’s mental health assessment during the critical period.
Recommendations include: work with the local safeguarding adults board to oversee the review of approaches to the assessment and interventions with whole families where the criteria for a referral to adult services is met; promote the learning from this review across relevant partner agencies, and hold a multi-agency workshop in order to increase working relationships and practitioner awareness; work with the local safeguarding adults board to maximise practitioners’ skills in the assessment of parental mental health and the impact on children including an audit of single and joint training with a view to strengthening arrangements across agencies; oversee the review of multi-agency policies, procedures and protocols relating to parenting capacity and mental illness; work with the local safeguarding adults board to review and update its information sharing code of practice, including the value of working closely with and seeking information from extended family members.
Keywords: child deaths, financial support, housing, homicide, parents with a mental health problem, psychiatric care
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2022 – Buckinghamshire – Family T
Significant non-accidental physical injuries sustained by female twin siblings aged 14-weeks-old.
Learning includes: a need for risks and vulnerabilities to be effectively identified; the importance of stronger decision making procedures for unborn babies when parents have known vulnerabilities; a need to understand the impact of pregnancy on a looked after child and provide the necessary support; a need for improved information sharing; better understanding around the different roles and responsibilities of various professionals; where relationship coercion concerns are present, clarity is needed around the nature of the concerns and any support or intervention required; a clear understanding of escalation policies to ensure concerns are acted upon; the importance of following the correct policy and procedure when non-mobile infants require a child protection medical for suspected non-accidental injuries; and a robust multi-agency plan to safeguard vulnerable infants should be established during meetings prior to them being discharged from hospital.
Recommendations include: timely communication with the parents if there are concerns for the infant; identification of parental support needs; clear communication between social workers for the parent and social workers for the infant; opportunity for parents to contribute to care plans for the infants; improved process and procedures for multi-agency assessments, particularly regarding the involvement of fathers and the use of historical information to inform analysis; and early identification of actions required to safeguard infants when a looked after child becomes pregnant.
Keywords: infants, injuries, siblings, twins, pregnancy, risk assessment
> Read the overview report
2022 – Calderdale - Baby Q
Referral of a 5-month-old baby to the multi-agency screening team after they were observed to be very pale and underweight.
Learning themes include: policies and procedures for monitoring of babies' growth and development; information sharing and effective working between professionals; relationships between parents and professionals; and identification and escalation of safeguarding concerns.
Recommendations include: multi-disciplinary professionals meetings should be used to discuss how the needs, wellbeing or safety of children are being met when experiencing difficulties, or plans are not meeting expected progress; there must be a clear handover between professionals who are making or receiving referrals and the management plan should be clearly documented in the child’s records; accurate recordings of a child’s clinical observations and growth parameters are essential; differences of opinion and varying perspectives about events and professionals' and families' views should be recorded as such, and not translated into 'fact'; an entry must be made in the child health record after a child is discussed at a GP safeguarding meeting to reflect the discussion and any agreed actions; make sure key professionals are involved in safeguarding discussions; growth/centile charts should be used to give a consistent overview of trends in weight, length and head circumference; when there are disparities in measurements there should be a joint approach to clarifying the issues; children with a faltering weight pattern should be kept under review to ensure progress against targets set; and individual health professionals should seek advice from their safeguarding leads when safeguarding concerns continue to escalate.
Keywords: birthweight, bodyweight, feeding behaviour, health visitors, midwives, parent-professional relationships
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2022 - Cambridgeshire and Peterborough - Child D
Spans the period from March 2018, when concerns relating to physical abuse by Child D’s father and indicators of sexual abuse were raised, until August 2020 when Child D’s brother admitted sexually abusing his sister.
Learning themes include: signs and indicators of child sexual abuse, especially the possibility of sibling perpetrated sexual abuse; cultural considerations; language barriers; the role of family members within a household; and no recourse to public funds.
Recommendations include: seek assurance from partner agencies that work relating to child sexual abuse that has been undertaken in the past 12 months has been embedded; make information available to practitioners within their agencies for them to gain a better understanding of cultural considerations such as attitudes towards relationships, family life, child development and abuse; all agencies should ensure that the needs of children and families who have a limited understanding of English are met via the use of face-to-face interpreters, translated written material and additional time allowances for meetings; consider whether resources available to parents and families relating to safeguarding such as leaflets should be made available in additional language formats; seek assurance that existing tools such as genograms are utilised for the purpose of considering a family’s composition and the roles that all family members play within a unit especially male family members; and make information available to practitioners within their agencies to improve their knowledge and skills in relation to the financial pressures and impact of having no recourse to public funds.
Keywords: child sexual abuse identification, children with learning difficulties, interpreters, language, sibling abuse, no recourse to public funds
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2022 - Cambridgeshire and Peterborough - Nadia
Suicide of a 16-year-old girl in 2021 at a low secure (inpatient) unit. Nadia had experienced sexual assault, difficult family relationships, and suffered from anxiety and depression. She had been living in inpatient psychiatric units for 12 months.
Learning includes: understanding the impact of parental conflict on children; providing the right support at the right time for children with mental health concerns; seeing a child as a whole with regards to multi-agency and multi-familial working; breaking the silence with regards to sexual violence; risks of inpatient stays; and lack of alternative placements to home.
Recommendations include: further work to raise awareness about the impact of parental conflict on children and consider whether zero suicide multi-agency approaches/strategies/guidance adequately take account of the recent findings from the National Child Mortality Database (NCMD); to learn from examples of good practice and consider what more may be needed to embed a culture of muti–agency working across the system; ensure a review of multi-agency work includes mapping and engaging immediate and extended family, engaging fathers and building provision in the community to avoid inpatient admission, wherever possible; review service developments in relation to identifying and responding to child sexual abuse, including extra familial sexual assault; and explore how multi-agency partners are working across the organisational hierarchies to find bespoke solutions for children in challenging circumstances.
Keywords: suicide, children with a mental health problem, psychiatric hospitals, family conflict, child sexual abuse, voice of the child
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2022 – Cardiff and Vale of Glamorgan – C&VSB 042019
Death of a 16-year-old young person from suicide, who had difficulty in managing emotional regulation from a young age. The young person was receiving professional support due to adverse childhood experiences and developmental trauma experienced within the family unit.
Learning is embedded in the recommendations.
Recommendations include: a child or young person who is being considered as a child looked after and where placements are being sourced, should have a shared multi-agency chronology, the chronology should detail the risks and triggers for the child or young person and should be shared with agencies who will have direct involvement, to ensure they can plan and respond effectively; review the multi-agency arrangements for information sharing and planning for an effective transition of a child or young person into an out of county therapeutic placement, to ensure it is fit for purpose; agencies to be accountable for the transfer of services and care arrangements; no service should discharge their involvement until the receiving area has engaged and there is a continuous service between local authority areas; ensure that a child, young person and their families are listened to and are able to fully engage in the care planning process; ensure the voice is captured at all stages of working with a family; and all agencies to receive training and fully understand the relevance of attachment theory, trauma, and adverse childhood experiences and for this to be evidenced as embedded into practice.
Keywords: suicide, self harm, voice of the child, family conflict, adverse childhood experiences
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2022 – Cheshire East – Children H and I
Serious sexual offences committed by the mother and a former partner, against Child I. These offences came to light in 2021 but took place in 2013. Concerns for the subject children and/or their siblings are recorded from 2000. There have been many changes in professional practice in all agencies over the course of time considered in the review.
Learning themes include: escalation of practitioners’ concerns; inter-generational abuse; management of sex offenders and risk assessments; the voice of the child in assessment and planning; timeliness of forensic testing where children are at risk of abuse.
Recommendations include: ensure planned review of the escalation policy is completed; increase awareness and confidence in using the escalation policy and monitor its effectiveness; ensure practitioners have access to training in respect of the impact of inter-generational abuse and tools to support risk assessments; ensure that, where convicted sex offenders are in contact with children appropriate and effective risk management mechanisms are in place; consider the arrangement for risk assessments and safety planning where the allegation is regarding an alleged offender rather than one with convictions; agencies should work together to ensure that potential risk from sex offenders in the family network are assessed in respect of other children with whom they have contact; ensure policies and procedures reenforce the importance of specific risk assessments, such as the ‘Persons who Pose a Risk of Harm’ tool, being completed pending the outcome of forensics.
Keywords: abusive fathers, abusive mothers, child abuse images, child sexual abuse, child sexual abuse identification, voice of the child
> Read the overview report
2022 - Cheshire East Cheshire West and Chester - Contextual Safeguarding Thematic Review
Incident in October 2020, involving five adolescent boys, in which three adults were stabbed and one ultimately died.
Learning themes include: the child criminal exploitation (CCE) ‘system’; mental health and young people known to the CCE system; prevention, early identification and early help; definition of risk and vulnerability; transition for young people in the CCE system to adult services; school exclusions; empowering communities; and workforce development in relation to CCE.
Recommendations include: create a multi-agency vision statement regarding contextual safeguarding that informs and directs future practice; enhance existing multi-agency universal and targeted training and support to professionals in relation to CCE; share the learning from this review with the local All-Age Contextual Safeguarding Task Group so that it informs and directs developments in relation to policy and practice (including managing demand on the system); be assured that the local early help offer focuses and responds to known vulnerability indicators associated with CCE and that there is a shared and widely understood definition of vulnerability to CCE; ensure there is sufficient focus on the physical and mental health needs of young people at risk of or involved in CCE and that pathways, such as the ADHD and CAMHS, are appropriately linked so that non-engagement is assessed in the context of potential increased vulnerability; work on communicating prevention messages to local communities and services to recognise indicators of CCE; and ensure young people transitioning to adult services are offered a transition plan and appropriate ongoing support.
Keywords: adolescent boys, adverse childhood experiences, child criminal exploitation, contextual safeguarding, county lines, exclusion from school
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2022 – City and Hackney – Child Q
Child Q, a girl of secondary school age, was strip searched by female police officers from the Metropolitan Police Service in 2020. The search, which involved the exposure of Child Q's intimate body parts, took place on school premises without an appropriate adult present and with the knowledge that Child Q was menstruating.
Learning includes: the decision to strip search Child Q was insufficiently attuned to her best interests or right to privacy; all practitioners need to be mindful of their duties to uphold the best interests of children; school staff had an insufficient focus on the safeguarding needs of Child Q when responding to concerns about suspected drug use; the application of the law and policy governing the strip searching of children can be variable and open to interpretation; the absence of any specific requirement to seek parental consent when strip searching children undermines the principles of parental responsibility and partnership working with parents to safeguard children; adultification bias is believed to have a significance to the experience of Child Q; racism (whether deliberate or not) was likely to have been an influencing factor in the decision to undertake a strip search.
Makes 14 recommendations to improve practice, including: the Department for Education should review and revise its guidance on Searching, screening and confiscation (2018) to include more explicit reference to safeguarding and to amend its use of inappropriate language; police guidance governing the policy on strip searching children should clearly define the need to focus on the safeguarding needs of children; where any suspicion of harm arises by way of concerns for potential or actual substance misuse, practitioners should contact children's social care to make a referral or seek further advice.
Keywords: children’s rights, racism, schools, police, supervision, adolescents
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2022 – Coventry - Stephen Wilson
Concerns a 16-year-old boy’s experiences as an inpatient in various mental health units since early adolescence. In November 2020, Stephen was admitted to an acute hospital, where significant concerns were identified with the care he received.
Learning themes include: early intervention in transition to secondary school, CAMHS and children’s services; meeting the needs of children with autism spectrum disorder (ASD); Education, Health and Care Plans (EHCPs) and the importance of school life; responding to complexity; availability and suitability of care in general hospital wards and inpatient units; governance and assurance after a significant safeguarding incident has occurred; collaboration across the multi-agency system; voice of the child; and advocacy.
Recommendations include: the partnership to seek assurance that primary schools routinely identify children who may struggle with transition, with a focus on children with ASD; the partnership to strengthen multi-agency working with children who have mental ill health; the partnership to maintain an active overview of the waiting times for ASD assessment; local education services to review the EHCP strategy to reflect the urgent need for an EHCP assessment to be expedited for children at the point of admission to an inpatient unit; for partner agencies to review their approach to children with severe complex needs arising from ASD and/or mental health needs in the community; to ensure that support provided to staff on general paediatric wards enables the best possible care to children suffering from a mental health crisis; to review referral pathways for notifying the partnership of serious incidents, including incidents involving children placed out of area; to include the importance of trusted adults in the multi-agency framework; and to ensure children in inpatient mental health units are offered an independent advocate.
Keywords: autism, child neglect, psychiatric hospitals, child mental health services, children with a mental health problem, provision of services
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2022 – Coventry – Child T
Physical and sexual abuse of a 2-year-old boy. Child T was presented to hospital by his mother on 21st July 2020. Extensive bruising was noted on examination, including to genital area. There was a lack of recognition of the potential sexual abuse in this case, and physical abuse was the initial focus.
Learning includes: the importance of recognition or consideration of the potential of sexual abuse; the importance of a robust, appropriately attended and informed strategy discussion to provide opportunities to gather information to protect a child; need for the Sexual Assault Referral Centre (SARC) to attend the strategy meeting in child sexual abuse cases; the importance of awareness, policy and guidance for practitioners regarding the accessing and coordination of medicals for child sexual abuse.
Recommendations include: consider what the barriers are to professionals considering the potential of sexual abuse in the family environment; agencies involved in referring children to the SARC for examination should ensure that full relevant records of previous examinations (including body maps) are made available to the SARC to fully inform the examination and that they are available for retention; where a child is examined at the SARC, on each occasion, consideration should be given to examine the child for any signs or indications of sexual abuse where clinically and evidentially appropriate and with appropriate consent, accompanied by easy to follow staff guidance; consider what information is available to practitioners to effectively seek and record the voice of the child, in particular in young pre-verbal children.
Keywords: abused boys, bruises, child sexual abuse, child sexual abuse identification, medical assessment, voice of the child
> Read the overview report
2022 – Coventry – Matt
Death of 2-and-a-half-month-old boy in June 2019. Cause of death has not been formally determined.
Learning includes: need for all agencies to ensure practitioners are aware of the lived experience of the child and understand the cumulative effects of continued neglect; where there is concern regarding safe sleeping, despite advice, there is a need for escalation and differentiated response; clear procedure required once disguised compliance is identified; suspected drug use by parents should be effectively considered in social work assessments, to allow this is be ruled in or ruled out; there should be a clearer pathway between children’s social care and early help; exploration required of how well children leaving care are prepared for parenthood; pre-birth assessment should be considered when there are concerns around neglect or other vulnerabilities; where a referral is made to the MASH and a strategy meeting takes place, the professional making the referral should attend, and any assessment by children’s services should seek the views of other involved professionals.
Recommendations for the local safeguarding partnership include: review of the neglect strategy, including implementation and embedding of the Graded Care Profile 2 (GCP2); review the approach to safe sleeping, with particular focus on parents that are suspected or are known to use substances and/or alcohol; review the support, training and advice for professionals dealing with families demonstrating disguised compliance or who are avoidant and/or resistant.
Keywords: adults in care as children, infant deaths, neglect identification, parenting capacity, preparation for parenthood, sleeping behaviour
> Read the overview report
2022 – Croydon - Jake
Suicide of a 17-year-old boy. Jake was subject to a care order, living in supported accommodation and awaiting an alcohol rehabilitation placement at the time.
Learning themes include: early help; the help seeking nature of challenging behaviour; drug awareness; responding to risk in adolescence, especially for high-risk children who are not engaging in services; identity and belonging and youth culture; engaging family members; and models of care for children with a complex and high-risk presentation.
Recommendations include: consider how multi-agency reflective forums will be built into multi-agency meetings or panels and other current established processes; develop and promote the directory of statutory and voluntary services so that services and referral pathways are visible and known to all agencies; promote substance misuse training; raise awareness of intersectionality and the use of an appropriate framework or tools to consider a child’s presenting needs; assess the number of services involved with a child, their engagement and impact; consider how current training and awareness raising forums can be used to facilitate an understanding of youth culture; review, with services, support offered to families; oversee the development of multi-agency plans for children where contextual risks exist and when risks do not fit into the usual categories of gang affiliation and sexual exploitation; and agree across agencies the main principles for in-patient admission, welfare secure or other response including clarification about who is the lead agency in the child’s care to ensure multi-agency ownership of care for children who are known to be at high risk.
Keywords: suicide, adolescent boys, substance misuse, exclusion from school, child mental health, youth justice
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2022 – Cumbria – Leiland-James Michael Corkill
Murder of a one-year-old male child in 2021. At the time of his death, the child was in the care of the local authority and was placed with prospective adopters. The female prospective adopter was found guilty of his murder and child cruelty.
Learning includes: medical assessments of potential adopters require a thorough consideration of their medical records and include information from specialists and providers of mental health support; the system would be more robust if these assessments were updated at the point of matching and before an adoption order is made; improvements are required regarding seeking, sharing, and considering any adult vulnerabilities that could be a risk to children; adoption systems and practice must ensure that there is improved consideration of the lived experience of other children in an adoptive household; when it is apparent that there are issues with prospective adopters bonding with a child placed with them, a robust and timely professional response is required that recognises the emotional impact on the child and the pressure on carers.
Recommendations include: the Child Safeguarding Practice Review Panel to ask the Department for Education to review adoption guidance considering the learning from this review.
Keywords: child deaths, murder, adoption
> Read the overview report
2022 – Cwm - Child M
Death of a 16-year-old boy in 2019. Child M was in and out of care throughout his life and experienced multiple placements. There were significant concerns each time M returned to the care of his mother, linked to neglect and emotional harm.
Learning themes include: the importance of placement permanency planning; the importance of escalation and professional challenge; and the importance of record keeping, decision making and accountability.
Recommendations include: the child’s wellbeing should be central to decision making in identifying permanency options; updated plans to support placement should be informed by the child’s multi-agency chronology, specialist reports, assessments, and research relevant to the child’s specific circumstances; the evolving view of the child should be obtained, recorded and considered as a critical element to permanency planning; clear handover arrangements should be in place when cases are transferred between teams or reallocated to a newly appointed worker; where a care and support protection plan is not keeping the child safe all involved professionals have a responsibility to challenge using existing processes; independent reviewing officer (IRO) resolution processes should be used and followed by IROs; proper consideration of S5 of the Wales Safeguarding Procedures (Concerns about practitioners and those in positions of trust) and S3(1) (Responding to a report of a child at risk of harm, abuse and/or neglect) must be followed; and agencies should provide the safeguarding board with assurances that record-keeping is robust and provides clarity of context, incorporates the voice of the child and includes records of decision-making.
Keywords: permanency planning, placement breakdown, emotional abuse, child deaths, decision-making, accountability
> Read the overview report
2022 – Cwm Taf – Child T
Death of a 5-year-old boy in July 2021. Child T's mother, mother's partner and the stepchild of mother's partner were subsequently convicted of Child T's murder.
Learning includes: the impact of COVID-19 restrictions on the ability of agencies to implement optimum child protection processes; the complexities of adult relationships overshadowed understanding of Child T's lived experience; a lack of understanding from professionals of their duty to inform any person who holds parental responsibility of child protection concerns; professionals did not fully explore the context of Child T's race and ethnicity on his lived experience; information sharing systems not supporting multi-agency information sharing and being a barrier to systemic decision making; and an inconsistent approach within children's services to quality assurance of assessments and planning across several areas of case management.
Recommendations include: the Wales Safeguarding Procedures Project Board includes guidance for child protection practitioners on their duty to include all persons with parental responsibility in child protection assessments and processes; a pan-Wales review of approaches to undertaking child protection conferences to identify effective chairing/facilitation methods and ways of ensuring full multi-agency attendance and participation; the Welsh Government considers commissioning an annual national awareness campaign to raise public awareness on how to report safeguarding concerns; the Welsh Government considers commissioning a full review of health, social care, education and police recording, information gathering and sharing systems; and the President of the Family Division considers the imposition of a12-week minimum for any social work assessment within public law proceedings.
Keywords: child deaths, injuries, murder
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2022 – Derby and Derbyshire - Baby RD
Death of an infant in 2020 while in a mother and baby unit of a psychiatric hospital. The mother admitted she had caused Baby RD’s injuries and was subsequently charged, convicted, and sentenced.
Learning themes include: the potential impact of a parent’s significant mental ill-health on their children and in particular the challenge of assessing risk when the illness is of a cyclical nature; the role of early help for vulnerable parents, making a referral and planning an intervention; the benefits of the ‘think family’ message; the response to emergency situations, for example suicidal behaviour or attempts to harm a child when the adult concerned is a parent.
Recommendations include: consider how best to promote and embed the ‘think family’ agenda and seek information from each agency about how they evaluate the effectiveness of the initiative; seek assurance that all agencies, including adult services, are fully engaged with the use of early help assessment; engage in discussion with commissioners of service about developing and strengthening the team working on the mother and baby unit in order to ensure a multi-disciplinary approach to risk assessment and that the voice of the child is not lost in the midst of a parent’s mental health crisis and medical treatment; seek assurance from the local Healthcare Trust that an effective protocol is in place which addresses the response to a medical emergency and that all staff are familiar with the content and its application within their working environment.
Keywords: bipolar disorder, infanticide, maternal depression, parents with a mental health problem, psychiatric hospitals, psychoses
> Read the overview report
2022 – Derby and Derbyshire – Child QDS 20
Death of 10-year-old girl in April 2020, found in bed with a ligature around her neck. Her father was in prison following a violent assault on the mother.
Learning themes include: the lived experience of domestic abuse for a child; vulnerable children remaining the focus of agency concern when they move areas; parental alcohol abuse; cultural and language considerations; signs and triggers of emotional distress in children; and online safety and the dangers of children viewing age-inappropriate content.
Recommendations include: all guidance should emphasise the importance of understanding the lived experience of the child; re-emphasise the message that domestic abuse is always harmful to children; proactively offer support to those families who are transitioning from refuge into independent living; review training needs to ensure professionals have a better understanding of the complexity of parental alcohol misuse and include training on interpretation and understanding of hair strand samples; continue to emphasise the dangers of children viewing age-inappropriate content; ensure processes are in place so that when children on a Child Protection Plan move areas, they are not removed from systems automatically and their information is reviewed; ensure schools display the appropriate level of professional curiosity and proactively seek information for new pupils transferred in; ensure that third sector organisations such as refuges share information so that partner agencies have clarity about their role in safeguarding existing and previous residents; ask the ‘Victim Care’ service to consider reviewing the current arrangements governing the sharing of information regarding the prison release of perpetrators within the family.
Keywords: child deaths, family violence, alcohol misuse, culture, online safety, prison and prisoners
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2022 – Derby and Derbyshire - LDS 19 / OD 20
Joint review considering the experience of two infants from two separate families. Death of a 6-month-old infant from oxygen deprivation as the result of unsafe sleeping with the mother, and serious injury suffered by an infant with significant medical needs. Neglect was a feature of both cases. The review also refers to the case of a third infant who suffered serious non-accidental injury.
Learning themes include: intrinsic risk to infants due to their immature anatomy, physiology and rapid development; the introduction of any infant into a household resulting in some level of stress; the need to quickly identify and assess any additional risks an infant will face, such as additional needs, challenges in the home environment, carer response to stress, and current/history of carer mental health problems or substance misuse; the importance of good multiagency communication and relationships built on understanding, valuing, and trusting each other's roles; and the importance of recognising and having ways of addressing hidden risk when carers are not accessible to assessment or there is a lack of openness by carers about potentially harmful behaviours.
Recommendations include: the development of a universal risk assessment tool to guide professional practice in safeguarding infants; recognising the importance of supervision in supporting implementation of all actions aimed at keeping infants safe; child safeguarding learning programmes across all agencies to address the need for practitioners to be knowledgeable about the roles of all professionals involved in child safeguarding; and a review of current practice for partnership working at all levels in cases involving infants, including clarity about multiagency plans, and due attention given to stress points within a family.
Keywords: infant deaths, children with disabilities, stress, non-attendance, parental involvement, interagency cooperation
> Read the overview report
2022 – Derbyshire – Child G
Death of a 2-month-old child in June 2019 following admission to hospital with severe breathing difficulties. Child G was found to have died from non-accidental injuries; their father was charged with manslaughter.
Learning includes: a need for 'hidden men' training to be reinforced on a regular basis, in order to keep this issue current to practitioners; interventions could be strengthened by a more professionally curious approach around parental history, relationships and dynamics; concerns and subsequent actions need to be clear in the GP record, and information placed on health IT systems; need for better cross border communication to help safeguarding between community midwives and hospitals.
Recommendations include: the safeguarding partnership ensures their 'pre-birth protocol' is operating effectively; all assessments and interactions with families to consider the role, presence and the history of fathers to the children and male partners living in or associating closely within a household; the local parent education programme on 'shaking the baby’ is delivered by community midwives to both parents if the programme is not delivered in hospital.
Keywords: infant deaths, neglect, non-accidental head injuries, parenting capacity, shaking, unknown men
> Read the overview report
2022 – Dudley – Child Y
Significant developmental delay in a 7-year-old boy due to neglect. Developmental delay issues were identified when Child Y started school in October 2020.
Learning includes: when a young child is missing from education, while it is a priority to ensure that the child starts or returns to school, the possibility of parental neglect should also be considered; systems need to support information sharing between health professionals to ensure that a child's needs are met if there are indications of developmental issues or if appointments are missed; when professionals have concerns that a child is not in education, there needs to be timely information sharing and consideration of the child's lived experience, which includes the child being seen; COVID-19 restrictions have allowed parents who are hard to engage with to avoid professional contact, which indicates that professional rigour and persistence are required to meet the needs of children during a pandemic.
Recommendations include: review procedures in relation to children missing from education to ensure that reference is made to younger children, and to links with neglect; seek assurance on the effectiveness of the local authority education service when a child missing education meets the criteria for a school attendance order; ensure partner agencies hold Working Together compliant strategy meetings to plan investigations and visits, and that there is consideration of a child protection medical in neglect cases.
Keywords: child neglect, school attendance, coronavirus, information sharing
> Read the overview report
2022 – Doncaster - Cameron
Death of an infant in 2020. Cameron was attacked in the family home by a dog owned by the father.
Learning themes include: parental neglect; analysing risk in relation to ‘Signs of Safety’ guidance; parental mental health; responding to indications of domestic abuse; assessing the risks which dogs may present to children; the GP practice response to an earlier dog bite; GP practice involvement in child protection planning; and the impact of Covid-19 restrictions.
Recommendations include: monitor progress against the strategic priority of neglect and associated workstreams; seek assurance the 'Signs of Safety' approach ensures that all risks to a child receive appropriate attention and that the cumulative impact of multiple risks is not obscured by a requirement to focus on a small number of risks; consider both maternal and paternal mental health and their potential impact on parenting capacity; learning from the case informs Doncaster’s domestic abuse training programme; share the concerns about the system for combining reports of the same domestic violence incident reported to different agencies by the victim and perpetrator; revise referral criteria in the partnership's 'Dangerous dogs practice guidance' to include injuries to children by a dog who are subject to child protection or child in need planning; introduce the mandatory use of the partnership's 'Assessing dogs who may pose a risk to children' alongside all pre-birth assessments where there is a dog in the family home; and seek assurance that all GP practices accurately code any involvement that children's social care has with every child.
Keywords: infant deaths, pets, partner violence, child neglect, general practitioners, risk assessment
> Read the overview report
2022 - Ealing - Young Person H and others
Review of three cases involving adolescent self-harm, including a young person who attempted suicide in 2021.
Learning includes: professional fears around challenging conversations with young people on self-harm being rooted in a fear of making situations worse; if foster carers are equipped and supported when taking on a young person who self-harms; issues around risk management plans and working collaboratively to find the best support for a young person; issues of working across boundaries, including young people being registered for services in a different borough and in relation to child and adolescent mental health service (CAMHS) provision; if therapeutic interventions are focused enough on the impact of adverse childhood experiences; lack of knowledge or experience in discussing gender identity with young people.
Recommendations include: review working practices to improve the confidence and ability of practitioners to have difficult conversations that focus on mental health; adolescents are able to have agency over their own risk management plans; training on gender identity and what this means for young people; support parents struggling with self-harming behaviour; support the training of foster carers in understanding self-harm and risk management; the young person and their parent/carer have continued access to a CAMHS clinician regardless of where they are living; agree a mechanism for managing risk across agencies; ensure gender identity is a key strand of equality action planning across all agencies.
Keywords: adolescents, self harm, child mental health, child sexual abuse, gender identity, children in care
> Read the overview report
2022 – East Sussex – Child AA
Stabbing of a 17-year-old in April 2021, resulting in life threatening injuries, and a need for long term medication.
Learning themes include: robustness of multi-agency activity to disrupt criminal exploitation and county lines; impact of missing education for vulnerable children and young people; transfer of safeguarding information between schools; transition between educational establishments for children who are excluded from school; and family engagement and environmental factors.
Recommendations include: the Multi-Agency Child Exploitation (MACE) Silver Group should review measures of effectiveness of disruption tactics currently used in plans and what legal orders, if any, would be most effective in supporting disruption plans; the police force should strengthen communication between themselves and MACE partners to ensure effective involvement of partner agencies; the local safeguarding children’s partnership (LSCP) and safeguarding adult board should develop a strategy to ensure there is adequate transition provision to support criminally exploited children as they move to adulthood; embed the referral process to MACE with schools and facilitate improved information sharing of safeguarding records between schools and colleges; develop a robust register of children who are permanently excluded which is monitored and reviewed to ensure support and a full-time education offer; the local authority should establish a clear pathway for how alternative provision is accessed and the role of the pupil referral unit for permanently excluded children; embed a protocol to follow for the transfer of records between schools; and the LSCP should encourage the use of therapeutic thinking across all secondary schools so that suspensions and permanent exclusions are used as a last resort.
Keywords: child criminal exploitation, children missing education, county lines, exclusion from school, pupil referral units, young offenders
> Read the overview report
2022 – East Sussex – Thematic review
Thematic review focusing on two families where adults had significant vulnerabilities, including a history of abuse and neglect in their own childhoods, previous relationships where domestic abuse featured, mental health issues and substance misuse.
Learning includes: systems must enable the impact of a parent’s vulnerabilities and associated risks to be understood by all professionals working with the family; professionals require support when trying to work with resistant and hard to engage families who do not acknowledge professional concerns and refuse to ‘own’ a child protection plan; when the concerns or allegations do not meet the threshold for criminal charges, formal multi-agency consideration should be given to why this is and to the potential need to safeguard the child and/or their siblings; professionals need to understand the ongoing and reoccurring nature of domestic abuse and parental mental health issues to fully appreciate the impact on children; there is cumulative risk of harm to a child when parental and environmental risk factors are present in combination or over periods of time; as children approach adulthood, those who are known to be vulnerable, particularly those that are on a child protection or child in need plan, require on-going and focused multi-agency support with a clear plan; and COVID-19 had an impact on the families and the professional response.
Recommendations are embedded in the learning.
Keywords: adverse childhood experiences, substance missuse, family violence, transition to adulthood, mental health
> Read the overview report
2022 – Essex - Child P
Death of a 13-year-old girl in September 2019 from suicide five days before her 14th birthday.
Learning is embedded in the recommendations.
Recommendations include: be able to articulate what the barriers might be to hearing the voice of the child at a system and practice level; make clear the expectation that all working with vulnerable children are alert to the depth and breadth of knowledge that they hold about the child’s history and current networks and ensure that this is incorporated into ongoing assessments and plans; where there is a significant change in a child’s circumstances a swift meeting should take place with relevant practitioners and family members in order to agree a multi-agency response and any adaptations to the Child in Need plan; work with partner agencies to clarify the expected steps to take when young people engage in sexually harmful behaviour; ensure that staff have the knowledge and skills to work confidently with young people and support families, where there are risks associated with their engagement in the digital world; ensure that strategy meetings/discussions are child focused and separately identify the vulnerabilities of the young person alongside risks to others; promote a balanced approach to discussions about whether a child should become looked after; clarify the process for the provision of financial support for family and friend carers and make sure that this is used creatively to prevent children becoming looked after; and review the training and development opportunities for staff who are expected to chair Child in Need meetings to ensure that all staff are adequately supported to undertake this task.
Keywords: bereavement, foster care, sexting, children with a mental health problem, adolescent girls
> Read the overview report
2022 - Gloucester – Laura and Ella
Joint domestic homicide review and serious case review. Murder of an 11-year-old girl by her stepfather in May 2018. Ella's mother was also murdered.
Learning includes: the important role of family and friends as source of support; the need to consider the voice of the child; consider the impact of a new step-parent and their background on a child's life; health professionals need to know and document who has parental responsibility for a child as well as the other adults in a child's life; the need for all services to ensure they have policy, training and record-keeping procedures to adequately address domestic abuse, and for services to benchmark themselves against best practice or national guidance; all frontline professionals need to confidently speak to survivors of domestic abuse about their situation despite any denial or minimisation, to understand where barriers come from, and to address domestic abuse beyond basic inquiry; the need for strategic boards for domestic abuse, safeguarding and health and wellbeing to work together to adequately resource and support multi-agency and best practice in relation to domestic abuse.
Recommendations include: all agencies should provide domestic abuse training, including economic abuse and the homicide timeline; local safety partnership agencies to ensure stronger links with the domestic abuse board; local safety and children's safeguarding partnerships to ensure that national mapping data on domestic abuse, child fatalities and child safeguarding is applied countywide.
Keywords: child death, murder, family violence, voice of the child, interagency cooperation
> Read the overview report
2022 - Halton - Child G
Non-accidental brain injuries to a 6-month-old boy in May 2021, thought to have been caused by shaking. A subsequent investigation made adverse findings in respect of his father.
Learning themes include: transfer in arrangements, and meeting the health and education needs of children; safeguarding and the importance of recognising the impact of domestic abuse on children including unborn babies; and consideration of cultural background.
Recommendations include: make sure that local health and education providers have effective arrangements in place to share information about children moving in and out of the area; seek assurance from all relevant agencies that when information is shared or received about an Acute Life-Threatening Event (ALTE), steps are taken to identify and safeguard any siblings; seek assurance from the local health trusts that health visitors and midwives exercise ‘respectful scepticism’ and curiosity when parents deny reported incidents of domestic abuse, especially if the mother has previously been subject to domestic abuse, and/or she is pregnant, and consider the potential impact on the unborn child and any siblings; support partner agencies to raise awareness about the dangers of shaking babies and how to reduce the risk, ensuring that fathers are also aware of the dangers and that this is also addressed in the roll out of the programme ‘Babies cry you can cope’; seek assurance from partner agencies that they have or will develop training and briefing materials for practitioners about working with BAME people, including how to find out about unfamiliar families’ cultural backgrounds.
Keywords: abusive fathers, crying, family violence, non-accidental head injuries, physically abused infants, shaking
> Read the overview report
2022 – Hampshire - Amelia
Multiple injuries to an infant girl in May 2019. Amelia's mother was later charged for child cruelty.
Learning includes: the local safeguarding children partnership to consider further promotion of its practitioner-based toolkits to support working with unidentified adults and adopting a family approach; children's services and the local NHS Trust to share the toolkits again with frontline staff, and ensure the toolkits are included in training; future audits of multi-agency practice to review agency record keeping, ensuring that records are clear regarding what information has been shared by service users, and what information has been passed to other agencies for further action; the need to develop information for partner agencies on the use of agreed escalation routes; seek assurance that the voice or perspective of the child is included in case files and safety plans.
Recommendations are embedded in the learning points.
Keywords: infants, physical abuse, information sharing, voice of the child
> Read the overview report
2022 – Hampshire – Child P
Death of a 5-week-old infant in 2019 due to severe, widespread and irreversible brain injury. Both parents were arrested and subject to criminal investigations. Mother was subsequently convicted of manslaughter.
Identifies learning for all agencies around the following themes: information sharing and assessment of risk; professional over optimism and professional curiosity; and substance misuse.
Recommendations include: request health partner agencies to review and develop guidance on the use of vulnerable families meetings to share information and assess risk; promote awareness and undertake training on the themes of professional over optimism and professional curiosity; request that health agencies review their missed appointments policies to ensure this is identified as a potential risk factor, alongside apparent compliance; consider developing best practice guidance and training for universal services on responding to potential risk issues of substance misuse by parents.
Keywords: infant deaths, risk assessment, optimistic behaviour, substance misuse
> Read the overview report
2022 – Hampshire – Emma
Death of a 16-year-old girl, Emma who was staying with a relative at the time of her death. The relative's partner was convicted of Emma's murder and sentenced to life imprisonment.
Learning includes: Emma's positive presentation may have resulted in professional over-optimism and disguised her ongoing vulnerability; when an adolescent is on a child in need plan the supporting professional network needs to consider the parent's ability to support the child; when children are linked to exploitation it should be established if the parent is able to understand the risk posed by contextual safeguarding issues; practitioners outside of children's social care do not always clearly record the voice of the child.
Recommendations include: encourage practitioners to operate a reflective mind-set with their case work, being aware of over-optimism and ensuring continuing practice of professional curiosity; practitioners understand expectations regarding recording standards, including how the child's voice is recorded; education settings should ensure that child protection records are transferred in a timely fashion at points of transition; practitioners questioning the language used to describe a child, their presentation and context in assessments and other recording; practitioners knowing how to respond when unreported domestic abuse is raised by a child service user; the local safeguarding partnership conducting a multi-agency audit of adolescents known to agencies due to risk of harm following neglect.
Keywords: adolescent girls, murder, contextual safeguarding, optimistic behaviour, professional curiosity, voice of the child
> Read the overview report
2022 – Hampshire – Liam
Professional concerns regarding an 11-year-old boy admitted to hospital in April 2020. Liam's presentation at hospital was due to an accidental injury, but his appearance and history of previous medical presentations raised concerns about his care and resulted in the instigation of care proceedings.
Learning includes: practitioners should take into account the impact of parental anxiety on a child's overall welfare; practitioners learn strategies for working with parents who are highly anxious; children cannot always easily articulate their day-to-day life experience, particularly when they have no ongoing relationship with an adult outside of the home; the need for practitioners to be professionally curious about information provided by parents and how that impacts upon the care provided; the challenges of working with families where there is partial engagement and disguised compliance.
Makes no recommendations but notes that learning has been incorporated into the local safeguarding partnership's workstreams, including multi-agency training, planned audits and professional guides.
Keywords: injuries, disguised compliance, parents, anxiety, professional curiosity
> Read the overview report
2022 – Hampshire - William
Serious neglect of a 12-year-old boy identified at admission to hospital in April 2020.
Learning includes: need to develop clear treatment pathways for specialist services; need for patient information for a family which details what the parental or carer expectations are to support the child's treatment; need for managerial oversight and supervision in complex cases, especially where there are concerns regarding parental engagement and compliance with advice and treatment; past information about a child and their parents or carers should inform the child's future health care; have honest and clear conversations with parents about their role in supporting health needs and what will happen if those needs are not met; be professionally curious about information provided by parents and how that impacts upon the care provided; professionals supplying referral information or agency reports for meetings need to be explicit when there are safeguarding concerns about a child; importance of seeking specialist support to ensure medical tests are completed in a timely manner; have robust conversations with other agencies to ensure they understand the significance of a child not having important medical tests completed.
This review makes no specific recommendations.
Keywords: child neglect, medical care, parent-professional relationship, supervision, professional curiosity
> Read the overview report
2022 - Haringey - Baby Mary
Death of a 10-week-old infant in February 2018 from significant non-accidental injuries whilst in the care of her parents. Mary was born prematurely and spent several weeks in a special care baby unit prior to discharge home.
Learning themes include: information seeking, sharing and usage to inform assessments, decision making and intervention; over-optimism in parenting capacity; professional challenge and escalation; cross border working arrangements; parents’ engagement with the professional network; transient lifestyle and housing difficulties; and practitioners and managers’ knowledge and confidence in understanding risk of harm, abuse and neglect.
Recommendations include: to seek assurance that professionals across the partnership have knowledge about how to respond to professional challenge, professional disagreements and the use of the escalation policy; to review arrangements for discharge planning from hospital when there are concerns about a child’s safety and welfare, and where there are multiple statutory agencies involved; to seek an update about the progress made regarding efforts to unify and promote consistency of practice for children and families moving across London boroughs; to promote a dialogue with relevant partner agencies about how to consistently interpret, apply and evidence threshold decisions when making referrals, with the use of scaling being one tool for achieving this; and to seek assurance that the local housing service is fulfilling its statutory obligations under the Housing Act 1996 regarding notifications to other housing authorities when placing families, or pregnant women, outside of their borough, and their responsibilities under the Children Act 2004 in relation to sharing information with other professionals.
Keywords: infant deaths, premature infants, injuries, housing, optimistic behaviour, parenting capacity
> Read the overview report
2022 - Hartlepool - Alex
Serious injury to a 3-month-old baby in April 2019; baby was taken to hospital twice in one day, firstly following a reported choking episode and secondly with seizures. The baby was later diagnosed with a subdural haematoma and a healing rib fracture, which were determined to be non-accidental.
Learning includes: information regarding parental history and any information on the children known by all agencies should be sought, shared and considered; there needs to be clarity across agencies when a case is closed to Social Care regarding what should happen if any concerns emerge or if the family do not continue to cooperate with any agreement made at closure; impact of parental risks and vulnerabilities should be considered in assessments and when working with a family; when none of the injuries in themselves are likely to meet the threshold for a child protection intervention, consideration of the wider picture may be helpful; if the case is not yet allocated to a midwife, information should be shared with the safeguarding nurse for the midwifery service if a pregnancy is known or suspected; at the point of closure information should be shared with those continuing to work with the family; GP information should be considered as part of a strategy discussion and additional information sought as part of the assessment; strategy discussions should include consideration of whether siblings require a Child Protection Medical; and professionals should be alert to whether assumptions are being made about a family and whether any professional disagreements need resolving formally.
Recommendations are embedded in the learning.
Keywords: premature infants, non-accidental head injuries, information sharing, parenting capacity, professional curiosity
> Read the overview report
2022 – Herefordshire – Louise
Serious, life changing injuries, sustained by 18-month-old girl in June 2019 while in the care of her mother's partner.
Learning includes: training on the cycle of change and motivational interviewing; escalation and professional disagreement; and recognition and prevention of abusive head injury in infants.
Recommendations include: ensure that there is a joint understanding and agreement in the application of thresholds of all levels of need and that referral pathways are clear and understood; ensure that both child in need and child protection plans and processes are robust, outcome focused and clearly understood and owned by all agencies; to develop a one multi-agency safeguarding access point, that there is robust and consistent management oversight; to ensure that information is effectively shared to make effective and safe decisions including in domestic abuse cases; ensure multi-agency responsibility to identify and respond to all aspects of neglect, including educational and emotional neglect and the effects of non-dependent alcohol use by parents and the impact of these on children; to ensure the impact of domestic abuse on children is understood and prioritised.
Keywords: child neglect, partner violence, non-accidental head injuries, information sharing, professional curiosity
> Read the overview report
2022 – Herefordshire - Thematic learning following allegations of peer-on-peer abuse
Disclosure of peer-on-peer abuse experienced by a young person. YP1 made two disclosures to a school nurse, who referred the case to the multi-agency safeguarding hub (MASH) and the police.
Learning includes: MASH decision-making should be collaborative and multi-agency, and there should be a clear process to record referrals, decisions and actions to ensure that information is not lost when more than one agency makes a referral; family history of relevance to safeguarding should be included in the social care records of all children to facilitate holistic consideration of issues which may impact on children; when there are concerns about peer-on-peer abuse, child and family assessments should be considered for both the alleged victim and the young person alleged to have caused harm; when there are concerns that a child has suffered significant harm as a result of peer-on-peer abuse, it is important that a coordinated multi-agency plan is agreed to focus on the needs and vulnerabilities of both the victim and young person alleged to have caused harm; when speaking with young people about their sexual health, it is important that professionals provide an opportunity for young people to be seen alone without a parent or carer.
Recommendations include: implement action plans to improve the multi-agency response to peer-on-peer abuse; ensure that the views and experiences of young people involved in peer-on-peer abuse and their parents and carers inform practice improvements.
Keywords: adolescents, harmful sexual behaviour, referral procedures, decision-making
> Read the overview report
2022 – Hertfordshire – Child N
Death of a 13-week-old child due to injuries consistent with trauma. There were 41 separate injuries including fractures to her ribs and spine. Child N's mother and her partner were convicted of offences relating to her death and are serving prison sentences.
Learning includes: the importance of accessing and analysing historical information about families; the potential risks from the mother's new partner were not understood; the need for practitioners to comprehend fully the significance of bruising to non-mobile infants; transfers of case responsibility between teams, individuals and services were problematic and would have benefitted from a more collaborative child centred approach; inconsistent understanding of the significance of faltering weight and growth measurements in babies; the over reliance on members of the extended family as a protective factor; and the failure to reassess when different information emerges.
Recommendations are made in the following areas: antenatal identification of need and risk; background family information; bruising policy; case transfer; poor weight gain, neglect and faltering growth; and assessment of extended family.
Keywords: infants, physical abuse, fractures, bruises, feeding behaviour
> Read the overview report
2022 - Hounslow - Child A
Long-standing chronic neglect suffered by a child whilst in the care of her mother. She was removed from her home under police protection and admitted to hospital due to the impact of severe physical and emotional neglect in August 2020.
Learning includes: the need for professionals to collate and consider information which raises concerns about the safety of a child being home educated; when a child has a history of non-school attendance professionals need to recognise this as a serious safeguarding issue; the necessity for professional challenge when there is indecisiveness and or inappropriate decisions being made during the course of child protection conferences; use of resources available to assess neglect is vital if professional practice is to be improved and children protected.
Recommendations include: the Department for Education (DfE) consider amending statutory guidance so that when a parent gives notice of their intention to electively home educate their child, information should be collated from safeguarding partner agencies prior to the child being removed from mainstream education; the DfE consider amending statutory guidance so that local authorities have authorisation to seek assurance that the parent has the intellectual capability and appropriate resources to provide suitable home education to the child, and decide whether it is in the child's best interest; the Safeguarding Review Panel consider including a section on children who are electively home educated in any future revision of Working Together to Safeguard Children.
Keywords: child neglect, home education, parents with a mental health problem
> Read the executive summary
2022 - Isle of Man - Child J
15-year-old Child J experienced a high number of adverse childhood experiences (ACEs) in their life. Child J’s long involvement with social workers revealed a childhood of domestic abuse.
Learning themes include: Child J’s ACEs; multi-agency working and information sharing; and contextual safeguarding.
Recommendations include: establish with partners a multi-agency strategy and procedural framework for contextualised safeguarding and exploitation, this should ensure it includes an information sharing protocol and consider adopting a vulnerable adolescent service strategy; seek assurance from partners that an early help strategy is being considered and developed to intervene early in the lives of children similar to Child J, this should include a professional framework to improve professional’s knowledge and understanding of the impact of ACEs, implement that understanding in response to children and young people, and for professionals to provide a trauma informed response; ensure that learning is provided that highlights to professionals the importance of identifying and acting on a ‘reachable moment’ for a child at risk of child criminal exploitation; seek assurance from the safeguarding strategic partners that they have systems and structures in place through them working as a multi-agency team with joint responsibility to be able to capitalise on this moment; and support the implementation of the proposed standard operating procedure for a ‘Child presenting to emergency department with a Mental Health Crisis Out of Hours’ as this would help to ensure there is in place actions to deal with similar situations in the future.
Keywords: adverse childhood experiences, child criminal exploitation, family violence, mental health, trauma informed practices
> Read the overview report
2022 – Islington - Child R
Sexual abuse, including rape of a child by their foster carer from March to July 2020.
Learning themes include: children looked after (CLA) who are placed ‘out of borough’; decision making following placement breakdown; exploration of local authority designated officer (LADO) concerns; use of ‘safer care’ agreements; issues of relationships, sexual health, and contraception; and the influence of the COVID-19 pandemic on hearing the voice of the child
Recommendations to the partnership include: review and update procedures in relation to sourcing fostering placements for CLA so that, regardless of their status they are subject to the same rigour as occurs for all other fostering placements; the senior leadership team should oversee a review of policy and application of safer care agreements; requests for CLA to take part in activities that involve risk should be agreed in line with the current care plan and only by heads of service; safer care agreements need to be updated in light of changing information; when children are out of borough all the professionals providing the local services should be linked into the team around the child; provide reminders and training to GPs to ensure that they understand their responsibilities in assessing risk when prescribing contraception to young people who are looked after.
Recommendations to the corporate parenting board include: review care planning decisions about contraception for CLA who are victims of sexual abuse are or at risk of CSE; oversee a multi-agency task and finish group to review how sexual health is incorporated into CLA care and pathway planning.
Keywords: child sexual abuse, children in care, disclosure, foster parents, placement breakdown, rape
> Read the overview report
2022 – Kensington and Chelsea and Westminster - Holland Park School
Allegations of staff bullying, poor safeguarding practice, discrimination, and intimidation of students, as well as health and safety issues at a secondary school in summer 2021.
Learning themes include: understanding and learning from complaints; school policies; recruitment and training; and school culture.
Recommendations to the school include: revise and update the complaints policy and implement a system to review complaints on a regular basis in order to identify areas of strength and areas for development; school policies should be reviewed (annually) and approved by the governing body and shared with school staff; devise systems for maintaining staff training records centrally in line with statutory guidance and managing staff exit interviews; ensure that the staff and governors have sufficient knowledge, safeguarding training and skills to undertake their roles effectively, in order to adopt a whole-school approach to safeguarding; review the use of safeguarding recording systems in line with statutory guidance, including where there are low-level concerns about an adult; review and update its line management systems to ensure that all staff, including senior leaders, are held effectively to account; ensure school governors receive refresher training on how to manage allegations about staff, including senior leaders; review the range and purpose of sanctions in line with DfE guidance including the use of the isolation room to ensure that this is consistent with good practice; the Local Authority Designated Officer (LADO) service should review how low-level concerns about children’s settings are recorded and tracked in order to help identify patterns and trends that may indicate further concern.
Keywords: complaints, secondary schools, school records, staff welfare, teachers, leadership
> Read the overview report
2022 – Kent – Children O and P
Death of two 23-month-old toddlers in December 2018.
Learning includes: a need for information sharing between the general practitioners (GP) and the health visitor; a need to draw on the wider healthcare team to obtain as full a picture as possible of a child’s life in order to recognise those in need; a need for insight into the impact of the breakdown in the parents’ marriage on the children; a need for information sharing with regards to updating the NHS spine when people move address; professionals need to recognise the relationship between adult mental health and safeguarding children; a need for further focus on the impact of a parent’s deteriorating mental health on their capacity to care for their children; and recognition that there is less likelihood of determining a patient’s true condition when contact with a service is over the telephone.
Recommendations include: review the effectiveness of the ‘health visitor/GP link meetings’ in relation to parental mental health issues; consider how to enable patient’s addresses on local records and the NHS spine to reflect their current whereabouts; review the effectiveness of telephone and email contact and its impact on mental health assessments and practitioners’ capacity to assess risk; and ensure all professionals are aware of the risks around parental mental health, including the potential for children being harmed, and that children should not be viewed solely as a protective factor.
Keywords: parents with a mental health problem, filicide, official inquiries, injuries, information sharing, health
> Read the overview report
2022 – Kent – Child S
Death of a 7-week-old infant boy in August 2020. The cause of death was ruled as sudden unexpected death in infancy (SUDI).
Learning focuses on: risk assessment and decision making; child neglect; substance misuse; and safe sleeping.
Recommendations include: undertake an audit of the processes of convening child protection conferences to review the attendance of key agencies and the quality of reports submitted by agencies; consider learning from the Child Safeguarding Practice Review Panel's report "The myth of invisible men" to ensure the overt engagement of men in risk assessments across the partnership; raise awareness and understanding of the Public Law Outline (PLO) process so that practitioners are clear of the processes and aware of opportunities to influence risk assessment and decision making; children's services review the arrangements for risk assessment and decision making in the PLO process and the interface between the legal advice received and the decisions taken to ensure this is a constructive process with sufficient challenge; review the neglect strategy to develop a clear shared understanding of "good enough" home conditions that provide practitioners with an agreed baseline; develop a substance misuse strategy, with a specific focus on cannabis use, to support a shared understanding of risks, appropriate interventions and decisions on the threshold for escalation; and to promote and raise awareness of the need to deliver safe sleeping advice, particularly when there is substance misuse by parents.
Keywords: sudden infant death, substance misuse, sleeping behaviour, child neglect
> Read the overview report
2022 – Kent – Harm to Under 2s in Kent
Explores the death or serious injury to 17 under 2-year-olds in Kent to identify key themes that help us understand when and why harm occurs, and what practice can safeguard young children from harm.
Learning is embedded in the recommendations.
Recommendations include: seek clarification on current Health Visiting operating standards around face-to-face visits; Early Help assessments and plans to be shared with involved multi-agency partners (with family consent); the positive practice audit to be published and shared as a standalone report, as a reminder that familiar, expected, basic practice works, and avoid a sense of needing to wait for learning from individual LCSPRs to be published before seeking to change or improve practice; the need for universal services to be more inquisitive and alert to less obvious risks has been clearly identified, particularly when considering the inherent physical vulnerabilities of children under 2-years-old; that practitioners, against human instinct, must be prepared to think the worst – even where there are not clear ‘red flags’; and professionals need to understand that significant harm occurs to children in families where risk is not obvious, where universal services may be the only ones engaged, and to consider whether there is one more question which might help identify an obscured risk.
Keywords: early intervention, home visiting, infant deaths, parenting capacity, safety measures
> Read the overview report
2022 – Kent – Lost in plain sight
Death of a pre-school aged child in 2019. The child sustained head injuries when in the care of the mother’s partner and died some days later in hospital.
Learning includes: adequate consideration must be given to the practical implications of significant changes to a child’s lived experience when planning for their ongoing care and support needs; when a child with a disability is presenting with injuries reported to be self-inflicted, there is a need for further consideration and enquiry; and a need to remain mindful that there may be factors impacting a caregiver’s ability or willingness to give an accurate explanation for a child’s injuries.
Recommendations include: each agency to be aware of the challenges some staff may face in keeping abreast of safeguarding policies; update forms used in Minor Injury Units to include consent to share information and referral to onward services; and seek assurance that safeguarding concerns within Accident and Emergency and Minor Injury Units are raised to professionals of appropriate seniority and expertise, and that parental explanation is explored and challenged where necessary to consider all likely causes.
Keywords: infant deaths, head injuries, professional curiosity, hospitals, children with disabilities, siblings
> Read the overview report
2022 – Kent - Oliver Steeper
Death of a 9-month-old boy. Oliver choked on food at nursery school, and following admittance to hospital died six days later. It was concluded that Oliver had choked due to being fed food which was not age appropriate.
Learning includes: early years settings should clearly and regularly discuss, and record, appropriate foods and progression of the introduction of solids for young children with parents; empower parents to ask questions about provisions in settings; and it should be clear and documented within settings who is responsible for ensuring food is suitable for children.
Recommendations include: encourage early years settings to have a food policy which considers the individual needs of each child, and resources for practitioners documenting the individual needs of a child regarding appropriate foods; resources for parents to build confidence in pro-actively seeking reassurance from early years settings on feeding in non-familial settings; engage with early years qualification providers to include safer eating materials into foundation training for early years staff; include safer eating in the broader sense (as opposed to solely regarding allergies or healthy eating) into the early years foundation stage (EYFS) requirements; review the position of pre-2016 qualified nursery staff being included in staff ratios without current paediatric first aid; and include a 'thinking about nursery' section in the personal child health record ('red book'). N.B. This report includes a photo of the child.
Keywords: infant deaths, nurseries, feeding behaviour
> Read the overview report
2022 - Kirklees - Child A
Death of a 9-week-old girl in January 2018. Following the conclusion of the inquest it was confirmed that Child A died from unknown causes following unsafe sleeping environments at her home.
Learning includes: children's social care assessments should ensure historical concerns including home conditions and suitable sleeping arrangements for children are explored during re-assessment; risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services as this may indicate an ongoing, abusive relationship; retractions of statements regarding domestic abuse may be indicative of ongoing contact between the victim, the perpetrator and their children; social workers should speak directly to children being 'programmed' by their parents, without the presence of their parents, to explore their wishes and feelings; perpetrators of domestic abuse should be directly spoken to about the impact of their abusive behaviour on children and included in the assessment process or safety plan for children; consideration should be given to de-escalating to a team around the family plan if low level concerns still need to be addressed when child in need plan is closed; written agreements are not effective tools for managing risk and their use should be avoided; managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information.
Recommendations are embedded in the learning.
Keywords: family violence, infant deaths, parenting capacity, professional curiosity, sleeping behaviour
> Read the overview report
2022 – Kirklees - Child I
Significant injuries sustained by a 5-month-old girl while in the care of her grandmother in January 2019. A pre-birth assessment was undertaken due to the mother being pregnant at 15- years-old and her being assessed as vulnerable to exploitation.
Learning includes: the need for pre-birth assessments to be undertaken in a timely manner and professionals to take early action to minimise the impact of any known risks to the unborn baby; a need for professionals to establish and share a parent’s full history, to avoid missed opportunities to reassess a family situation; the importance of and need to support social workers to determine how long to spend on individual cases; and to ensure the quality of pre-birth assessments is sufficient to meet the needs of the parent(s) and unborn child.
Recommendations include: the Local Safeguarding Children Partnership should review compliance with procedures for pre-birth assessments, with the aim of ensuring pre-birth assessments are undertaken to a good standard within timescales; responses to young people should be fully informed and evidenced by an understanding of adverse childhood experiences; assessments must be outcome focused, the plan reviewed regularly, and evidence collected to determine that progress is being made; and multi-agency plans for young people at risk of, and vulnerable to exploitation should be coproduced with young people to fully capture their voice.
Keywords: head injuries, infants, teenage pregnancy, family conflict, adverse childhood experiences, parent-child relationships
> Read the overview report
2022 - Kirklees - Child K
Death of a 4-month-old child in October 2019. Child K was found dead in the family home, after having been asleep on the sofa.
Learning includes: need for greater focus on children's lived experiences and the emotional impact of substance misuse; need to develop practice of 'respectful uncertainty' as a means to combatting disguised compliance, particularly where substance misuse is a concern; risk to children was increased by parental drug misuse going undetected; need for consideration of reasons for grandparent's caring role as this can help professionals with their work with the family and the plans they develop; need for multi-agency approach to assessment of risk.
Recommendations include: safeguarding children partnership to ensure all agencies are using age appropriate tools in all assessments to understand children’s lived experience, and incorporating children's lived experiences into all plans; to ensure all partners incorporate disguised compliance into all safeguarding training, supervision and managerial sessions with frontline workers; seek assurance from children’s social care and local drug services that changes to service design, and ways of working have improved the reliability of testing, communication, information sharing and risk assessing of parents who are misusing substances; ensure that, where grandparents are playing a significant caring role, this is fully explored as part of assessments and contained within all action plans; explore ways of ensuring information about risk is provided by all relevant services and incorporated into safeguarding assessments and plans.
Keywords: infant deaths, substance misuse, sleeping behaviour, addicted parents, voice of the child
> Read the overview report
2022 – Lambeth – Angela
Sexual abuse of a girl by her mother’s partner. Angela disclosed multiple counts of rape and sexual assault to hospital staff in June 2020.
Learning includes: protection of children should not rely solely on disclosures from children; lack of grasp by professionals on the lived experience of the child; lack of awareness of the impact of domestic abuse in the safeguarding system; the need to support professional curiosity regarding recognition and response to sexual abuse; differing levels of confidence in the recognition of child sexual abuse, leading to professionals deferring to unspoken hierarchies; even for parents whose first language is not English who appear to have a good grasp of the English language, language used by professionals is more complex than conversational language.
Recommendations include: consider development of a multi-agency neglect strategy; any individuals or families living in property deemed unfit for human habitation are offered temporary accommodation without delay; consider a pan-London protocol about children missing education that move between boroughs; remind partner agencies of the function and purpose of a multi-agency risk assessment conference (MARAC) and the specialist domestic abuse services available; children services to consider a practice standard requiring a strategy meeting or management overview where there have been three or more referrals of children involved in domestic abuse incidents; ensure that practitioners and managers are aware of child sexual abuse expertise available in the borough; emphasise the importance of professional difference by developing the escalation process to create space for a multi-agency professionals meeting to explore perplexing cases; ensure availability and quality of interpreters used for children and parents whose first language is not English.
Keywords: abusive men, child sexual abuse identification, family violence, rape, sexually abused girls, unknown men
> Read the overview report
2022 – Lambeth - Dawit
Death of a 16-year-old boy by suicide in May 2021. Dawit had arrived in the UK from Africa in October 2020 to live with his sister after both his parents had died. His family had suffered religious persecution in their home country.
Learning themes include: developing a clear pathway and protocol for unaccompanied children who do not have anyone with parental responsibility in the UK to ensure their needs are met; supporting the integration of migrant children into schools and the wider community that takes cognisance of their cultural, religious, physical, or emotional needs; and the role of the partnership in safeguarding unaccompanied minors who do not have anyone with parental responsibility in the UK.
Reflections suggest: every child/family should be given the right advocate/support to navigate complex systems and bureaucratic processes, to ensure that they are not just matched up with universal services but are also supported to fully access them; there is a need to increase professionals’ knowledge and confidence in being curious about and exploring parental responsibility; all services must commit to using high quality translation services for all spoken and written information and in a school environment good quality English as an Additional Language (EAL) support is essential; and children’s social care should, once they have completed their child and family assessment, share the conclusions and outline plan with partners, including GPs, schools, and housing.
Keywords: African people, child deaths, suicide, unaccompanied asylum seeking children, language, parental responsibility
> Read the overview report
2022 - Leicestershire and Rutland - Child R
Significant harm to a 9-year-old boy over a number of years due to alleged fabricated or induced illness (FII). These concerns became heightened when Child R was placed in foster care where he was seen to flourish, including being fully mobile and eating without medical intervention.
Learning includes: agencies, particularly health professionals, may benefit from systems that help recognise fabricated illness; when a child is under the care of multiple teams and the diagnosis is unclear, there is a need for a multi-disciplinary team meeting between health professionals; a need for continuing professional curiosity rather than relying on parental response; loss of focus on the harm to the child can occur when concentration on proving FII becomes a distraction; need for a move away from the inability to appropriately challenge parents because of concern about FII; multi-agency representation in strategy discussions is essential so that a full picture of the child’s life can be formulated.
Recommendations: N/A
Keywords: fabricated or induced illness (FII), feeding behaviour, information sharing, interagency cooperation, professional curiosity
> Read the overview report
2022 – Lewisham – Child FA
Death of a girl due to systemic inflammatory response syndrome during a COVID-19 pandemic lockdown in England.
Learning themes include: child experience of domestic abuse; child protection in complex families across households; cultural assumptions; parent-professional relationships; the impact of COVID-19 and access to healthcare; and the quality of working together to safeguard children.
Recommendations include: agencies should align adult and child risk management by case mapping to ensure there is a focus on the child where there is a parent or carer involved in historic domestic abuse; seek assurance that any potential risk to siblings is fully considered via assessment when a sibling or child living in the same household is being assessed under statutory safeguarding procedures; provide a development plan to ensure practitioners have relationship-based practice skills; agencies should ensure that there is a safeguarding supervision strategy that enables staff to reflect on how their own views and beliefs impact on their work; child protection procedures should ensure that there is continuity of child in need work when a family move; and the local authority should report on work done to learn from the pandemic in checking on children who are not attending school.
Keywords: family violence, coronavirus, parent-professional relationships, siblings, culture, health care
> Read the overview report
2022 – Manchester – Child S
Murder of a 16-year-old boy who received fatal knife wounds during an incident in September 2021. No motive, rationale or explanation for the attack was identified during the criminal trial.
Learning themes include: managing behaviour and risks at school, exclusions and elective home education (EHE), the importance of multi-agency safety planning and intervention; engagement with parents and wider family members; ethnicity and gender; responses when a parent reports a threat to life in respect of their family; the importance of mapping young people involved in serious youth violence; contextual safeguarding; and the National Referral Mechanism (NRM).
Recommendations include: communicate any safeguarding concerns with regards to children receiving EHE to the safeguarding in education team and involve them in strategy meetings, section 47 enquiries and child and family assessments; housing providers should also be included in these meetings, especially when there has been information to suggest that threats to people or property have been made; review procedures and training to ensure that the learning highlighted in this review is embedded in practice; distribute it across the children’s workforce and seek reassurance from agencies that practitioners are provided with continuing professional development in trauma informed, relational practice, which address the rule of optimism, over reliance on self-reporting and the importance of holistic assessment; ensure through its training programme that staff in all agencies are aware of what constitutes a threat to life and what responsibility individual agencies have.
Keywords: child deaths, contextual safeguarding, exclusion from school, home education, murder, youth justice
> Read the overview report
2022 – Manchester – Jacob
Injuries indicative of physical and possible sexual abuse of a 7-year-old boy in May 2019.
Learning includes: practitioner knowledge and beliefs about children and families from different ethnic groups or migrant backgrounds can influence their ability to address children’s needs; when a school records safeguarding concerns in the CPOMS electronic system, used by many schools, to report, record and track safeguarding concerns, they should notify key professionals and record any discussions and plans made between agencies; the need for clear terms of reference for safeguarding teams in schools; seek out information about significant people in a child’s life in order to recognise risks posed by some men; information about commissioned services proposed by schools should be provided to parents; designated safeguarding leads should have access to opportunities to develop their practice; well-kept records in schools are vital to keep children safe; professionals need to be supported to remain curious about children’s lives.
Recommendations include: assurance sought through the local workforce safeguarding strategy, that agencies provide briefings and access to training supporting culturally competent practice; seek assurance that all professionals, including safeguarding leads in schools, are well equipped to work with diversity, culture and ethnicity in safeguarding work; explore how supervision, team learning, training and programmes can help professionals improve their skills as professionally curious practitioners in relation to relation to ‘significant males’; ensure a robust system for quality assuring safeguarding audits and action plans in schools and partner agencies.
Keywords: abused boys, abusive men, child abuse identification, injuries, professional curiosity, unknown men
> Read the overview report
2022 – Merton – Eddie
Overdose by an adolescent boy, Eddie, in May 2019, following an argument with a friend on the phone and following negative comments from his father. There had been four incidents of intentional self-harm since 2016.
Learning themes include: taking a ‘think family’ approach that recognises successful change within the family requires working with all members as a whole; the importance of agencies constructively challenging each other; contextual safeguarding/harm; the importance of trauma informed practice; self-harm and suicide risk and prevention; continued support when making a decision to end social care involvement.
Recommendations include: agencies to agree what a ‘think family’ way of working means, supported by a practical approach and the tools to deliver this; request all partner agencies refresh their escalation procedures with a reminder of professional responsibility to escalate if they consider a child is in need or remains at risk; training to be provided for awareness of the social and professional tolerance of cannabis use and associated harms, including use for self-medication to manage trauma and contextual harms; request all providers of training incorporate trauma informed practice, ‘think family’ and ACE’s in course materials and delivery; review the provision of trauma based services for boys experiencing domestic abuse, neglect, poverty and risk of exclusion; in conjunction with a ‘think family’ approach, implement a universal family friendly template for a single plan designed with users of services; support a trusted adult approach in working with young people by considering adaptive mentalisation based integrative treatment training.
Keywords: adolescent boys, adverse childhood experiences, children in violent families, children with a mental health problem, family functioning, self harm
> Read the overview report
2022 – Merton – SUDI review
Two cases of sudden unexpected death in infancy (SUDI). It was concluded that neither of the SUDI cases met the criteria for a serious incident notification, but a joint agency response (JAR) meeting identified that there could be learning for multi-agency partners.
Learning includes: the importance of children’s services pursuing the need for housing support for families experiencing homelessness; the socioeconomic impact of poor housing on families, especially mothers and babies; agency checks should be completed and obtained in a timely manner to establish past concerns about a family and current intervention; more professional curiosity from health visitors and midwives regarding the home environment of a family.
Recommendations include: safeguarding partnership to commission training or briefings on the impact of poor housing and homelessness on safeguarding children and families; undertake a review of the effectiveness of early help in dealing with issues of homelessness; provide and promote information and training around the risk factors relating to SUDI identified nationally, including signposting partners to the national SUDI review and considering the availability of safe sleeping advice in a range of languages.
Keywords: home environment, homelessness, infant deaths, professional curiosity, sleeping behaviour, sudden infant death
> Read the overview report
2022 – Mid and West Wales – Cysur 4/2019
Intra-familial sexual abuse of two generations of children and adults which came to light in 2018.
Learning is embedded in the recommendations.
Recommendations include: children’s services to reinforce the need to ensure staff are well trained on both the indicators and best practice multi-agency response to sexual abuse and exploitation; further work is needed to support practitioners to work with confidence, particularly in ‘grey’ areas of professional uncertainty where concerns exist, but where the threshold for statutory intervention is not met; the need to make improvements to their recording systems that did not always demonstrate good practice, and have introduced electronic recording for safeguarding in schools; the importance of the role of the School Safeguarding and Attendance Team who played an important role in monitoring and supporting the family outside of formal statutory intervention in safeguarding; legal challenges and professional frustration associated with obtaining consent and its link to establishing paternity raised some dilemmas for all professionals and agencies; share the learning from this case in internal safeguarding training; the GP surgery conducts regular multi-disciplinary meetings, and has introduced a flagging mechanism to alert all staff of any safeguarding concerns; and adult safeguarding recognise the need to further develop joint working opportunities with children services.
Keywords: child sexual abuse, grooming, adverse childhood experiences, trauma, paternity, sexually abusive parents
> Read the overview report
2022 – Milton Keynes – Child K
Alleged rape of a 16-year-old boy in May 2020. Child K disclosed that he had been assaulted by another looked after child whilst in semi-independent accommodation.
Learning includes: decision-making when identifying placements for young people with autism and additional vulnerabilities should be needs led; key partners should have confidence that placements for young people with complex needs have the capacity and expertise to meet assessed needs, and that specialist services are spot purchased if necessary; effective collaboration, as directed by the Transforming Care Programme, will prevent inappropriate hospital admissions; a multi-agency discharge plan for young people admitted to a mental health in-patient unit is essential in preventing further hospital admission; professionals require appropriate knowledge, skills, and competence, to effectively support young people with autism and for a clear understanding of needs and vulnerabilities; professionals should have a shared understanding of the impact of autism on the behaviour, wellbeing and mental health of young people and work collaboratively to understand what the young person may be attempting to communicate by their behaviour; multi-agency assessments of young people with autism should inform a consistent approach to care; when young people with autism are home-schooled, effective oversight is required to ensure that education and health care needs are met; when professionals are concerned about the provision of care, a formal escalation policy is important in highlighting unmet needs and practice shortcomings.
Recommendations: are embedded in the learning.
Keywords: autism, child behaviour problems, placement, rape, sexually abused children, voice of the child
> Read the overview report
2022 – Norfolk - AL
Death of a 17-year-old boy in January 2022 by apparent suicide. He had experienced several years of poor mental health and was in acute grief after the death of his mother.
Learning themes include: agency responses to mental health/safeguarding; family approach to multi-agency safeguarding and mental health; bereavement and trauma; older children and young people living with neglect; recognition of the needs of young carers; multi-agency arrangements for risk management, service provision and children and young people in specialist education.
Recommendations include: seek assurance from health commissioners and partners that protocols are in place to ensure the safe management of medication for young people known to have mental health problems, including monitoring use, and advice to carers on storage and administration; referral processes and forms should seek relevant information about family history, especially history of trauma and any concerns about current parental mental health or substance misuse, including appropriate checks to see if parents are known to adult mental health services, when children are being referred; review its guidance on thresholds in order to support practitioners’ understanding of neglect, the cumulative impact of neglect and how to identify non-cooperation of care givers, as possible evidence of neglect; produce and promote sector specific good practice guides on understanding the importance of fathers and father figures; seek assurance that there are processes in place to identify and note when vulnerable adults, including men, have parenting or caring roles; review how the Joint Agency Group Supervision process is working across services.
Keywords: anxiety, child deaths, children with a mental health problem, grief, parents with a mental health problem, suicide
> Read the overview report
2022 – Northamptonshire – Young Person BG
Fatal stabbing of a 16-year-old in August 2021 whilst in a local public space with a friend. BG and friend were accosted by young person A and an associate. Considers the context of six young people (including BG and A) drawn into exploitation and youth violence.
Learning themes include: extra-familial harm and professional understanding of gangs, including identification, risk assessment and multi-agency responses; consideration of ADHD in relation to access to education and risk assessment formulation; consideration of cannabis use in safeguarding risk thresholds; diagnosing neurodevelopmental disorders in children; the impact of adolescent neglect and prevalent key adverse childhood experiences such as domestic abuse; the practice context of Covid-19; and ethnicity, representation and adultification.
Recommendations include: the partnership develop and implement a multi-agency strategy and practice framework to support the identification, risk analysis, intervention and disruption of child exploitation; various agencies conduct a needs analysis to review domestic abuse services for young people aged 16-18-years-old who may be at risk of perpetrating domestic abuse; and the local NHS Trust in collaboration with key partners review their existing ADHD pathway, to ensure advice is given for non-medication options and to enhance safeguarding practitioner understanding of how to support young people with neuro-diverse conditions such as ADHD.
Keywords: gangs, criminal child exploitation, attention deficit disorder, drug misuse, violence, child neglect
> Read the overview report
2022 – Nottinghamshire – SN20
Death of a 19-month-old infant girl in March 2020. The mother was convicted of her murder.
Learning includes: the importance of recording information accurately and the need to be precise in the language used, to avoid formulaic language and better support understanding of risk; the importance of implementing a holistic assessment of the adult and child which considers predisposing vulnerabilities, risks for the adult and child and the potential impact on and experience of the child in relation to those vulnerabilities and risk; ensure children's workers have access to expertise in adult factors such as mental health and substance misuse which may affect their care of a child; address any gaps in understanding between children's services practitioners and adult mental health services; and the need for empathetic curiosity and doubt about what parents say on topics which are inherently sensitive.
Recommendations include: review correspondence sent out to patients when they are offered an intervention specifically in relation to waiting well whilst on the list; and explore models of integration between adult and children's health and social care services so that the services can undertake joint assessments of adults with parental responsibilities who have issues including mental health problems and substance misuse.
Keywords: parents with a mental health problem, drug misuse, parenting capacity, risk assessment, mental health services, infant deaths
> Read the overview report
2022 – Nottinghamshire – Tom
Death of a two-week-old boy from positional asphyxia on a sofa where his father was sleeping.
Learning includes: safe sleeping is an issue for services broader than health visiting and midwifery; the importance of parents having an effective relationship with key health and social care professionals; a need for sufficient curiosity about evidence of indicators of domestic abuse; reasons for parents not wanting family support when it was offered or help from substance misuse services could have been clarified with more purposeful curiosity; there was a need for a good chronology of contacts with the family to help detect patterns and cumulative indicators; and a need for services to use tools and practice frameworks that are available to assist professionals to make a more informed judgment when dealing with complex and complicated family circumstances.
Recommendations include: recognising the danger of co-sleeping has implications for any services visiting homes with infants under 12-months-old; a safe sleep assessment should result in a record being left with the family and be included in any other risk-based discussions or actions including child protection plans; and intervention is likely to be more effective through a service that can allocate a dedicated worker offering consistent relationship-based and practical help informed by a well-informed assessment.
Keywords: infant deaths, professional curiosity, health visitors, substance misuse, alcohol, mental health problems
> Read the overview report
2022 - North Lanarkshire - Anne
Death of a girl from an acute medical condition in 2018. Concerns were expressed that neglect of Anne's medical needs had been a factor in her death.
Learning includes: issues around mechanisms for bringing the right people together to share information and make joint decisions, resulting in some children not receiving the right service at the right time; issues across children's services in relation to the use of assessment tools and frameworks, running the risk of failing to identify the point at which older children are in need of protection; and the need for opportunities for formal critical reflection within and across agencies at all levels, as not having these opportunities makes it more difficult to develop and revise shared understanding of the needs of children in complex circumstances, and exacerbates the risk that assessments may rest on untested assumptions.
Recommendations: N/A
Keywords: child deaths, adolescent girls, child health, medical care neglect
> Read the overview report
2022 - Oldham - Child J
Serious non-accidental injuries to a 7-month-old child in July 2015. Both of Child J's parents were charged with causing grievous bodily harm. Child J had been placed in foster care from birth and was returned to the care of the parents aged six months.
Learning points include: responding robustly to domestic abuse within a safeguarding plan requires an approach that works with both victims and perpetrators to support robust analysis of risk and change; comprehensive assessment of risk and planning for children is best supported through adopting a common model of assessing motivation and capacity for change; management oversight at critical points of assessment needs to support practitioners to utilise critical thinking techniques to draw confident conclusions and develop plans that appropriately address risk; for children reviewed within looked after children arrangements, systems to support multi-agency working should remain a priority where more than two agencies continue to be involved with the child and family; and the local authority must carefully and robustly exercise its parental responsibility for children placed with parents.
Recommendations include: the local safeguarding children board (LSCB) should promote the use of a model of change within partnership agencies to assist single and multi-agency assessment of parenting capacity; the LSCB should require children's social care (CSC) to ensure that every child for whom they share parental responsibility and is placed with parents is subject to ‘placement with parents’ regulations reviewed alongside the child's care plan; and CSC should review and report to the LSCB how multi-agency work is promoted through systems that support children subject to care orders.
Keywords: family violence, injuries, drug and alcohol services, parental responsibility, risk assessment, child protection registers
> Read the overview report
2022 - Redbridge - Baby A
Head injury to a 10-week-old girl in 2022. Baby A was on a child protection plan at the time of the incident due to risk of neglect.
Learning includes: a need for professionals to consider and apply the impact of cumulative harm and parental history to the current situation; a need at every meeting to consider fathers as a protective factor or potential risk to a child; professional responsibility to engage with fathers or question any apparent lack of engagement from other agencies; a need to balance supporting a vulnerable parent with clear child-focused challenge about the potential for a negative impact on the child; a need for professionals to be clear about the impact of substance misuse on children and unborn babies, including on the parent/carer’s ability to protect their child from harm; and strengths-based models of assessment and planning for children need to have a clear focus on risk and ensure that all available information is considered when deciding on the safety plan for a child.
Recommendations include: promote the involvement of fathers as a key focus; consider the timeliness of pre-birth assessments and assessing application and impact; review approaches to neglect and seek assurance that consistent trauma informed, strengths-based models of working are being implemented across agencies; and ensure agency policies that are applied when people “do not attend” or “do not engage” with services are reflective of safeguarding risk.
Keywords: head injuries, adults abused as children, infants, adverse childhood experiences, care proceedings, child protection registers
> Read the overview report
2022 - Salford - Nicholas
Death of a 4-year-old boy in 2022 due to a serious incident whereby he was found face down in a bath. Nicholas had been subject to a pre-birth assessment in a different local authority.
Learning includes: consideration needs to be had of a national, uniformed, transfer information policy; and there is a need to develop professional curiosity.
Recommendations include: assure of a robust transfer of information policy to be used when a person presents safeguarding concerns from out of area, and when a person with safeguarding concerns moves to another area; assure the partnership around discharge processes and the flow of information from all maternity services; remind and encourage professionals to practice an open-minded awareness of the differences that cultural background can produce; and assure the partnership that professionals from all agencies know when and how to escalate any concerns.
Keywords: drowning, information sharing, professional curiosity, injuries, transient families, early intervention
> Read the overview report
2022 – Sandwell – Child LS
Death of a child in June 2018 due to significant non-accidental injuries. The stepfather was found guilty of the murder of Child LS, the mother was found guilty of causing/allowing their death, and both parents were found guilty of multiple counts of child cruelty.
Learning includes: that an early help intervention may have provided support to mother and her children, as there were indications that mother was struggling to cope; Child LS’s personal circumstances and developmental issues meant that there should not have been a gap in their nursery education; whether or not any professional intervention could have prevented the injuries to LS.
Recommendations include: review training provided to agencies regarding the thresholds for early help, and ensure that agencies are aware of their responsibilities to apply thresholds correctly; the local authority ensures that funded nursery provision is promoted and encouraged, particularly for families with vulnerable children; remind agencies of the need to include the voice of the child when recording information.
Keywords: child deaths, physical abuse, murder
> Read the overview report
2022 – Sandwell – Child RS
Serious and potentially life changing non-accidental injuries to a 4-month-old baby in June 2019. A police investigation and care proceedings were instigated.
Learning includes: bruising on non-mobile babies should always be treated seriously and advice immediately sought from the safeguarding lead; practitioners should guard against second guessing the response of the multi-agency safeguarding hub (MASH) to a referral of concern about a child; importance of early identification of vulnerability, assessment of risk and consideration of appropriate services; importance of gaining an understanding of who lives in a household and their role, not focusing solely on mothers but proactively engaging with fathers; information sharing alone does not safeguard children; be aware of the impact of professional desensitisation and cultural normalisation; importance of professional curiosity and respectful challenge; be aware that moving between areas, away from support systems, can increase a family's vulnerability.
Recommendations include: ensure that the learning from this review is disseminated widely and incorporated into updates, and the development of policies and procedures; ensure that the safe sleeping policy is shared with all relevant staff; ensure that guidance on bruising to non-mobile babies is widely disseminated and embedded in practice across all agencies.
Keywords: infants, bruises, physical abuse, professional curiosity, sleeping behaviour
> Read the overview report
2022 – Sandwell – Child VS
Death of an infant in 2020.
Learning includes: the need for a whole systems approach to safeguard unborn babies; where a child is subject to a child in need (CIN) plan due to neglect, and isolated incidents occur such as an injury, these should be managed with the same rigour as that for children not previously known to children’s services; history not always being drawn on to provide context for new assessments; all case discussion should include discussion about the legality of a child’s living arrangements; information sharing practice in CIN cases may not be robust; professionals were insufficiently curious, and they did not ask pertinent questions to better inform their plans.
Recommendations include: ensure frontline workers receive clear and consistent messaging on how to refer and work with pregnant women where there are concerns for unborn babies; professionals are encouraged to challenge and take an active role in progressing cases, escalating cases where insufficient progress has been made; agencies conduct holistic assessments inclusive of all individuals linked to the subject child; information is shared with all staff groups regarding how to recognise when a child is a looked after child versus a child living within a family arrangement; information sharing in cases where children are subject to a CIN plan is timely, recorded and shared.
Keywords: infant deaths, pregnancy
> Read the overview report
2022 – Sandwell – Child YS
Assault on a 7-month-old child by their father, resulting in life threatening injuries.
Learning includes: understand the impact of trauma and become more trauma-informed in practice; understand the way in which different faith communities perceive domestic abuse and the difficulty in speaking openly; the importance of professional curiosity and challenge; the importance of clear and factual record keeping and interagency cooperation; create a safe space for multi-agency reflection and supervision; the importance of cultural awareness and challenging assumptions recognising that different families from the same cultural or religious group may have different views and practices.
Recommendations include: ensure effective implementation of information sharing, 'think family' approach, using evidence-based tools, trauma informed practice, resolution and escalation policy; work with community groups to combat domestic violence; host training on effective safeguarding of Black, Asian and minoritised ethnic, cultural and faith groups.
Keywords: infants, physical abuse, family violence, ethnic groups, religion, trauma-informed practice
> Read the overview report
2022 – Sefton - Delilah
Death of a 12-week-old infant girl in October 2021 following co-sleeping with her mother and twin sibling. Delilah’s mother had consumed alcohol and cocaine the previous night and had experienced multiple incidents of domestic abuse.
Learning themes include: the effect of twin births on risks associated with co-sleeping; viewing substance use in the context of domestic abuse and depression; impact of alcohol use on parenting capacity; the presence of domestic abuse in current and past relationships; limitations in the child and family assessment; effectiveness of the child in need plan; understanding family composition and functioning, including older children living with family members in other local authority areas; and disguised compliance.
Recommendations include: remind partner agencies of the importance of an early referral for an assessment of risk to an unborn child; obtain assurance from partner agencies that consistent, unambiguous safe sleep advice is given to parents in respect of multiple births; develop a policy outlining action to be taken when parental consent to observe sleeping arrangements for new born children is declined; empower professionals with knowledge of alcohol risk identification; ensure the local Domestic Abuse Partnership Board address the training needs of non-specialist domestic abuse professionals, reflecting on the many ways domestic abuse may affect victims; ensure child and family assessments explore relevant issues in sufficient depth; ensure child in need plans are specific about what needs to happen and by when, and that plans are not ended prematurely; and commission a case study highlighting the challenges of professional engagement and the importance of exercising professional curiosity.
Keywords: sudden infant death, sleeping behaviour, substance misuse, family violence, parents with a mental health problem, professional curiosity
> Read the overview report
2022 – Southampton - Ted
Non-accidental injury to the leg of a 1-year-old boy who was identified with significant emerging health needs prior to the injury. He is developmentally delayed and was described as ‘non-mobile’.
Learning includes: the importance of knowing and understanding the impact of a parent’s vulnerabilities and history on their parenting; parental substance misuse, mental health, and prescribed pain medication; working with homeless families; exploring and understanding a disabled child’s likely and actual lived experience; considering absent parents, even when domestic abuse is alleged; considering what support is required to ensure a lone, non-birthing parent acquires ‘parental responsibility’; referring/ transferring a child in need plan across local authority borders; and the need to consider if the parent requires an assessment or support due to their own needs or as a care leaver.
Recommendations include: the partnership should request that agencies review their practice in respect of ensuring that the person caring for a child has parental responsibility and provide feedback on what recent progress has been made; the MASH to be asked to consider their expectations and processes regarding transfers from other local authorities in respect of children subject to a Child in Need plan; and the partnership to consider how it can promote the responsibilities of partner agencies to care leavers.
Keywords: children with disabilities, injuries, fathers, housing, substance misuse, adverse childhood experiences
> Read the overview report
2022 - South East Wales - SEWSCB 2/2022
Suicide of 17-year-old girl in October 2021 while living in a supported accommodation.
Learnings is embedded in the recommendations.
Recommendations include: supported accommodation providers ensure there is a safeguarding training and development plan in place for all staff; the importance of acknowledging the age of the child when considering the presenting concerns, and the child’s lived experience; review internal recording tools to ensure the voice of the child is promoted and evidenced; ensure children are seen (and seen alone if appropriate) as part of an assessment; escalate concerns if parents refuse or challenge the need for a child to be seen (and seen alone if appropriate) and to record that decision; develop practice guidance on the lived experience of the child to assist practitioner insight, to ensure that the voice of the child is actively heard and to support effective action to safeguard children and young people; ensure that relevant staff are aware of the Southwark Judgement and how the key principles can be applied to assessments with homeless young people; review their assessment tools to ensure they are child focused, promote the voice of the child and record that the child has capacity to provide informed consent; ensure they have procedures in place to gather historical information from other areas where there has been known involvement with child or family and to have clear escalation policies in place if this information is not provided in a reasonable timescale; and have clear contingency plans in place for children and young people to ensure that they are seen face to face in the event of any future pandemics.
Keywords: suicide, homeless adolescents, adverse childhood experiences, child sexual exploitation, mental health
> Read the overview report
2022 - Staffordshire - J and K
Siblings J and K (aged 16-years-old and 12-years-old) reported missing in September 2021. The referrer expressed concerns about their safety, stating their father had taken the children from the UK and they might be entered into a forced marriage.
Learning includes: practitioners’ confidence and skills in recognising the warning signs for forced marriage and how to respond; understanding how Forced Marriage Protection Orders (FMPOs) should be used and which agency should take the lead in making an application; raising awareness of both the issue and the warning signs of forced marriage with young people in a school environment; raising awareness of the support that is available from the national Forced Marriage Unit; and ensuring widespread understanding of the ‘One Chance Rule’ - that practitioners may only have one chance to speak to a potential victim and therefore one chance to safeguard the child. Learning will be developed into formal recommendations.
Action taken includes: children’s social care to lead on FMPO applications related to children; training for the social care workforce to ensure all workers have an up-to-date understanding of the risks and indicators for forced marriage; a whole system transformation in the local authority to prevent multiple handovers; improved processes by police within the Force Control Centre to enhance safeguarding and ensure warning markers are accurate; education safeguarding leads to ensure warning signs of forced marriage are increased across education settings; and steps taken by the Intensive Prevention Service to disseminate national guidance on forced marriage and raise the profile of the Forced Marriage Unit.
Keywords: forced marriage, culture, siblings, abusive fathers, emergency protection orders
> Read the overview report
2022 – Stockport - Child A
Alleged interfamilial sexual abuse of female Child A (9-years-old in 2017) by male sibling B (11-years-old in 2017) in May 2017 and April 2021. Family history includes domestic abuse perpetrated by the birth father against the birth mother, criminal activity, and the children living with their birth father and stepmother.
Learning includes: ensuring the voice of the child and understanding their experience is a focal point in education system record keeping; the importance of looking at family history within a social work assessment to avoid focusing on a single issue, and to include all adults with parental responsibility in the assessment; the need to risk assess parent safety plans to ensure sibling abuse does not re-occur; professionals understanding the complexity of the health information recording system; the impact of a criminal investigation on working with a family and delays to intervention; fully considering the role of the non-resident parent; practitioners acquiring the right skills to support young people who behave in a sexually harmful way so appropriate interventions take place; and making sure the knowledge, understanding and use of the processes and policy around sexually harmful behaviour are embedded in practice.
Recommendations include: makes no recommendations but documents system changes made since 2017.
Keywords: sibling abuse, harmful sexual behaviour, family violence, parental responsibility, assessment [social work], voice of the child
> Read the overview report
2022 – Stockport – Child F
Sexual assault of a 17-year-old girl in October 2020 by a male while missing from care. Child F has complex needs and required 2:1 staffing 24/7.
Learning includes: professional understanding of health pathways, what they mean and how to access them for children with complex needs; knowledge of processes and policy within various health systems to ensure greater co-ordination of the services working with children who are involved with several agencies; management of multiple and changing diagnoses in the context of what this means for the child and access to services or placement provision; the need to undertake risk assessments during placements when there are signs that a placement is not fulfilling its responsibilities; and professional understanding of the Dynamic Support Database (DSD) and the Care Education and Treatment Review (CETR) processes.
Formal recommendations are not included, but actions include: reviews to be undertaken of the transforming care hospital discharge and DSD information to ensure processes are working effectively for children with complex needs; children's social care to receive training in relation to the DSD, CETR and related processes for children with complex needs; challenges associated with commissioning specialist placements and availability of these will be raised with the National Panel; a universal information sharing system that would benefit agencies in ensuring robust information sharing will be shared with the National Panel; and arrangements will be reviewed to ensure that external placements will provide the best possible service for children with complex needs.
Keywords: runaway adolescents, children with multiple disabilities, placement breakdown, children in care, supervision orders
> Read the overview report
2022 – Suffolk – Andy and Arin
Joint serious case review following two cases of filicide and maternal suicides which occurred within a two-month period between March and April 2019.
Learning includes: professionals must consider the implications and risk for wider family members, especially children, when dealing with vulnerable people with mental ill-health; checks must be made by health professionals to establish if the patient or child are known to other agencies or teams in order to share relevant information; the use of information systems and good practice in sharing information must be part of any procedure and practice guidance within any health settings; practitioners should be proactive in sharing information as early as possible to help identify, assess and respond to risks or concerns about the safety and welfare of children; agencies must review their assessment processes to ensure they include mechanisms to support teenage fathers; health professionals need to be professionally curious as well as dealing with the clinical care of a patient; assessment process for health visitors and midwives must be reviewed to ensure they include professional curiosity around impact and cultural isolation; and health visitors need to consider the support needs of transient families, particularly when from communities who may be culturally isolated.
Recommendations include: review assessment processes to ensure they include consideration of the impact on individuals, the subject of the assessment, and to ensure they consider the support offered to young parents; and consider the effect of parental mental health or physical needs when planning service provision.
Keywords: filicide, information sharing, professional curiosity, social isolation, suicide
> Read the overview report
2022 – Suffolk – Child G
Injuries and hospitalisation of a 2-and-a-half-year-old boy in 2020. Child G was found to have a depressed skull fracture, resulting in a section 47 enquiry.
Learning is embedded in the recommendations.
Recommendations include: decisions stated in MASH outcomes as 'necessary' need to be actioned; MASH decisions which are not the outcome of strategy discussions and require adjustment to reflect local considerations and knowledge of the family must have a clear rationale recorded; workers and agencies who are key to the understanding and progress of a case should always be kept updated; the possibility of non-accidental injury should always be considered in the case of multiple injuries and bruises and when parents' explanations for these are inconsistent; professionals should always check the history, past referrals and the social worker/social work team to ensure all relevant and significant information is gathered; social care should routinely update all agencies involved in a case; all professionals involved in a case should ask questions and get clarity about the key adults in a child's life, and these questions should be standard practice for supervisors and managers to ask at supervision; all professionals should be guided to read the Child Safeguarding Practice Review Panel’s report 'The myth of invisible men' (2021); supervision in social care must always allow for reflection by the social worker.
Keywords: interagency cooperation, non-accidental head injuries, parenting capacity, supervision, unknown men
> Read the overview report
2022 – Suffolk – L, M and N
Thematic review based on the rapid reviews for three young infants who were born in Suffolk in 2021. Two infants died and one infant was injured whilst in the care of their parents.
Learning: N/A
Recommendations include: raise the profile of safer sleeping and associated risks across partner agencies including support to increase knowledge of this area for social workers; embed recognition that house moves and temporary living arrangements are seen as situational risks for babies which need proactive plans that recognise and addresses before babies are born; closer working together between social care and health services in pre-birth assessment and child in need processes; increase recognition of the importance of the health visitor's role; parents' own life experiences are explored in depth and understood; fathers are central and must be included whether they are living with the family or not; understanding and use of family network in pre-birth assessments, parents may highlight family as support; professionals need to explore and be respectfully challenging; supervision is used effectively to explore risk and hypothesis, ensuring that information has been verified or explored; pre-birth assessment to remain open until after the baby is born and there has been time for stress-testing of plans and support; hospital discharge planning meetings to be considered for child in need cases as part of the plan for younger parents, and parents with other vulnerabilities including where there are several addresses and uncertainties; recognition of the power imbalance between agencies and parents, relationship based case work that starts with this awareness is essential.
Keywords: sleeping behaviour, infant deaths, abused infants, home visiting, risk assessment
> Read the overview report
2022 – Suffolk – Young People F
The sexual abuse of an 11-year-old girl, and grooming of her 8-year-old sister, by their mother and her boyfriend over a 12 month period prior to April 2020.
Learning: N/A
Recommendations include: schools should consider how they monitor and review the concerns logged on their child protection online management system, there should be an automatic review built in when a certain number of concerns are logged within a specific period; safeguarding leads within schools should ensure that any referral to another agency is always followed up and that the nature of the response is recorded at the time; health services need to ensure that all transfers in families where children are at risk are accompanied by appropriate documentation, management review and a visit; when a concern is raised with health services by another agency, consideration should be given to a visit being undertaken by a health visitor rather than relying on what was seen at a visit some weeks or months earlier; children and young people services should ensure that at the point of referral, any extensive history is carefully considered within the multi-agency safeguarding hub as part of effective decision making on what action to take; and children and young people services should set any retracted compliance regarding a common assessment framework within the context of the family history and consider stepping up for a social work assessment rather than simply accepting that nothing can be done as parental co-operation is withdrawn.
Keywords: child sexual abuse, grooming, self harm, child abuse images, physical effects
> Read the overview report
2022 – Sutton – Child X
Death of a 3-and-a-half-month-old girl in May 2021. Child X was in the care of foster parents when she was found unresponsive in an unsafe sleeping position.
Learning includes: joint working between midwives and social workers should be a core element of discharge planning for vulnerable new babies, even when they are going to foster carers; rigorous checks and assessments of foster carers taking on infants; gaps in supervision can occur when services use agency staff who might not have the appropriate knowledge and skills to undertake safe practice with vulnerable families; where there are concerns that a child has been harmed, there is a need for equivalent response when the child is in the care of foster carers as in the care of their birth parents.
Recommendations include: a campaign to raise awareness of safe sleeping arrangements for infants to include 'what if' questions; to seek assurance that independent fostering agencies comply with standard 10 of 'Fostering services national minimum standards' (2011), relating to suitable physical environments; to ensure managers and supervisors are aware of the importance of following up in supervision that safer sleeping arrangements have been checked by social workers and health professionals; all services ensure that their staff are aware of the neglect toolkit and bruising of non-mobile infants guidance.
Keywords: bruises, neglect identification, parents with a mental health problem, private foster care, sleeping behaviour, sudden infant death
> Read the overview report
2022 – Swindon – Babies with injuries
Reviews the assessment and safeguarding of infants prior to and following a non-accidental injury, focusing on three infants aged 7, 9 and 11-weeks-old.
Learning focuses on: the need to increase awareness of the unborn baby protocol; child protection processes and case management across perinatal mental health services; the response to anonymous referrals and the scope of the resulting health checks; the need to consider and involve fathers; improving the exercise of professional curiosity; the impact of COVID across agencies; use of targeted support in pregnancy in order to prevent escalation of concerns post-birth; improved awareness of the voice of the child; need for improved information sharing and recording; understanding that parents can be persuasive and that a parent may not be protecting their child; how caring for a new baby can lead to increases in parental mental health issues and domestic abuse; how professionals providing support to families with a new born baby need to be aware of fathers' mental health.
Recommendations include: ensure the attendance of the appropriate health professionals at strategy meetings, including when these take place out of hours; consider how to encourage and support all professionals to talk to each other and collaborate, so that that all information is known and considered; review systems and practice to ensure that fathers or male partners are equally considered by services.
Keywords: infants, physical abuse, injuries, pregnancy, fathers, men, voice of the child
> Read the overview report
2022 - Tameside - Ben and Alex
Harmful sexual behaviour and disclosure of rape by a female child in 2020, and neglect and non-accidental injuries to a young male child. Both Alex and Ben have been known to agencies since birth, with recurrent re-referrals for both children.
Learning includes: professionals' knowledge of strategy meetings and recognition of their positive effects upon case progression; professionals' understanding of how and when to complete the Graded Care Profile (GCP) effectively or when to seek the advice of a manager or supervisor; including the voice and lived experiences of young, non-verbal children in assessments; concerns regarding the success of the Signs of Safety model and its use in practice; some families consider child protection plans to be intrusive and not a source of support, this reduces their level of true engagement.
Recommendations include: ensure that the GCP training package is completed and evaluate whether professionals are understanding the tool and embedding it into their practice effectively; consult with general practitioners (GPs) to gain a better understanding of their roles and responsibilities, and to understand what can realistically be expected of GPs in terms of safeguarding; remind staff in partner agencies to fully explore the lived experience of a child and to include their findings in all records including assessments, alongside the voice of the child; consider developing a parent advocate scheme to support families coming to case conferences.
Keywords: harmful sexual behaviour, child sexual abuse, injuries
> Read the overview report
2022 – Tameside - Craig
Allegations of rape and sexual abuse of a boy in care by another child living at the children’s home in 2019.
Learning includes: the importance of having specially trained interviewers in police and social work services available to undertake forensic interviewing with a good enough understanding about helping children disclose information and being sufficiently well informed about current guidelines for interviewing; there was a belief that the risk assessment measures put in place in the care home were impenetrable which excluded the possibility of abuse taking place; a need for strategic leaders to create a context in which practitioners and front-line staff are better equipped and supported to make effective and timely responses to children in care with the most complex needs; a need to ensure that therapeutic reports and updated risk assessments are received and considered as part of on-going, overall risk assessment; and a need for professional curiosity about allegations being made and a need for a neutral and enquiring position to support further exploration of allegations.
Recommendations include: provider impact assessments should have clear mitigations in place for children who exhibit harmful behaviour and are a risk to other children; ensure reviews of looked after children include a full account of any therapeutic input and how it integrates with the care plan; and ensure information sharing protocols reflect the national information sharing protocol issued by the Government and take into account immediate risk and assessed risk either identified through reports or assessment processes.
Keywords: harmful sexual behaviour, residential child care, risk assessment, abuse allegations, disclosure
> Read the overview report
2022 – Tameside – Dominik
Non-accidental injury to an infant boy in 2019 including eye injury, cracked ribs, and a fractured leg.
Learning includes: a need to assess the impact of parental mental health on parenting capacity; a need to identify potential safeguarding concerns to a new-born baby following a family dispute; a need for information held on early help systems to be held on children's social care systems; a need for a pre-birth assessment by children's social care which could have informed part of the court proceedings; and a need to ensure GDPR guidelines are correctly applied by children's social care.
Recommendations include: information sharing policy, between the multi-agency safeguarding hub (MASH) and partners, should not allow GDPR to act as a barrier to sharing information when there are safeguarding concerns; the quality of recording and decision making based on effective triage in the MASH needs to continue to be improved and monitored for consistency so that information, risks and vulnerabilities can be connected; the sharing of information between early help and children social care systems needs to be strengthened so that there is a stronger interface between them; there needs to be assurance, from children's services and midwifery, that the threshold for initiating the pre-birth protocol is being applied appropriately; and any agency that identifies that parental mental health needs are impacting on parenting capacity needs to share that with other partner agencies working with the family so that information can be triangulated and an appropriate response agreed.
Keywords: injuries, infants, mental health problems, record keeping, grandparents, pregnancy
> Read the overview report
2022 - Tameside - Ellie
Death of a girl in 2021. Ellie's brother, a young adult, was found guilty of manslaughter.
Learning focuses on: the assessment of children and young people as young carers; procedures to address domestic abuse in families where a child is a perpetrator of abuse; how capacity to parent a child is assessed when mental ill health has been identified in a parent; how the impact of parental mental ill health on a child is assessed; recognition and response to vulnerability in an adult who has parenting capacity; availability of help and support for a person who has a diagnosis of autism.
Recommendations include: adult and children's multi-agency services should address transitional care between adult and children's services; children's social care to provide evidence of robust procedures when closings cases, ensuring there is clear identification of the services continuing to support the child and family; social work assessments should include an effective consideration of history and parenting capacity that informs thorough analysis of risk; commissioners should provide assurance on improving waiting lists for neurodevelopmental pathways timescales, so that children don’t wait too long for support and diagnosis; review the availability of services and support for families who are waiting for an autism spectrum disorder (ASD) diagnosis and post diagnostic support; the safeguarding children partnership to seek assurance on the effectiveness of interventions available for children with complex and challenging behaviours.
Keywords: child deaths, sibling abuse, autism, children as carers
> Read the overview report
2022 – Thurrock - Serious Youth Violence
Local learning review conducted following a serious incident of youth violence.
Learning includes: agencies would like clearly defined thresholds in relation to contextual safeguarding; agencies do not always feel confident on what information they should be sharing, with who, and how to escalate concerns of poor information sharing; it is difficult to evidence change where there appears to be positive engagement and possible disguised compliance; the benefits of extensive mapping, including the collection of data on gang related violence, hotspots, presentations at local hospitals, and local police intelligence data; the value of child criminal exploitation leads in agencies including children's social care.
Recommendations include: the completion of a review into information sharing between local police, children's social care and youth offending services; ensure information relating to the transfer of care of vulnerable children and their families from 'out of area' is shared with relevant local health agencies; information about hospital attendances by young people related to serious youth violence, especially in hospitals outside the young person's local area, is shared with relevant agencies; ensure the inclusion of health representatives in multi-agency forums related to children who are at high risk of youth violence; develop a clear threshold and pathways document on contextual safeguarding; consider the development of a transitional safeguarding approach with the Safeguarding Adult Board.
Keywords: adolescents, violence, contextual safeguarding
> Read the overview report
2022 – Torbay – C92 and C93
Stabbing of a boy by his mother in December 2021 when she suffered from an acute and transient psychotic episode.
Learning includes: the importance that professionals working with children have the skills and knowledge to identify parental alcohol misuse and neglect and intervene for children who are not able to voice their experiences; there tends to be an over optimism about parent’s self-reporting and that quite often substance misuse is known about but not seen as excessive; in instances where an individual smells of alcohol but there is no evidence of intoxication this may reflect that they have a tolerance for alcohol at harmful or dependent levels.
Recommendations include: assurance that practitioners have sufficient training and development to enable professionals that work with children to understand the impact of parental alcohol misuse and recognise and respond to children exposed to parental alcohol misuse; assurance that local education settings have an effective policy and systems in place to ensure that information is available to inform decision making by the MASH during school holidays; and ensure that children are put on school roll immediately that a place is accepted and that this is not a systemic problem in their area.
Keywords: alcohol misuse, child neglect, children missing education, professional curiosity, referral procedures
> Read the overview report
2022 – Trafford - Teddy, Wilbur and Peter
Suicide of a 17-year-old and attempted suicides of a 16-year-old and 17-year-old, all cases occurred separately, in England.
Learning includes: a need for local authorities to find suitable alternative placements and health and social care to commission appropriate placements for 16 and 17-year-olds; the impact of chronic underfunding of mental health services nationally on young people’s timely access to appropriate mental health services; the need to consider each individual in the context of their age, maturity and mental capacity at each contact; a need for professionals to maintain high levels of engagement and support throughout a young person’s admission into hospital; a need for resources to support 16-17-year-olds who do not meet the threshold to be detained under the Mental Health Act, but are deemed to require a level of care that cannot be fully met within the home or by community services; and a need for triggers for harmful behaviours to be sufficiently considered when formulating plans of care.
Recommendations include: ensure appropriate services are being commissioned that can meet the needs of young people aged 16-17-years-old within the community; ensure that there is a clear record of parental responsibility that is amended if a child is placed on an interim/full care order or adopted; review discharge planning processes and ensure a multi-agency response to discharge planning that commences on admission; and strengthen trauma informed practice and safety plan intervention.
Keywords: suicide, child mental health, adolescents, transgender, LGBTQ, child mental health services
> Read the overview report
2022 - Wandsworth - Alsami
Death of a 14-year-old boy by suicide in June 2021.
Learning includes: the importance of taking time and assertive commitment to understand the lived experience of a child; ensure that professionals are proactive in understanding and working with the religious, cultural background of children they are in contact with; the impact of adverse childhood experiences (ACEs) and childhood trauma on children whether they verbalise their concerns or not; take particular care and attention towards 'sensitive and quiet' children in a large family group, ensuring that their views, worries, concerns and lived experience are sought and assertively included in plans and any work with them; purposeful parental engagement which takes account of the parental vulnerabilities, ACEs, and childhood trauma on their parenting; have an informed view about the impact of alleged sexual abuse on all children in the family and in particular male children where the perpetrator is a male and the victims are female children; take account of research into the impact on male self-image, masculinity, and self-esteem of male abuse in families; recognition of the impact of contextual safeguarding to adolescents, especially young men who may be subject of exploitation and fear in communities.
Keywords: suicide, adolescent boys, adverse childhood experiences
> Read the overview report
2022 – Wigan - George
Multiple injuries including significant subcutaneous swelling to the head of a 23-month-old boy in March 2022. George was brought to nursery by his mother and shortly after his arrival staff noticed several bruises and abrasions to his face. George’s mother was arrested on suspicion of assault.
Learning themes include: supporting the transition to adulthood, especially for those approaching parenthood; considering the meaning behind missed appointments, late cancellations and rearranged appointments; the impact on young carers when their siblings are placed in care; ensuring the child’s voice and lived experience leads decision making; critical thinking, professional curiosity and over optimism; threshold application at point of closure of cases; unseen men and their relationships with vulnerable women / those with experience of abuse; development of practice approaches for those working with individuals who have experienced trauma.
Recommendations include: consider whether transitional planning is aligned with the Care Act 2014 and whether the correct trigger points are in place to start that planning (in order to help support adolescents who have multiple areas of vulnerability as they transition into receiving an adult service offer); review the data infrastructure cross-agency to identify whether improvements can be made within current systems, for example, automatic chronological entry to be implemented, a possible positive outcome being the ability for practitioners to see real-time updates across agencies outside of set review timings.
Keywords: abused boys, bruises, child abuse, child neglect, cycle of abuse, transition to adulthood
> Read the overview report
2022 – Wiltshire – the long-term sexual abuse of children in care
Long-term sexual abuse of three siblings in foster care. The abuse was perpetrated by the male foster parent.
Learning includes: professionals should not assume that when a child has had therapeutic interventions this will be protective in the longer term; as children with disabilities are more vulnerable to sexual abuse, professionals need to ensure that this is considered when their behaviour is being assessed; professionals need knowledge and confidence about adult behaviours that might indicate a sexual risk to children; professionals need to be able to consider the 'unthinkable' about carers they may know well and be alert to the possibility of sexual abuse; when professionals predominantly work with one carer, they need to ensure that equal professional scrutiny applies to the second carer; opportunities should always be taken by trusted professionals to have age and ability appropriate discussions about sexual abuse with children in care; schools are key in providing an environment where children know who they can talk to about sexual abuse and what will happen if they tell someone; children in care in long term placements need significant relationships with professionals and/or their carers if they are to disclose sexual abuse.
Recommendations include: ensure professionals are thinking and talking about the risk of sexual abuse of children in care; learning from the review is shared with the local corporate parenting panel; training foster carers about intra-familial sexual abuse; and assurance of the local plan to include direct information from respite carers in child in care reviews.
Keywords: child sexual abuse, foster care, children with learning difficulties, siblings, abusive men
> Read the overview report
2022 – Wokingham – Aisha and Ciara
Sexual abuse of two siblings under 6-years-old by an acquaintance of their mother. Both children were also subject to neglect by their mother.
Learning includes: the importance of understanding the circumstances of parents or family members who are identified as having unmet and unassessed learning needs or learning difficulties; the need for a structured approach to identify and address child neglect; ensuring professionals are equipped when working in the area of child sexual abuse and improved awareness of the importance of clarity regarding risk; professionals balance intuitive reasoning with analytical reasoning; and a need for discussion in a multi-agency context about how to facilitate communication with a child and ensure their needs and voice are brought into focus, considering issues of disability, age and language.
Recommendations include: build a stronger, structured approach to neglect; and remind practitioners that verbal or written communication is adapted to ensure accessibility during contact with families where there are potential learning needs.
Keywords: child sexual abuse, child neglect, family conflict, professional curiosity, children’s services, language development
> Read the overview report
2022 – Wokingham - Young Person Harry
Arrest and conviction of a 13-year-old boy for a serious violent crime.
Learning includes: children and young people with special educational needs and disabilities (SEND) need to be understood, and local capacity improved, so that these specialist needs can be met; the quality of information sharing when a child or young person with an education health and care plan (EHCP) changes schools is crucial; new pathways are required for young people with complex needs if exclusions from school are to be reduced; there is a need to develop a culture of safeguarding within front line staff to improve the service offered to young people by Thames Valley Police.
Recommendations include: develop new procedures for the early review of EHCPs when a child or young person moves local authority area at the same time as transitioning from primary to secondary school; develop new information sharing procedures when students with an EHCP change schools, including professional meetings attended by the relevant schools, the agencies working with the young person, and the parents/ guardians; Thames Valley Police should produce new policy and guidance in relation to children and young people who are identified as suspects in a criminal investigation and develop a culture of safeguarding and partnership working, with training delivered to all police officers and police community support officers; update policy and guidance for the review of referrals and contacts that involve children and young people with SEND.
Keywords: children with a learning disability, county lines, criminal child exploitation, exclusion from school, police
> Read the overview report
2022 – Wolverhampton – Child R
Suspected non-accidental head injury to an 8-day-old baby. At the time of Child R’s birth all of the children in the household were the subject of child protection plans.
Learning themes include: knowing and considering the parent’s history and vulnerabilities when working with a family; understanding a child’s lived experience and what they may be communicating by their behaviour; the likelihood of child neglect coexisting with other forms of abuse; the impact of ‘growing families and growing children’ on the ability of parents’ to cope; the cumulative impact of long-term neglect; awareness among professionals of control and coercion and non-violent domestic abuse; need for professionals involved with adults to be aware of plans for the children in the household; the effect of COVID-19 on families and services received; considering making older siblings aware of safe handling and careful behaviour around a new born baby; child protection procedures regarding parental contact following an injury.
Recommendations include: ensuring improvement actions are taken, including seeking assurance that the learning from this review is considered by those responsible for ICON training, and that ICON recognises the need for bespoke plans about safe handling for parents with learning difficulties and where there are older children in the family; ensure that services are aware of the need to follow child protection procedures when a non-mobile child has injuries; and ensuring that when children are the subject of a plan, this is recorded on the GP record of any adults in the household.
Keywords: abusive men, family violence, neglected children, non-accidental head injuries, parenting capacity, siblings
> Read the overview report
