Recently published case reviews

Last updated: 07 Jun 2019
Case reviews published in 2019

Case reviews published in 2019

A list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2019. To find all published case reviews search the national repository.


2019 – Anonymous - Katie

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

2019 – Anonymous – John

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

2019 – Anonymous – Patrick and Patricia

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

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

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

2019 – City and Hackney - Rachel

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

2019 - Croydon - Child A and Baby N

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

2019 - Croydon - Vulnerable adolescents

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

2019 – Hertfordshire – Child I

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

2019 – Lincolnshire– G

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

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

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

2019 – Tower Hamlets – Baby ‘Adam’

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

2019 – Tower Hamlets – Child Elias

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

Case reviews published in 2018

Case reviews published in 2018

A list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2018. To find all published case reviews search the national repository.


2018 – Anonymous – Baby L

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

2018 – Anonymous – Charlie and Sam

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

2018 – Anonymous – Children F, G and H

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

2018 – Anonymous – Child G

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

2018 – Anonymous – Child H1

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

2018 – Anonymous – Child L and Child M

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

2018 – Anonymous – Child S

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

2018 – Anonymous – Child Z

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

2018 – Anonymous – Darry

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

2018 – Anonymous - Emily

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

2018 – Anonymous – Siblings A and B

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

2018 – Anonymous – Young Person

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

2018 – Anonymous – Young Person F

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

2018 – Barking and Dagenham – Child C

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

2018 – Bedford – Rosie

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

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

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

2018 – Blackburn with Darwen – Child G

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

2018 – Blackburn with Darwen – Child Y

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

2018 – Blackpool – Baby BZ

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

2018 – Blackpool – Child BY

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

2018 – Blackpool – Child CA

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

2018 – Blackpool – Child CB

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

2018 – Bolton – Baby D

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

2018 – Bristol – Aya

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

2018 – Bristol – Becky

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

2018 – Bristol – Child D

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

2018 – Camden – Baby C

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

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

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

2018 – Cardiff and Vale of Glamorgan – Young Child

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

2018 – City of London and Hackney

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

2018 – Coventry – Baby F

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

2018 – Croydon – Child J and Child K

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

2018 – Croydon – Joe

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

2018 – Croydon and Lambeth – Child L

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

2018 – Derby – Child FD17

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

2018 – Derbyshire – 9-week-old Child

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

2018 – Dorset – Child M

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

2018 – Dorset – Child S

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

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

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

2018 – Durham – Charlie and Charlotte

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

2018 – East Sussex – Family S

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

2018 – Edinburgh – The Sexual abuse of children in care

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

2018 – Greenwich – Child V

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

2018 – Greenwich – W Family

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

2018 – Greenwich – Young Person X

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

2018 – Hampshire – Child U

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

2018 – Hull – Baby D

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

2018 – Kent – Child D (Jamie)

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

2018 – Lancashire – Child LG

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

2018 – Leeds – Callum Garland

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

2018 – Leicestershire and Rutland – Child A

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

2018 – Lincolnshire – Child F

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

2018 – Manchester – Child F1

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

2018 – Manchester – Child G1

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

2018 – Manchester – Child L1

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

2018 – Manchester – Child M1 and M2

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

2018 – Manchester – Child N1

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

2018 – Medway – Dawn

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

2018 – Medway – Ellie

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

2018 – Mid and West Wales – Child A

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

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

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

2018 – Newham – Chris

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

2018 – Norfolk – Case Y

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

2018 – Norfolk – Child V

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

2018 – Norfolk – Child Z

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

2018 – Norfolk – Family U

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

2018 – Northumberland – Olivia

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

2018 – Nottinghamshire – Madison

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

2018 – Nottinghamshire – Peter

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

2018 – Oldham – Baby H

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

2018 – Oldham – Child G

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

2018 – Portsmouth – Child E

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

2018 – St Helens – Baby A

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

2018 – Shropshire – Child C

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

2018 – Somerset – Family A

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

2018 – Sunderland – Baby A

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

2018 – Sunderland – Young Person Mark

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

2018 – Wakefield – Ollie

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

2018 – Walsall – Child A

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

2018 – Walsall – Child W8

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

2018 – Wigan – Child M

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

2018 – Wiltshire – Family M

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

2018 – Wolverhampton – Child G

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

Case reviews published in 2017

Case reviews published in 2017

A list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2017. To find all published case reviews search the national repository.


2017 – Anonymous – Alex

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

2017 – Anonymous – Child AB

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

2017 – Anonymous – Child F and Family

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

2017 – Anonymous – Child Y

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

2017 – Anonymous – Considering child sexual exploitation

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

2017 – Anonymous – Martin

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

2017 – Bedford – Baby Sama

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

2017 – Birmingham – Child D

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

2017 – Birmingham – Child S

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

2017 – Birmingham – Isobel

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

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

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

2017 – Blackpool – Child BW

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

2017 – Bournemouth and Poole – Child O

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

2017 – Bradford – Jack

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

2017 – Brighton and Hove – 'A'

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

2017 – Brighton and Hove – Siblings W and X

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

2017 – Bristol – ZBM

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

2017 – Buckinghamshire – Child sexual exploitation 1998-2016

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

2017 – Central Bedfordshire – Nolan

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

2017 – Croydon – Claire

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

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

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

2017 – Derbyshire – Polly

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

2017 – Dudley – Child P and Child H

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

2017 – Durham – Baby Bailey

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

2017 – Enfield – Child YT

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

2017 – Halton – Young Person

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

2017 – Hertfordshire – Child G

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

2017 – Hertfordshire – Family H

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

2017 – Hull – Baby J

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

2017 – Isle of Wight – Child G

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

2017 – Kent – Child C

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

2017 – Liverpool – Chris

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

2017 – Luton – Child J

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

2017 – Manchester – Child H1

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

2017 – Manchester – Child I1

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

2017 – Manchester – Child K1

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

2017 – Merton – Child B

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

2017 - Middlesborough - Jenny, Molly and Emily

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

2017 – North East Lincolnshire – Child T

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

2017 – Nottingham – Child J

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

2017 – Nottingham – Baby ON16

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

2017 – Nottinghamshire – LN15

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

2017 – Rochdale – Child K

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

2017 – Rochdale – Child L

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

2017 – Somerset – Child L and Child J

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

2017 – Somerset – Child Sam

Severe and irreversible brain damage caused to a 6-month-old boy as a result of non-accidental injury.
Learning: importance of professionals working with families to recognise the increasing risk factors within the family and the impact these might have on the parents' ability to care; importance of information sharing.
Recommendations: ensuring that agencies identify and respond to risks and vulnerabilities within families where domestic abuse is a concern; appropriate training given about the importance of measuring and recording growth measurements; and training for health care professionals to highlight the signs and symptoms of brain injuries in young babies.
Keywords: infants, physical abuse, non-accidental head injury
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2017 – Somerset – Fenestra

The child sexual exploitation (CSE) of Child C and Child Q by Perpetrators A and B between 2010 and 2014. Police Operation Fenestra led to their convictions for sexual offences against 6 children (including Child C and Child Q) in 2016.
Learning: professionals' difficulties in recognising 'inappropriate relationships'; not recognising parents' concerns; safeguarding risks for children in relation to piercing and tattoo salons.
Recommendations: uses 'considerations' for the LSCB as opposed to recommendations: are the police sufficiently resourced to support complex CSE investigations and take the lead in multi-agency working; is the LSCB satisfied with mental health services to support CSE victims; how can safeguarding be improved locally; do practitioners understand the need for persistence and curiosity when developing trusting relationships with children.
Model: uses the Social Care Institute for Excellence (SCIE) Learning Together methodology.
Keywords: child sexual exploitation, children’s attitudes, parent-professional relationships, pregnancy, Police
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2017 – Staffordshire – Child B

Death of a 14-month-old girl in July 2014. Cause of death was not ascertained but there were concerns she had died while co-sleeping with her mother and maternal grandmother who were both believed to have been under the influence of alcohol.
Key issues: Child B and her siblings were on a child protection plan under the category of neglect. There were 5 critical incidents related to the mother’s alcohol misuse.
Key findings: there were a number of missed opportunities to safeguard Child B and her siblings; there was a tendency to parent-centred practice; professionals did not listen to the views of Child B’s siblings; birth fathers were not involved in assessment and planning.
Recommendations: involving fathers and other significant men connected to a child in child protection cases; listening to the voice of the child; interagency communication.
Model: Uses the Social Care Institute for Excellence (SCIE) Learning Together systems methodology.
Keywords: child neglect, alcohol misuse, optimistic behaviour, children’s views
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2017 – Stockport – Pip

Death of a 15-year-old girl as a result of a collision with a train in December 2015. The coroner’s inquest concluded that her death was suicide.
Learning: the need to understand that anorexia places strain not only on the child, but also on the family and professionals working with them; recognition that anorexia has safeguarding issues for multi-agency advice, not just health professionals; the need for all assessments carried out to be coordinated into one record of evidence.
Recommendations: the development of eating disorder pathways; ensure that the views and feelings of young people and their families are considered; the use of national guidance to support medical practice.
Keywords: anorexia nervosa, adolescent girls, child deaths, depression in childhood, eating disorders, family therapy
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2017 – Sunderland – Family X

In 2014 a large sibling group were removed from parental care because there were concerns they had been exposed to and were suffering from chronic neglect.
Learning: better outcomes would be achievable for children at risk from neglect if multi-agency activity was underpinned by a common assessment tool; to focus on parental capacity for change to avoid drift in achieving positive outcomes for children; where children are at risk of harm, a multi-agency approach is best delivered through a child protection plan that adopts SMART planning techniques; when working with chaotic families it is important for professionals to remain focused on the children and their voice.
Recommendations: to develop a clear neglect framework, assessment tools, processes and practice models; to work with the Children’s Strategic Partnership to develop and implement a model for assessing capacity to change; to oversee the introduction of quality assurance processes which ensure that children subject to child protection plans remain categorised to the most appropriate source of risk; and in order to maintain a focus on the voice of the child in practice around neglect, findings of recently completed audits on the Voice of the Child and Section 11 must be acted on.
Keywords: child sexual abuse, disguised compliance, listening, neglecting parents, optimistic behaviour, parenting capacity
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2017 – Sunderland – Young Person Rachel

Circumstances leading to a 15-year-old girl being placed in a secure setting in summer 2015.
Learning: better understanding by professionals and practitioners of the interplay between adolescent choice and risk, especially in relation to sexual behaviour and sexual exploitation; importance of multi-agency assessments which focus on the child’s care and experiences; child sexual abuse in the family will often come to the attention of services as a result of a secondary presenting factor; the range and nature of adolescent risks are different to those facing younger children and the traditional response to such risks does not necessarily fit with young people’s lived experience.
Recommendations: strengthen skills and knowledge base of the children’s workforce so that professionals are better equipped to recognise and respond to sexual abuse within the wider family; ensure that services to young children with harmful sexual behaviour are proportionate and timely; improve the effectiveness of multi-agency practice with adolescents who are at risk due to substance misuse and other risk taking behaviours and/or abuse and exploitation.
Keywords: adolescents, child sexual exploitation, risk taking
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2017 – Surrey – Adult S and Child CC

Death of a 14-year-old girl and her mother, who were both killed by the girl’s father, who subsequently committed suicide.
Learning: provided in the form of analytical observations, which include: private health services have been reluctant to share information; police did not enquire about the presence of children when called to the domestic abuse incident; some missed opportunities were noted in dealing with the same incident.
Recommendations: police to analyse their response to domestic abuse incidents; community interventions using the concept of co-production to be trialled; the independent school to integrate domestic awareness in safeguarding domestic abuse; HM Government to develop statutory guidance to include private medical care and oblige them to take part in DHR process.
Model: this is a joint Domestic Homicide Review and Serious Case Review.
Keywords: family violence, filicide, homicide, police, suicide
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2017 – Surrey – Child BB

Death of a 23-month-old child in May 2014 due to non-accidental injuries.
Key issues: Child BB was taken to hospital in a state of extreme physical collapse, with bruises and burn marks, and died the following day. Criminal charges were brought against the mother and her partner in March 2015, but the partner committed suicide before the trial. Mother was found not guilty.
Learning: better interagency work and closer communication between police, probation services and children’s services could have resulted in a better understanding of the behaviour of the mother’s partner; safety messages on dating websites focus on the users’ personal safety but not on potential risks after a relationship is established.
Recommendations: include: police, probation service and children’s services to review processes for liaison about incidents and call-outs in relation to domestic violence; national consideration be given to how mothers can be alerted to the need for caution when engaging in new relationships with previously unknown men, potentially with an emphasis on relationships made through internet dating sites and social media.
Keywords: child deaths, physical abuse, online safety, domestic abuse
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2017 – Surrey – Child GG

Concerns about child sexual exploitation (CSE) of a 16-year-old girl.
Learning: lack of recognition among professionals of the risk of CSE as well as 'drift'; lack of coordination of services; the importance of relationship-based practice with children who have been involved in CSE; the need to avoid blaming or holding children responsible for the abuse and CSE; the importance of information sharing.
Recommendations: audit the extent to which children involved in or at risk of CSE are no longer blamed or held responsible and that records are respectful about the child and their family; raise awareness of CSE with taxi drivers, hotels, after school clubs, youth groups, park wardens and sports clubs.
Keywords: adolescents girls, behaviour, child sexual exploitation
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2017 – Swindon - Child S

Death of an 8-week-old girl in October 2015 whilst sleeping with her mother on the sofa. Child S was taken to hospital following a cardiac arrest and life support was withdrawn after three days.
Background: Child S was subject to an interim supervision order and a child protection plan at the time of her death. The family was known to Swindon Borough Council Children, Families and Health; Great Western Hospitals NHS Foundation Trust; CAFCASS.
Key issues: neglect, the impact of time spent in hospital on ability to care for children, communication gaps between organisations, health visit delays.
Learning: The impact of time spent in hospital on ability to care for children.
Recommendations: include: make training available to Children and Families staff regarding the effects of long term drug use on the brain and to consider the impacts on patient’s ability to care for their family after a discharge from intensive care.
Keywords: sleeping behaviour, child neglect, depression
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2017 – Thurrock – Harry

Death of a 16-year-old Black British boy of West African parentage in a young offender institution (YOI). He had a history of epilepsy and a post-mortem examination confirmed death from natural causes.
Key issues: a formal diagnosis of epilepsy was made at age 7. The diagnosis was not recorded by either primary or secondary school and prescribed medication may not have always been ingested. His aggressive behaviour caused concern from age 13; he was excluded from school on several occasions and 2 separate assaults of railway ticket inspectors led to his detention in the YOI.
Learning: possible side effects of medication (aggression, impulsivity, violence) should have been explored; annual reviews by the GP practice of medication should follow practice policy; response times to medical emergencies in the YOI should be reviewed; internal information sharing within the YOI should be improved.
Recommendations: the YOI should strengthen procedures around medical risk factors of under-18-year-olds; the health provider at the YOI should undertake an audit of the ordering of medical tests to ensure procedural compliance; school nurses should alert teaching staff if a pupil has a diagnosis of epilepsy; NHS England should ensure that GP practices have policies in place with respect to regular medication reviews for children with epilepsy.
Keywords: aggressive behaviour, detention centres, exclusion from school, information sharing
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2017 – Trafford – Child N

Circumstances around Child N becoming a looked after child at the age of 7. Following placement in foster care after the father’s physical assault of an older sibling, Child N and siblings disclosed physical, sexual, emotional and psychological abuse.
Learning: identifies learning lessons in relation to multi agency working maintaining the child as the focus.
Recommendations: focused outcomes and plans for children; the value of multi-agency working; undertaking a thematic audit on working with violence and aggression; and developing a strategy to hear the voice of a child for children subject to multi agency procedures.
Keywords: physical abuse, disguised compliance, listening
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2017 – Trafford – Child PB

Alleged sexual abuse of an adolescent boy by foster carers in two separate placements between 2013 and 2015. A criminal investigation was initiated but neither foster carer was charged with criminal offences.
Key issues: Child PB became looked after aged 12 due to behavioural problems. His first long-term foster carer (FC1) requested that the placement be ended, citing ill health. PB was placed in a residential educational setting, living with a second foster carer (FC2) during weekends and holidays. His behaviour deteriorated and he was moved to a permanent residential placement. PB went missing several times, returning to FC2 although this was not always reported. On one occasion FC2 told police he hadn’t seen PB, but PB was found hiding undressed at FC2’s home. Despite FC2 being suspended as a foster carer, PB was persistently found at FC2’s home. Weeks later, following therapeutic support, PB disclosed sexual abuse by both foster carers.
Learning: although these disclosures have not led to prosecutions, the actions and behaviours of both foster carers should have led professionals to consider at a much earlier stage whether they could keep children in their care safe and whether they posed a risk to children placed with them.
Recommendations: ensure foster carer assessments and reviews are robust, thorough and appropriately challenging; ensure supervision files have carefully maintained chronologies to support supervision and review so that any emerging concerns or issues can be addressed; ensure all practitioners have a sound understanding of the range of characteristics, motivations and behaviours of people who seek to sexually abuse children.
Keywords: child sexual abuse, foster carers, placement breakdown, runaway adolescents
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2017 – Waltham Forest – Child S

Death of 3-year-old Child S, cause unknown, in summer 2014, 6 months after moving to a London borough.
Background: Child S’s mother had a history of long term substance misuse. Child S, a sibling Child Y and the mother were known to Children’s Social Care, universal and specialist health and disability services, pre-school support services and drug support services in both local authorities. Child S had been the subject of a Child Protection Plan in 2013 but removed from the plan in the same year. Child S had serious health concerns from birth, eventually identified as cerebral palsy. Contact with all agencies featured many missed appointments. The family moved to a London borough soon before Child S’s death.
Learning: escalation of concerns; core and follow up assessments; continuity in social work practice; healthy scepticism about long term drug use; reporting and sharing information in drug services; experience of the child; transferring information between areas; hidden men; safeguarding children with disabilities; police sharing information.
Recommendations: pre-birth planning and assessment appropriate with drug using parents; Children in Need meetings properly recorded and CSC assessments up to date; compliance with 2009 guidance on safeguarding children with disabilities; review compliance on transferring cases; embedding healthy scepticism about long term drug using parents.
Keywords: cerebral palsy, addicted parents, non-attendance
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2017 – Warrington – Child 1

Child 1 witnessed mother’s death in the family home in 2014 from multiple stab wounds caused by father. Child 1 sustained stab wounds including the partial amputation of finger during the incident.
Key issues: Child 1 was the eldest of 3 siblings, one of whom was also present in the home at the time of the incident. The children were not known to child protection agencies. They attended school and had no additional health needs. Father and mother were married for 16 years prior to the incident but were experiencing marriage difficulties and attending marriage counselling. Mother experienced domestic abuse and disclosed that she thought father bugged the house, her phone and computer and that she was frightened for her safety and that of her children. Both parents had been in contact with police with issues around domestic difficulties. The criminal investigation revealed that the family home was dominated by father’s controlling behaviour.
Learning: a point of separation represents increased risk of harm to a victim of domestic abuse as well as children within the relationship; stalking behaviour in the context of domestic abuse is an indicator of high risk and is significantly associate with dangerous acts; the sharing of information between professional agencies is critical.
Recommendations: development of early help initiatives to help children talk about domestic abuse; publicising and promoting the role for independent domestic violence advocates; the use of public information notices to maximise the impact of warnings in cases of stalking.
Keywords: partner violence, emotional abuse, family conflict, murder
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2017 – Warwickshire – Child J

Non-accidental leg fracture of a 7-month-old baby who had been on a child protection plan since birth and had been living in a mother and baby foster placement with her mother until aged 5-and-a-half-months.
Key issues: Family were known to agencies for about 6 years due to concerns about the care of 2 older children where a number of probable non-accidental injuries occurred and family violence and substance misuse were present in the household. These children were subsequently taken into care and adopted. After the placement in foster care ended, the mother was housed in her home town some distance from the foster carer.
Learning: importance of assessing the accuracy of current or historical concerns reported by others; the need to respond flexibly to requests to house families in other local authority areas; to consider what formalised support is required following a move out of a baby and mother foster placement.
Recommendations: to make arrangements for appropriate medical and health advice to be available at strategy meetings; to consider how new professionals working with a family are made aware of the case history and reasons for decision making.
Keywords: adverse childhood experiences, family violence, housing, parenting capacity, unknown men
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2017 – Warwickshire – Child T

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