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Recently published case reviews

Last updated: 16 Nov 2023
Case reviews published in 2023

Case reviews published in 2023

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

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

2023 – Anonymous – Child A

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

2023 – Anonymous - Child A

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

2023 – Anonymous - Child E

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

2023 – Anonymous – Thematic review of Infants Under 1 Year

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

2023 – Barnsley – Child ‘T’

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

2023 - Berkshire West - David

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

2023 - Birmingham - Adult A

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

2023 – Bradford - Sara, Edvina and Danuka

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

2023 – Cheshire East – Child K

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

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

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

2023 – Essex – Child C

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

2023 – Essex – Child I

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

2023 – Greenwich – Child C and D

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

2023– Guernsey and Alderney – John

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

2023 – Kent – Baby T

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

2023 – Norfolk – Child AK

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

2023 – Northamptonshire – Children N and O

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

2023 – North East Lincolnshire – W Siblings

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

2023 – Nottinghamshire - David and Daniel

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

2023 – Sandwell – Young Person SC

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

2023 – Solihull – Baby JS

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

2023 – South Gloucestershire – Family A

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

2023 – Swindon - Alan

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

2023 - Waltham Forest - Kubus

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

2023 – Wandsworth - Lloyd and Mark

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


Case reviews published in 2022

Case reviews published in 2022

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

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

2022 – Anonymous – Adam

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

2022 – Anonymous – Anya, Rosa, Whitney and Lena

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

2022 – Anonymous – Babies with injuries

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

2022 – Anonymous – Charley

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

2022 - Anonymous - Child 9

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

2022 – Anonymous – Child A

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

2022 – Anonymous – Child G

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

2022 – Anonymous – Child N

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

2022 – Anonymous - Children O, P and Q

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

2022 – Anonymous – Daisy

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

2022 – Anonymous – Family M

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

2022 – Anonymous – Joshua

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

2022 – Anonymous – Marie

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

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

> Read the overview report

2022 – Anonymous – Pippa

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

2022 – Anonymous – Riley

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

2022 – Anonymous – Ruby

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

2022 – Berkshire West – Aiden

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

2022 - Berkshire West - Serious Youth Violence

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

2022 – Birmingham – Hakeem

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

2022 – Blackburn with Darwen Blackpool Lancashire – Millie

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

2022 – Blackburn with Darwen, Blackpool, Lancashire – Sarah

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

2022 – Bradford – Harry

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

2022 – Buckinghamshire – Family T

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

2022 – City and Hackney – Child Q

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

2022 – Coventry – Matt

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

2022 – Croydon - Jake

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

2022 – Cumbria – Leiland-James Michael Corkill

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

2022 – Cwm Taf – Child T

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

2022 – Dudley – Child Y

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

2022 - Ealing - Young Person H and others

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

2022 - Gloucester – Laura and Ella

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

2022 – Hampshire - Amelia

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

2022 – Hampshire – Child P

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

2022 – Hampshire – Emma

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

2022 – Hampshire – Liam

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

2022 – Hampshire - William

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

2022 – Herefordshire – Louise

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

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

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

2022 – Hertfordshire – Child N

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

2022 - Hounslow - Child A

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

2022 – Kent – Children O and P

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

2022 – Kent – Child S

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

2022 - Kirklees - Child A

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

2022 - Kirklees - Child K

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

2022 – Lambeth – Angela

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

2022 - Leicestershire and Rutland - Child R

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

2022 – Manchester – Jacob

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

2022 – Merton – SUDI review

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

2022 – Nottinghamshire – SN20

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

2022 – Nottinghamshire – Tom

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

2022 - North Lanarkshire - Anne

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

2022 - Redbridge - Baby A

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

2022 – Sandwell – Child LS

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

2022 – Sandwell – Child RS

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

2022 – Sandwell – Child VS

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

2022 – Sandwell – Child YS

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

2022 – Suffolk – Andy and Arin

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

2022 – Suffolk – Child G

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

2022 – Suffolk – L, M and N

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

2022 – Suffolk – Young People F

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

2022 – Sutton – Child X

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

2022 – Swindon – Babies with injuries

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

2022 - Tameside - Ben and Alex

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

2022 – Tameside - Craig

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

2022 – Tameside – Dominik

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

2022 - Tameside - Ellie

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

2022 – Thurrock - Serious Youth Violence

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

2022 – Trafford - Teddy, Wilbur and Peter

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

2022 - Wandsworth - Alsami

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

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

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

2022 – Wokingham – Aisha and Ciara

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

2022 – Wokingham - Young Person Harry

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

2022 – Wolverhampton – Child R

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

Case reviews published in 2021

Case reviews published in 2021

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

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

2021 – Anonymous – Anonymous Family

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

2021 – Anonymous – Anonymous victims of FC1

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

2021 – Anonymous – Baby D

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

2021 – Anonymous – Child E

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

2021 – Anonymous – Child P1

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

2021 – Anonymous – Child X1

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

2021 – Anonymous – Family H

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

2021 – Anonymous – Hatty and Jen

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

2021 – Anonymous – PS

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

2021 – Bexley – Baby R

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

2021 – Bexley – Child O

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

2021 – Birmingham – BSCB 2017-18/02

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

2021 – Birmingham – Child A

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

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

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

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

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

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

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

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

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

2021 – Blackburn with Darwen, Blackpool and Lancashire – Holly

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

2021 – Blackburn, Darwen, Blackpool and Lancashire – Mia

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

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

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

2021 – Bradford – child sexual exploitation: thematic review

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

2021 – Bradford – Emily

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

2021 - Brent - Child K

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

2021 - Buckinghamshire - Baby N

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

2021 - Camden - Child E

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

2021 – City and Hackney – Child A

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

2021 – City and Hackney – Child B

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

2021 – City and Hackney – Child I

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

2021 – City and Hackney – Child R

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

2021 – Dudley – Children Q and R

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

2021 – Ealing - Child C

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

2021 – Ealing - James

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

2021 – East Sussex – Child W

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

2021 – Harrow – Child M

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

2021 – Hertfordshire – Child L

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

2021 – Medway – Baby Harris

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

2021 – Nottingham – Child R

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

2021 – Oldham – Child P

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

2021 – Oxfordshire – Jacob

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

2021 – Richmond Upon Thames – Maria, Luis and Carlos

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

2021 – Sandwell – TS

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

2021 – Somerset – Child Alex

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

2021 – Somerset – Child Charlie

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

2021 – South Tees – Daniel

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

2021 – South Tees – Fred

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

2021 – South Tees – Kingfisher

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

2021 – South Tees – Liam

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

2021 – South Tyneside – Child J

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

2021 – St Helens – Charlie

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

2021 – Surrey – Child B

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

2021 – Surrey – Sudden unexpected death in infancy

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

2021 – Sutton – Child V

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

2021 – Thurrock – Leo

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

2021 – Torbay – C67 and C68

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

2021 – Wakefield – Jason

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

2021 – Warrington – Case AB

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

2021 – Windsor and Maidenhead – Child T

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


2021 – Wirral – Liam

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

Case reviews published in 2020

Case reviews published in 2020

A list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2020. To find all published case reviews search the national repository.

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

2020 – Anonymous – Adolescent girl BR19

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

2020 – Anonymous – Baby L

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

2020 – Anonymous – Bilal

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

2020 – Anonymous – Child A and Child B

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

2020 – Anonymous – Child N

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

2020 – Anonymous – Child Sam

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

2020 – Anonymous – Child Tracy

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

2020 – Anonymous – Child Z

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

2020 – Anonymous – Children’s Case C

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

2020 – Anonymous – Family D

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

2020 – Anonymous – Family G

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

2020 – Anonymous - Georgia

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

2020 – Anonymous – Harry

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

2020 – Anonymous – Young Person B

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

2020 – Birmingham – BSCB 2015-16/03

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

2020 – Blackpool - Child CE

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

2020 – Bromley – Leo

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

2020 – Buckinghamshire – Baby S

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

2020 – Buckinghamshire – Child V

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

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

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

2020 – Bury – Isabella

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

2020 – Cambridgeshire and Peterborough – Jack

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

2020 – City and Hackney – Child C

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

2020 – Cornwall and Isles of Scilly – Child C

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

2020 – Coventry - Serious case review of eight children

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

2020 – Cumbria – Child CH

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

2020 – Dudley – Child A

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

2020 – Dudley – Child D

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

2020 – Dudley – Child L

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

2020 – East Riding – Baby B

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

2020 – Gloucestershire – Children of Family Y

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

2020 – Gloucestershire – Lauren

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

2020 – Gloucestershire – Liam

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

2020 – Gloucestershire – Megan

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

2020 – Greenwich – Child A

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

2020 – Hertfordshire – Child K

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

2020 – Hillingdon – Child X

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

2020 – Hounslow – Sasha

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

2020 – Hull – Baby B

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

2020 – Hull – Child H

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

2020 – Kent – Child I: Carys

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

2020 – Kent – Suicide: thematic analysis

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

2020 – Luton – Child G

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

2020 – Manchester – Child U1

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

2020 – Manchester – Child W

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

2020 – Medway – Faith

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

2020 – Medway – George

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

2020 – Merton – Child D

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

2020 – Newcastle – Laura

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

2020 – Norfolk – Child AG

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

2020 – Norfolk – Child AI

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

2020 — Nottinghamshire — Child RN19

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

2020 – Plymouth – Baby F

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

2020 – Plymouth – Baby G

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

2020 – Portsmouth – Child H

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

2020 – Portsmouth – Child I

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

2020 – Redbridge – Baby T

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

2020 – Richmond – St Paul’s School

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

2020 – Rochdale – Child A1

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

2020 – Salford – Baby MD

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

2020 – Salford – Helen

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

2020 – Sandwell – JS

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

2020 – Sandwell – Child NS

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

2020 – Sefton – Beatrice

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

2020 – Sheffield – Archie

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

2020 – Solihull – SC17 Unborn Baby A

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

2020 – Southampton – Freddie

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

2020 – South Gloucestershire – Toby

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

2020 – St Helens – Child B

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

2020 – Staffordshire – Child D

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

2020 – Suffolk - Young Person Mary

Death of a 13-year-old girl in February 2018 following a severe asthma attack. Her brother had died seven years before, aged 9-years-old, also following an asthma attack.
Learning includes: the way in which agencies and organisations recognise, respond to and manage long term life-threatening but common conditions such as asthma needs to be improved; highly articulate, plausible, and manipulative parents require confident and assertive practice, and a focus on the core issues; professionals need to act in the child's best interests and consider what their life (in all aspects) is like; professionals must challenge parental assertions, views, and behaviours from a child-centred viewpoint; parental views should not override evidence-based concerns; agencies need to coordinate or communicate sufficiently to fully understand what the issues are; failures by parents to comply with advice in relation to health care issues should be treated as a safeguarding matter, which triggers child protection processes, as necessary.
Recommendations include: improve the way long term conditions are managed such as evidencing in health records that every missed appointment matters holistically; supervisors focus on and audit the degree of assertive practice evidenced by practitioners in a case, and ensure staff are trained and supported in terms of their practice with challenging or plausible parents and carers; introduce better approaches to utilise contextual and historical information in assessing cases when multiple agencies are involved; and that the focus on assessing the risk of harm is changed from an incident focussed approach to a context focussed one.
Keywords: child deaths, children with a chronic illness, family conflict, home environment, medical care neglect
> Read the overview report

2020 – Sunderland – Baby Kate

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

2020 – Surrey – Child A

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

2020 – Surrey – Child G

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

2020 – Surrey – Children HH, II and JJ

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

2020 – Surrey – Baby KK

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

2020 – Surrey – Baby LL

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

2020 – Surrey – Family M

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

2020 – Sutton – Child O

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

2020 – Sutton – Child T

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

2020 – Swindon – Child G

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

2020 – Tameside – Child V

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

2020 – Thurrock – Frankie

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

2020 – Thurrock – Sam and Kyle

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

2020 – Walsall – Alex

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

2020 – Waltham Forest – Child C

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

2020 – Waltham Forest – Child D

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

2020 – Waltham Forest – Khalsa

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

2020 – Wandsworth – Child A

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

2020 – Wandsworth – Frankie

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

2020 – Warwickshire – Alice and Beth

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

2020 – Warwickshire – Amy

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

2020 – Warwickshire – Child K

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

2020 – West Sussex – Baby T

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

2020 – West Sussex – Child U

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

2020 – West Sussex – Child V

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

2020 – West Sussex – Family W

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

2020 – Wiltshire – Child L

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

Case reviews published in 2019

Case reviews published in 2019

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

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

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

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

2019 – Anonymous – Child 1

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

2019 – Anonymous – Child A19

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

2019 – Anonymous – Child F

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

2019 – Anonymous – Child H

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

2019 – Anonymous – Child K

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

2019 – Anonymous – Katie

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

2019 – Anonymous – John

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

2019 – Anonymous – Patrick and Patricia

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

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

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

2019 – Birmingham - BSCB 2017-18/01

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

2019 – Bolton – Baby C

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

2019 – City and Hackney – Rachel

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

2019 – City and Hackney – X

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

2019 – Croydon – Child A and Baby N

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

2019 – Croydon – Child Q

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

2019 – Croydon – Child Y

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

2019 – Croydon – Vulnerable adolescents

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

2019 – Dudley – Child A

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

2019 - East Lothian and Midlothian - Child R

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

2019 – East Sussex – Child T

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

2019 – Greenwich – Child U

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

2019 – Hertfordshire – Child I

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

2019 – Isle of Man – Several children

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

2019 – Kent – Child H

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

2019 – Kirklees – Child D

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

2019 – Lambeth and Bromley – Child K

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

2019 – Lancashire – Child LK

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

2019 – Leeds – Billy

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

2019 - Leicestershire and Rutland – Child A

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

2019 – Lewisham – Child X

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

2019 – Lewisham – Child Y

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

2019 – Lewisham and Harrow – Child LH

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

2019 – Lincolnshire – G

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

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

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

2019 – Northamptonshire – Child Ab

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

2019 – Northamptonshire – Child Ap

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

2019 – Nottingham – Child KN15

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

2019 – Oxfordshire – Child M

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

2019 – Portsmouth – Child G

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

2019 – Reading – Child I

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

2019 – Sandwell – Child KS

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

2019 – Staffordshire – Child E

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

2019 – Swindon – Child Q

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

2019 – Swindon – Child U

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

2019 – Tower Hamlets – Baby ‘Adam’

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

2019 – Tower Hamlets – Child Elias

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

2019 – Walsall – Charlie

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

2019 – Wandsworth – Baby Eliza

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

2019 – Wiltshire Child K

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