Julie Daly, Head of Service, Safeguarding and Quality Assurance

Yvonne Onyeka, BSCB Business Manager

Learning from the findings of Serious Case Reviews

Objectives of the Seminar

To enable participants to reflect on the findings of Serious Case Reviews and strengthen their practice and management

• Three reviews in Bromley conducted 2008 – 2010 (summaries on the BSCB website)

• A briefing on the main findings of the detailed review of the findings of 268 SCRs 2007 – 2009

The Purpose of Serious Case Reviews

• Public enquiries into child deaths• Chapter 8 of Working Together 2010

- when to conduct a case review - how to go about it

• Learning from cases• Accountability

– to the LSCB– to the community (via the local authority and other

agency boards)– to central government and the general public

The Process (1)

Internal agency reviews• Appoint a reviewer• Secure the written and computer records• Prepare a chronology • Interview staff • Write the agency management review• Submit the material to the safeguarding

children board SCR panel

The Process (2)

LSCB overview report• Appoint a SCR panel• Appoint an independent chair and report

author • Produce a joint chronology• Scrutinise the individual agency reports• Evaluate the practice and agree the ‘lessons

learnt’• Write the overview report• Recommendations and an action plan

Dissemination of the findings

• Feedback for staff involved

• Learning for other staff and managers

• Local agency boards and the council

• Reports submitted to central government– Department for Education– Strategic Health Authority

• Publication of the Full Report

Main themes from the latest review of SCRs

References Brandon, Bailey & Belderson: Building on the learning from serious case reviews: a two year analysis of child protection database notifications 2007- 2009 – 268 SCRS

M Brandon et al, Understanding Serious Case Reviews and their impact – A Biennial Analysis Of Serious Case Reviews 2005-7, (2009) DCSF and Families / University of East Anglia

Peter Reder and Sylvia Duncan, Lost innocents – a follow up study of fatal child abuse, 1999, Brunner-Routledge

An overview of 55 cases subject to serious case review and reported to government in one year

Peter Reder, Sylvia Duncan, Moria Gray, and Olive Stevenson, Beyond Blame: Child Abuse Tragedies Revisited,1993, Routledge An earlier review of a less representative sample of cases

M Brandon et al, Analysing child deaths and serious injury through abuse and neglect - what can we learn? A biennial analysis of SCRs 2003 – 2005, Department for Children Schools and Families, 2008.

The Review of Reviews

• SCRs in England • 189 in 2003-2005• 161 in 2005–2007• 268 in 2007-2009

2007-2009• 675 SINs to Ofsted• 152 (57%) died• 116 (43%) serious

harmed

0

50

100

150

200

250

300

2007-2009

2005-2007

2003-2005

Some population characteristics

Characteristics generally consistent over years.• Half of all SCRs are babies under 1 (importance of

universal services) 45%• 23% (1-5 years) (26%)• Quarter are older children – who pose a risk to

themselves &/ others and needs not recognised (25%)• Three quarters killed or harmed at home• 72% white (slight under representation)• 13% mixed parentage (slightly over represented)• 8% black / black British (slightly under represented)

Population characteristics

Characteristics generally consistent over years.

2007-2009

• Under 1 year 281 (45%)*

• 1-5 years 136 (22%)

• 6-10 years 54 (9%)

• 11-15 years 81 (13%)

• 16 + 66 (11%)

Population characteristics cont.

Ethnicity

• White 421 (75%)

• Mixed 54 (10%)

• Black/Black British 54 (10%)

• Asian/Asian British 27 (5%)

• Other 8 (1%)

Population characteristics cont.

• Male 331 (54%)*• Females 286 (46%)• Disabled 21 (8%)

Incident type• Fatal 381 (62%)• Serious 237 (38%) Injury

Case characteristics

Parents

• Domestic Violence 34%

• Mental Health 27%

• Drug misuse 22%

• Alcohol misuse 22%

• Child of teen pregnancy 7%

• Parent history of being in care 7%

Case characteristics

Child

More than one child abused 19%

Serious iIlness 7%

Drug/Alcohol misuse –child 7%

Mental health problems – child 6%

Themes: Legal and care status

• 16% subject to a child protection plan

• 13% had been previously subject to a plan• 23% listed multiple categories of abuse

(nationally only 8% of CP Plans are multiple)

• 4% were accommodated under s20

• 7% subject to a care or supervision order

• 5% residence order

Case characteristics

Relevant Factors

• Physic abuse 55%

• Long standing neglect 25%

• Recent neglect 18%

• Sexual abuse 14%

• Emotional abuse 11%

• Shaken Baby Syndrome 8%

Themes: Most frequent cause of death / injury

• 39% subject to physical assault

• (24% head injury to baby under age one)

• 16% died of neglect (fires, ingesting drugs, accidents)

• 12% adolescent suicide

Children who were missing or invisible

• Emotionally rejected by carers• Not spoken to or kept away from professionals• Specific vulnerability not appreciated (e.g. low

birth weight, developmental delay)• Siblings of the child wrongly thought to be most

at risk• Unable to speak through trauma, disability or

fearSo professionals need to see the child, know the child and see the world through the eyes of the child!

Chaotic, overwhelmed and unsupported families

• Physically and emotionally overwhelmed• 45% had moved very frequently• Negative relationships with extended family and

others such as neighbours• Deprivation and environmental dangers• Pattern of low expectations held by families and

by professionals • Half in families characterised by domestic

violence and almost two thirds in a family with a mental illness (past or current)

Large families & neglect

• 1 in 5 reviews on families with 4 or more children.

• Long standing concerns about older children not considered relevant in present time

• assessment of parental capacity for change needed ‘Start again syndrome’

• Focus on individual child can be lost

Community Context

• 35 aged 11+ killed /harmed in community context mainly older teenagers.

• Professionals increased awareness of the harmed caused by gangs/youth violence. Some victims were siblings of gang members

• Absconding (running away regularly)• Alcohol and drug excessive use• Aspects of unsatisfactory or neglectful care of a

disabled child –in/formal arrangements of care

Findings from the earlier 2003 – 2007 review of SCRs

• Significance of mental disorder, violence and substance misuse in the earlier sample

• Cumulative risk:– 34% of cases had 3 of these risk factors– 34% had two – (so 68% had 2 or more)– 19% had one – but 13% had none at all

A hazardous and frightening home life

• Substance misuse, mental ill health, domestic violence and poor living conditions

• Don’t always predict serious harm but these factors hugely increase risk to children

• Points to the need for a holistic assessment

The need for dynamic assessment

• Stresses the importance of assessment based on ‘dynamic analysis’ as opposed to ‘description’

• Risk produced by the interaction of experience, current environment, the challenge of parenting, family and personal history and relationships

• Developing and testing hypotheses about care and the child’s safety

• Identifying areas where change is needed• Predicting capacity to change and care

effectively• Analytical assessment leads to safer practice

Risks from organisations cont

• Lack of capacity / resources was not always a feature of the review

• Some individual professionals and organisations were overwhelmed by the nature and the volume of the work

• Some families can drain the capacity to think and see clearly

• This can contribute to lowered expectations• Refusal of some professionals to be ‘judgemental’• Attention focused in one professional or

organisational ‘silo’

Risks from organisations and professionals ….

• Fixed views about the family (not responsive to signs of deterioration)

• Risks associated with certain types of parenting were underestimated (e.g. ‘rough handling’)

• Underestimating the need for high level support for carers - foster care mother & baby placements

• A need for respectful uncertainty & dogged professional challenge

The assessment and involvement of men

• Dearth of information (some organisations and professionals collude in this)

• Failure to involve men in assessment

• Fear of some aggressive men shaped practice

• Rigid and fixed thinking – men seen as either ‘good’ or ‘bad’

Significance of supervision and management in this context

Critical and challenging thinking about:

• position and needs of the child

• history and circumstances of the family

• actions and attitudes of the worker

• functioning of the professional network as a whole

Bromley

Serious Case ReviewsJulie Daly

Head of Safeguarding and Quality Assurance, LBB

Findings from the Bromley SCR in relation to baby ‘P’

Key facts

• 3 month old Black African baby girl

• 3 older half siblings were looked after by the local authority due to mother’s mental ill health

• Abandoned by her mother after her mental health deteriorated seriously

• Injured in the incident, but not badly

Concerns pointing to the need for review

• No pre-birth assessment

• Limited collaborative working between agencies and no pre-birth conference

• Social care staff had not taken actions required by the procedures (and staff from other agencies had not challenged this)

• An opportunity to review working relations between mental health and children’s staff

Agencies involved

• Children’s Social Care Services• Bromley PCT• Bromley Hospitals• Oxleas NHS Foundation Trust• Metropolitan Police

Positive findings about practice

• As far as the mother herself was concerned and taken in isolation from one another provision by midwife, health visitor and mental health services was good

• Services were very responsive to ethnicity and cultural background

Key findings

• Weak assessment by social care staff failed to take into account key factors

• Rapid turnover of staff dealing with the case

• Management input failed to identify weaknesses and prevent drift

• Mother misled some professionals and facts weren’t checked

Key findings (2)

• Inappropriate optimism based on mother’s current presentation

• No challenge over referrals not responded to and actions not taken by other agencies

• Mental health service worked from the assumption that mother would be able to care for the baby

• CPA meetings did not consider the baby’s needs• Lack of curiosity about background and history• Level of interagency contact was far too low

Key recommendations

• Review of staffing and provision in social care referral service

• Routine joint planning between professionals and changes in the CPA approach in such cases

• Review and implementation of the peri-natal mental health protocol

• Review of joint training on mental health issues

• Revised procedures for use of mother and baby placements in such cases

Findings from the Bromley SCR in relation

to baby ‘C’

Key facts

• 3 month old mixed-race UK baby girl• Development impairment following head injury in

2009 while at home with her mother• Other injuries included old fractures of ribs, legs,

knee cap, hand & fractures of skull• Parents both had histories of depression, mother

self-harmed, father had a cognitive impairment

Concerns pointing to the need for review

• Both parents received treatment for depression from same GP practice

• Two notifications from police & evidence from midwives, health visitor of unstable parental relationship

• Reports that mother self-harmed & expressed distress & frustration to health visitor & midwives about child’s crying

• Father’s head injury impacted on his cognitive functioning

• Health visitor and midwives identified poor parenting capacity

Agencies involved

• Children’s Social Care Services• Bromley PCT• Metropolitan Police Service• Local Authority Adults & Community

Services• Two Hospital Trusts• Ambulance Service• Voluntary Agency

Positive findings about practice

• Health staff, having identified concerns, challenged the CSC manager regarding the decision not to undertake an assessment.

• Evidence of good supervision in health to consider different options for taking the case forward with CSC.

Key findings (1)

• Police and ACS fail to identify & share information with CSC on father’s risk to others

• GPs did not share information with ante-natal services

• CSC’s poor analysis of referral information leading to poor decision making.

• CSC’s fail to make full use of the London Procedures & risk assessment matrix

• The quality of the referral in relation to child protection

Key findings (2)

• Failure to pass on information by CSC to a voluntary organisation

• Pressure of workload and inexperience of staff in CSC leading to inappropriate allocations

• Lack of timeliness in progressing assessments • Failure to assess and mobilise potential source

of support in the extended family• Lack of any formal planning processes or

meetings

Key findings (3)

Themes

• Weaknesses in the quality of risk assessment:

• The relationship between adult and children’s services:

• The experience and confidence of staff coupled with level of demand

Key recommendations

• Review the effectiveness of the multi-agency risk assessment training

• Continued training on domestic abuse

• Improved information sharing by and with police

• Front line staff feel able to openly discuss and escalate concerns

• Agencies aware of the need to make timely referrals to Police CAIC out of hours service

• Practice Standards Board to keep practice & information sharing between adult and children’s service under review.

• Review progress on the implementation of actions from previous SCRs.

Recommendations

• CSC to reduce the impact of demand and workload on frontline staff & managers

• CSC to review effectiveness of arrangements with commissioned services to ensure they work within their remit.

.

Findings from the Bromley SCR in relation to Child D and Child B’

Key facts

• Two white British boys aged 5 and 6 years old

• Brought into care after one of the boys found to have injuries, said to be caused by father

• Substantial contact between the boy’s family and agencies in Bromley

• Continuing concerns about neglect over a period of five years

Concerns pointing to the need for review

• Mother’s presented very late with pregnancy and second child born at home a ‘surprise’ birth

• Mother was adopted & a period in care. She alleges that she was sexually abused

• Father reports that ill health causing increasing problems for him.

• Children’s growth and development showed signs of delay reported by many professionals

• Several attempts to refer to children’s social care• Parents various un/co-operative with agencies

involved.

Agencies involved

• Bromley Access and Inclusion Services• Bromley PCT• Children’s Social Care Services• Metropolitan Police Service• Pre-school• School• Two Hospital Trusts• Voluntary Agency

Key findings (1)

• CSC did not recognise the signs that the children were in need. No CSC assessment undertaken.

• Agencies did not adequately challenge the decision by CSC

• Insufficient emphasis on direct work with the children

• No comprehensive assessment of the needs of this complex family.

Key findings (2)

• Supervision arrangements did not challenge sufficiently the failure to make an enduring improvement to the circumstances of the children.

• Collective failure to intervene - possible negative effect from the involvement of many agencies

• Affirms the particular complexity of working with neglectful families

Key recommendations

• Safeguarding concerns must lead to thorough assessment and rigorous review of families.

• Assessment must be child focussed

• Responding to the challenges of working with unco-operative families

• Local procedures on concealed pregnancy

• Multi agency training on neglect

• All agencies to review safeguarding supervision to ensure it is challenging

• Agencies must follow up referrals to other agencies in writing as In LCPP.

• Services provided within specific catchment areas to have clear guidance on boundaries

Key recommendations 2

• LB Bromley must ensure adequate staffing to meet statutory responsibilities.

• A multi-agency review of Common assessment framework

• LA should be satisfied with safeguarding arrangements at the school

• Education Welfare Service provision must be flexible enough to address safeguarding

• Early Years Service to support small scare private providers with safeguarding advice and assistance

• Bromley PCT to review Community Paediatric Services’ processing, prioritising and review of referrals

• School nursing services reminded to take individual action when concerned about a child

SUMMARY

Professional qualities, attitudes and behaviours to make a difference (1)

1. Do everything you can to obtain and understand the history

2. As well as evaluating what you do know - be extremely aware of possible gaps in your knowledge

3. Be alert about aspects of the children’s needs outside of your own specific brief that may not be being met

Professional qualities, attitudes and behaviours to make a difference (2)

4. Be aware of the needs of other children in the family, make referrals and seek relevant information

5. Don’t accept one positive sign of progress as being the equivalent of numerous negative ones (avoid undue optimism)

6. Be prepared to listen to and challenge others – especially when action that was agreed has not been taken

Professional qualities, attitudes and behaviours to make a difference (3)

7. Take much more pro-active responsibility for information sharing

think pro-actively about the potential value of information you have for others

think about the information that others may have that may

be of use to you 8. Develop more effective working relationships with

mental health and substance misuse services for adults

9. Ensure the agency insists on pursuing the right course of action with avoidant and aggressive families

www.bromleysafeguarding.org