Serious Case Reviews Learning and Actions

What is a Serious Case Review? A serious case review is a local enquiry into the death or serious injury of a child where abuse or neglect are known or suspected. Commissioned by the Local Safeguarding Children Board and undertaken by police, health, social care, education – and is independently chaired.

Each agency will have a designated individual who will write an individual service specific report. From files and interviews and any relevant records e.g. accident logs, behaviour logs. These individual reports are then used by the independent chair to create the final report.

This report then generates an action plan with specific recommendations for each agency. These are then presented to the Board who through the various agency have a responsibility to ensure they are implemented. Summaries from Coventry SCR are available on the Safeguarding Board web site.(

Frequency and Underpinning Issues  115 serious case reviews on the DfE Child Protection database relating to the period 1st April 2009 to 31st March 2010  Approx 1 per 100,000 children aged 0-17  Local information.  63% fatal 37% non fatal. Boys have slightly higher representation than girls. 12% of SCR reviews related to disabled children. 60% of mothers under 21 when they had their first child. Deaths caused by:- Severe physical assault – 25% Deliberate overt homicide – 17% Deaths related to maltreatment -42%

Frequency and Underpinning Issues Domestic Violence present in 63% of cases. Mental ill health 58% Alcohol 27% Drugs 29% None of the above 14% Age ranges of children involved Under 1 – 36% % 6 – % % 16 – %

Some Underlying Themes Neglect is an underlying theme in many cases however information is not always clear unless this is a cause for a previous referral Neglect a feature in at least 60% Maternal age at birth of first child, The extent of children's social care involvement eg. 42% of cases open, 32% of cases closed, 14% had not reached thresholds, 21% were never known by social care Almost 66% of reviews featured domestic violence.

Vignette 1. : Behavioural indicators in school Briefly consider what action should have been taken and what learning might have been recommended

Vignette 1. : Behavioural indicators in school When children display behaviours such as truanting, running away or stealing food, attempts should be made to understand the child’s context and to listen to them, not merely to return them home. It is important to highlight that this is a critical stage in a child’s life and any manifestation of challenging behaviours are likely to have their foundation in the preceding middle childhood years. It is vital to understand and address the source of the behaviour rather than to focus on the behaviour as the problem.

Vignette 2 : Resilient Children Hidden Adversity Briefly consider what action should have been taken and what learning might have been recommended

Vignette 2 : Resilient Children Hidden Adversity Positive presentations in children may mask underlying adversity and distress making it difficult for the school to identify any issues. In this age group, the school is typically the key point of stable and ongoing professional engagement with the child. Any agency that identifies a concern must therefore share this appropriately with the child’s school. When children are known by the school to be in a risky home situation, apparent well-being in school should not be taken as a reason not to fully assess their needs and to take action to protect them.

Vignette 3 – Case closed through lack of Parental Co-operation Briefly consider what action should have been taken and what learning might have been recommended

Too much credence was given to the mother’s version of events, in particular her claim that A’s father was not part of the household, when in fact he still had significant contact. The mother’s retractions of her allegations of domestic violence was accepted without due weight being given to the level of fear and intimidation that she felt, which had led her into withdrawing the allegations. Agency responses tended to lack coordination or focus, and to concentrate on quick solutions, rather than a comprehensive assessment of the potential for long term change. Each child in the family and referral was considered in isolation, without adequate consideration of the past history of the family, and the ‘whole picture’. While the risk of harm was significant, it was not recognised or responded to in accordance with Section 47 child protection procedures. Non-cooperation should have been an indicator of increasing concern, rather than a reason for case closure, and closing the case was both inappropriate and premature.

Local Key Recommendations from a domestic Violence Case All agencies should ensure that there staff are trained and supported in engaging and assessing risk posed by domestic violence. Police and Children’s services should agree exchanging information on children living with DV. A strategy meeting should be held where there is evidence of serious domestic violence and information promptly shared.

Case Study SK is an 18 year old man with severe learning difficulties. Read the case study and identify the key concerns.

Key Recommendations Schools should maintain detailed records of all interactions with parents carers around the child ( with disability or for whom they have a concern) When key staff leave a school there should be appropriate hand over arrangements. There should be a half termly review of children for whom the school has a concern at an appropriate level of staff expertise. All staff should have regular and appropriate training for the type of children in their care.

Key Recommendations Schools should maintain detailed records of all interactions with parents carers around the child ( with disability or for whom they have a concern) When key staff leave a school there should be appropriate hand over arrangements. There should be a half termly review of children for whom the school has a concern at an appropriate level of staff expertise. All staff should have regular and appropriate training for the type of children in their care.

Governors should be aware through regular reports at governor meetings the effectiveness and engagement of the school in these issues. All schools should ensure that staff have signed and received their responsibilities in line with the schools Child Protection Policy. Update procedures/be aware of working with resistant families. Review training in respect of safeguarding children with disability. Effective supervision within the school to ensure that policies and procedures and carried out in line with policy. All staff should be aware of the escalation procedures and have the confidence to challenge decisions of other agencies. Clear monitoring and recording of attendance. What measures are school taking to respond to this and what impact is it having.

Local recent recommendations for Education - Local cases – issues for schools Professionals should consider the welfare of all children within the home and not focus on the behaviour or needs of one child. Frequent (National) Professional Recommendations Hard to engage families Need for safeguarding training Absence from meetings Poor information sharing Poor quality record keeping Lack of professional challenge.

Additional Support. Handout – Outstanding Practice Support from Liz Egginton L.A.D.O. Children and Family First Team.