Messages from Serious Case Reviews Patrick Ayre Department of Applied Social Studies University of Bedfordshire Park Square, Luton web:

Learning from enquiries Those who cannot learn from history are doomed to repeat it (George Santayana)

Plus ça change Every child matters & Keeping children safe Jasmine Beckford, Kimberley Carlile, Tyra Henry & Victoria Climbié, Lauren Wright and Ainlee Walker, Doing the simple things well

Serious Case Reviews Held when a child has died or suffered serious harm and abuse or neglect suspected Aim to identify lessons to be learned Action plan drawn up

Serious Case Reviews A panel of senior managers drawn from key local agencies Final report normally written by an experienced external consultant Examine management reviews prepared by each agency

Serious Case Reviews Produce overview report and action plan Executive summary of report becomes a public document

Learning from Past Experience Major themes from SCR reviews of the 90s: Inter-agency working  Limited inter-agency co-operation and service integration, especially child and adult services  Poor communication both between agencies and within agencies  Health services and child protection: variable levels of knowledge, especially among GPs and those in adult mental health service

Learning from Past Experience Collecting and interpreting information Importance of comprehensive family assessments, especially male figures Need for medical evidence to be considered within the overall context Receiving, interpreting and dealing with referrals Understanding thresholds, especially the importance of neglect and emotional deprivation and the need to accumulate evidence

Capturing chronic abuse Judging the impact of long-term abuse is an essential component of any assessment but how well do we do it? Judgements subjective and prone to bias Intangible: Difficult to capture and compare High threshold for recognition Neglect is a pattern not an event

Capturing chronic abuse Judging the quality of care is an essential component of any assessment but how well do we do it? Judgements subjective and prone to bias Intangible: Difficult to capture and compare High threshold for recognition Neglect is a pattern not an event

Our image of assessment

The reality of assessment?

Capturing chronic abuse Judging the quality of care is an essential component of any assessment but how well do we do it? Judgements subjective and prone to bias Intangible: Difficult to capture and compare High threshold for recognition Neglect is a pattern not an event

The pattern of neglect: atypical

The pattern of neglect: typical

The pattern of neglect

What we would hope to find

What we found

Chronic abuse and the principle of cumulativeness  Incidents scattered through files  The problem of proportionality  Acclimatisation

Pitfalls and How to Avoid Them Professionals think that when they have explained something as clearly as they can, the other person will have understood Parents’ behaviour, whether co-operative or uncooperative, is often misinterpreted Not enough weight to information from family friends and neighbours Not enough attention is paid to what children say, how they look and how they behave Attention is focused on the most visible or pressing problems and other warning signs are not appreciated When faced with an aggressive or frightening family, professionals are reluctant to discuss fears for their own safety and ask for help Information taken at the first enquiry is not adequately recorded, facts are not checked and reasons for decisions are not noted. In Cleaver, H, Wattam, C and Cawson, P Assessing Risk in Child Protection, NSPCC, 1998

Information handling Picking out the important from a mass of data Interpretation Distinguishing fact/opinion; too trusting/insufficiently critical Mistrusted source Decoyed by another problem False certainty; undue faith in a ‘known fact’ Discarding information which does not fit First impressions/assumptions Department of Health (1991) Child abuse: A study of inquiry reports, , HMSO,

Learning from Past Experience Decision-making Need for shared decision-making, especially in respect of not taking action or case closure Moving from data collection and sharing to strategic discussions and clear plans Planning a co-ordinated response across professionals and agencies

Learning from Past Experience Relations with families Dealing with hostile families or those who withdraw Lack of awareness of the impact of domestic violence on children and their safety. Seeing the child as the client, focusing on his or her protection and not being distracted by other problems or by adult or sibling concerns

A child centred approach The purpose of assessment is to understand what it is like to be that child (and what it will be like in the future if nothing changes)

Learning from Past Experience (2002) Geographical mobility: breaking contact Common understanding of what triggers an assessment of need or risk of significant harm? Information sharing and confidentiality Better identification of children vulnerable to abuse Understanding the process of change in public services

ANALYSING CHILD DEATHS AND SERIOUS INJURY THROUGH ABUSE AND NEGLECT (2003-5) ‘Hard to help’ young people Hesitancy in challenging Hostile and ‘difficult to engage’ families ‘Start again syndrome’. Very young children physically assaulted known to universal services or adult services rather than children’s social care Well over half: domestic violence, or mental ill health, or parental substance misuse

“Hard to Help”: The complexity of the challenge Young people may be Victims, Perpetrators Parents Any combination of the above but have the same right to be safeguarded as any other child.

The background “The reviews showed that state care did not always support these young people fully and that they experienced ‘agency neglect’” Brandon and others (2008).

The young people Adolescence marks start of serious problems for many children: –Onset of mental health issues –Family conflict –Drug use, offending –Sexual activity –Running away

The young people (Brandon and others) History of rejection, loss and, usually, severe maltreatment Long term intensive involvement from multiple agencies Parents: history of abuse and current mental health and substance issues Difficult to contain in school Typically self-harming and misusing substances, often self-neglect

The young people (Brandon and others) Numerous placement breakdowns Running away, going missing Risk of dangerous sexual activity including exploitation Sometimes placed in specialist settings, only to be withdrawn because of running away

The young people (My experience) Long involvement, but not always intense Sometimes few placements, but all wrecked by the young person Common factor that local services just did not know what to do with them. ‘By the time of the incident, for many of the young people, little or help was being offered because agencies appeared to have run out of helping strategies’ (Brandon and others, 2008).

The response Reluctance to identify mental illness and suicidal intent (CAMHS) Failure to respond in a sustained way to extreme distress manifested in risky behaviour (sex, drugs, suicide attempts) Arguing between agencies about responsibility and thresholds Reasons for running not addressed adequately

The response Running away leads to discharge [More generally, does rejection of services lead to total abandonment?] Age used as a reason for not imposing services No proper assessment of competence; allowed/forced to choose; [Dealing with incidents but failing to recognise patterns]

The obstacles Hard to get a purchase on the system Wrong children, wrong adults (Ayre, 2000) Lack of off-the-shelf resources The limited resources are poorly coordinated and integrated Government targets not child centred or child driven Different agency agendas and mutual misunderstanding; falling down the gap

The solutions? Biehal (2005) recommends adolescent support teams in the community [but is that enough?] The complexity of the challenge requires flexible collaborative, individualised responses built around the young person

Learning from recent SCRs Information drawn from: About 30 Serious Case Reviews and expert witness reports undertaken in local authorities around England since 2003 A ‘review of reviews’ undertaken for one authority

Learning from recent SCRs Key areas of concern Assessment practice Response to overload Communication and collaboration Child protection meetings and conferences Case management

Assessment Practice Great disquiet over assessment practice Failure to give sufficient weight to relevant case history Facts recorded faithfully but not always critically appraised Guidance and thresholds

Assessment Practice Use of trained staff Assessment of male carers Maintenance of a wholly child-centred approach Formal assessment of risk (How do you do a risk assessment?)

Risk assessment  The dangers involved (that is the feared outcomes);  The hazards and strengths of the situation (that is the factors making it more or less likely that the dangers will realised);  The probability of a dangerous outcome in this case (bearing in mind the strengths and hazards);  The further information required to enable this to be judged accurately; and  The methods by which the likelihood of the feared outcomes could be diminished or removed.

Response to overload Acclimatisation at individual and agency levels Lack of a strategic multi-agency response

The Child Safeguarding System (nominal)

The Child Safeguarding System (actual?)

Collaboration and communication Communication generally found to be good but… Communication with hospitals –Referrals –Medical reports Mental health or drugs issues

Working on the same case but not working jointly Mutual incomprehension and misunderstanding False expectations and assumptions Abdicating responsibility Need for ‘interpreters’

Child protection meetings Attendance at conferences Protection plans omit objectives and outcomes Removal from the register Use of strategy meetings Proliferation of meeting types

Case management File management: reading, recording decisions, auditing Case closure Chronologies CP and teenagers Effectiveness of Emergency Duty Teams

Training General disquiet over the level of training in child protection Specific training for children's services and mental health workers Enhanced training for conference chairs and or independent professionals Interagency training to cover the roles and priorities of the key agencies

References Brandon M. et al (2008) Analysing child deaths and serious injury through abuse and neglect: What can we learn?; London, Department for Children. Schools and Families Falkov, A. (1996) A Study of Working Together Part 8 Reports: Fatal Child Abuse and Parental Psychiatric Disorder, London: Department of Health James, G. (1994) Study of Working Together Part 8 Reports, London: Department of Health Owers, M., Brandon, M. and Black, J. (1999) Learning How to Make Children Safer: An Analysis for the Welsh Office of Serious Child Abuse Cases in Wales, University of East Anglia/Welsh Office Sinclair, R and Bullock, R (2002) Learning from Past Experience: A Review of Serious Case Reviews, London: Department of Health

Learning from Public Enquiries The unholy trinity following cp tragedies: aggressive public pillorying of agencies; ever more detailed recommendations resulting from public enquiries; increasingly intricately wrought practice guidance from central government

CLIMATIC CONDITIONS Climate of fear Climate of mistrust Climate of blame

HOW DID WE GET TO WHERE WE ARE NOW? This history may create a system: excessively concerned with identifying and eliminating danger rather than promoting well-being and undertaking treatment or therapy. excessively concerned with procedures and process rather than with objectives and outcomes. defensive, reactive and concerned with the collection of evidence at the expense of the assessment of need and proactive, co-operative, preventive provision.

Trusting procedures Procedural proliferation Blaming and training The myth of predictability

Procedures as a net to catch problems