Serious Case Reviews Local Lessons & Actions

Why do we undertake SCRs? Regulation 5 of the LSCB Regulations 2006 states: “(1)The functions of a LSCB in relation to its objective....are as follows- (e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.”

When do we undertake SCRs? When a child dies and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of the organisations and professionals in the lives of the child and family. (Working Together, 2010)

When do we consider undertaking SCRs? When a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse; or A child has been seriously harmed as a result of being subjected to sexual abuse; or A parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004; or A child has been seriously harmed following a violent assault perpetrated by another child or an adult; AND The case gives rise to concerns about the way local professionals and services worked together to safeguard the children.

What is the purpose of a SCR? To establish what lessons there are about the way professionals and organisations worked individually and together. To identify how theses lessons will be acted on; in what timescale; and what is expected to change To improve intra- and inter-agency working & therefore better safeguard children.

What would the role of the school be? An Individual Management Review would be completed by Standards & School Effectiveness This would look at he role & involvement of all educational staff, including school employees The report author would review school records & interview relevant staff The aim would be to establish if there are lessons to be learnt in respect of how the school contributed to safeguarding the child

The national picture Understanding Serious Case Reviews and their Impact A Biennial Analysis of Serious Case Reviews M Brandon, et al, 2009

The Children 30 % were aged 0-3 months 45% were under 1 year old 67% were 5 years old or younger 25% were over 11 17% were subject to a child protection plan About half were known to children’s social care

The Families 45% Families had had frequent house moves 53% Domestic Violence (current or past) 33% Substance Misuse (current or past) 63% Mental Health problems (current or past) 15% Parental learning disability 45% Parent with criminal conviction 75% of children had lived with domestic violence, parental mental ill health or substance misuse

The issues Chaotic behaviour in families can be mirrored in chaotic professional thinking and actions Failure to see the child - practice is not ‘child focused’ Efforts not to be judgemental becoming failure to exercise professional judgement Silo practice – professionals not looking at the needs of the child outside their own specific brief.

Issues (cont’d) ¾ of the families did not co-operate with services – a lack of authoritative child protection practice Multiple risk factors – parental substance misuse; mental health problems; domestic abuse; poor living conditions Little or limited information about men Fixed views of a family Perceived, or real, difficulty in engaging older children

SCR in Hertfordshire 5 SCR completed in past year 3 deaths and 2 serious injuries 3 under 5 years old 1 teenager Parental mental healthproblem3 cases Domestic Violence4 cases Parent with learning disability1 case Substance misuse1 case Neglect5 cases

What were the lessons in Hertfordshire Keeping a focus on the child –Can/are the parents meeting the child’s needs Working across adult and children's services –Making best use of expertise Accessing and taking account of past history –Start again syndrome & the rule of optimism The need for professionals to escalate concerns where they feel these are not being addressed appropriately

What were the lessons in Hertfordshire Assessing the impact of cumulative risk factors on parenting ability –Working with complexity All significant adults should be included in assessments –The absence of fathers, male partners, relatives Critical and authoritative child protection practice – Family & professional accountability