1. Working Together 2013- has been modified by Working Together 2015 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: – 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. – (2) For the purposes of paragraph (1) (e) a serious case is one where: – (a) abuse or neglect of a child is known or suspected; and – (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

2. Working Together 2015 SCRs and other case reviews should be conducted in a way which: – recognises the complex circumstances in which professionals work together to safeguard children; – seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; – seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; – is transparent about the way data is collected and analysed; and – makes use of of relevant research and case evidence to inform the findings.

3. Serious Case Reviews in Northamptonshire since 2012 20122 SCRs undertaken and completed in relation to babies who died aged less than 2 months, 1 of natural causes and 1 from injuries. Publication was delayed for inquest and criminal proceedings to be concluded. Both now published and on NSCB website 20134 SCRs initiated in respect of 3 children all under the age of 2 years. 3 of the children died, 1 was seriously injured. 3 of the SCRs have concluded. Fourth [current] in respect of 6 week old baby who was subject to CP plan for neglect, cause of death unascertained. 20142 SCRs commenced 1 in respect of 5 week old baby who suffered life threatening head injuries. Case also subject to criminal proceedings. Not previously known to CSC but known to adult mental health [current]. 1 SCR being conducted in respect of a baby who died as a result of injuries. Not previously known to CSC but parent known to adult mental health services. This is being conducted with another authority as services were provided across borders.

4. 2015 -1 relating to death of an infant following dog attack- focus on “ hazards identified by universal services 2015 -1 relating to death of an infant where safe sleeping and co sleeping identified as an issue. (sofas) 2015 - In addition a multi- agency review is being conducted in relation to a child who had unexplained bruising and trauma to head. Current SCRs being undertaken by Northamptonshire NSCB

5. Cases Considered in 2014 which did not meet SCR Criteria but needed Multi- Agency Review 2 referrals relating to dog bites -Case Mapping Exercises held and reported to NSCB A Scoping exercise was conducted in relation to 6 babies, under the age of 4 months who had sustained injuries, 4 had serious injuries, including to the head

6. Findings Lack of analysis of historical information Lack of robust planning and ineffective communication within and between agencies Lack of recognition of the vulnerabilities of babies or of young mothers Sleeping arrangements not seen or discussed Little, if any, evidence of the child’s voice – i.e. What was it like to be a child in that family? Lack of assessment of fathers or recognition of the role they play in the family – even if “absent” Disguised compliance and focus on adult needs Assumptions about professionals’ roles made and not challenged Lack of risk assessment of “family” members Child Protection plans not SMART

7. Actions Taken Self harm pathway revised –particular focus on young people who are about to be young adults Leaving care protocol revised Recognition of and response to reported sexual abuse included in training programmes Pre-birth assessment protocol revised and re-launched 2014 Use of CAF addressed Individual agency action plans reported to and monitored by NSCB Varied approach to dissemination of SCR recommendations taken, including training, newsletter and practitioner briefings. Promotion of safe sleeping

8. NSCB Contact Details: Telephone number: 01604 364036 Email address: NSCB@northamptonshire.gcsx.gov.ukNSCB@northamptonshire.gcsx.gov.uk Website: www.northamptonshirescb.org.ukwww.northamptonshirescb.org.uk