1. Serious Case Review Child H Learning Event
London Borough Barking and Dagenham
LSCB

2. Purpose of Session
Clarify purpose & process of the serious case review SCR (involvement of staff and family)
Summarise child H’s story
Share findings emerging
Encourage questions, debate & learning

3. Serious Case Reviews
Working Together to Safeguard Children criteria Serious Case Review: for every case where abuse or neglect is known or suspected and either, a child dies, or is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child

4. The Process (1)
Systemic / seeking to appreciate context / avoid individualisation
Involvement of practitioners
Emphasis on learning throughout
Proportionate to the need & with sufficient independence

5. The Process (2)
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
Makes use of relevant research and case evidence to inform findings

6. Process (3) Chronology & reports from relevant agencies
Consultation with current & ex-employees & father of child H (deferred pending criminal process)
Panel debate
Acceptance of report by LSCB & its publication in October 2015

7. Wider Environment
Difficulty in understanding recurrence of non- accidental child deaths;
Consequence: anger, condemnation (reinforced / exploited by politicians & media)
Perceived need for alternative approaches to traditional serious case reviews

8. Data Sources
Formal records & in-depth discussions with involved individuals
A less linear, more circular process
Encourages ‘ownership’ of results & their commitment to improvement.

9. Child H Child H was an 8 year old girl who died on 29th August 2013.
Post mortem results indicate she died of extensive head injuries.
Child H and her family were known to a number of services , and were last seen on 20th August when all appeared well.
Her mother and a female were charged with murder / later found guilty of manslaughter

10. Review Period
From birth onwards – no health or education- related issues
Father had experienced mental health difficulties in 2007
? Parental separations ?

11. Potentially Significant Issues
Ms FX appears in records early 2008 – some further medical presentations
Father experienced a recurrence of mental health difficulties during 2010
No concerns about children’s development amongst involved agencies

12. More Recent Events of Significance
Ms FX joined the family during early told GP of having a new partner
Still no health or education-related concerns about the children
Parents separated mid-December 2012

13. Allegations of Domestic Abuse
School of child H’s brother initiated a multi- agency referral in December 2012
Mother & children moved to North London
Child H’s elder daughter returned to live with father in January 2013

14. Final 6 months of Child H’s Life
Mother in early February obtained Ex-parte Non- molestation & Prohibited Steps Order
Significant level of emotional and practical support to her from a school-based ‘parent support adviser’ (PSA)
Cafcass involvement triggered by court actions

15. Final 6 months of Child H’s Life
Breaches of NMO by father
Significant over-involvement by PSA
Court ordered a Cafcass report (subsequent admin-related delay at court)
Child H’s appearance and behaviours prompted no concerns by GP or teachers (a ‘model pupil’)

16. Final 6 months of Child H’s Life
Multi-agency locality team allocated a family support worker (FSW)
Mother, child H & brother by then at Ms FX’s home
Mother’s commitment to Islam suddenly diminished e.g. alcohol consumption
Removal of a lap-top from matrimonial home

17. Final 5 months of Child H’s Life
Further breach of NMO – father charged
Child H seen (last time before her death) by GP in mid-April – no concerns
Father sentenced to a Community Order
Cafcass officer met all family members re: future residence arrangements

18. Final 5 months of Child H’s Life
Children did not confirm abuse of mother
Chief concern of FCA was emotional abuse of elder sister
Ms FX increasingly involved in day to day care of child H and brother

19. Final 3 months of Child H’s Life
Cafcass report submitted to court (raised option of s.37 report from Children’s Social Care due to rejection of elder sister)
Ms FX increasingly involved in day to day care of child H and brother

20. Final 3 months of Child H’s Life
Cafcass report mislaid ? at court (later re- submitted in July)
Mother’s life-style now seen to include smoking / discarding of her hijab
Father mistakenly denied a copy of child H’s (very positive) end of year school report

21. Final 2 months of Child H’s Life
A Cafcass referral in late June prompted a s.17 assessment of needs of all 3 children by Children’s Social Care
Process was slightly delayed at father’s request
Child H died before planned meeting with her and her brother
Cafcass was trying to expedite contact

22. Final Week of Child H’s Life
FSW completed home visit about a week before death of child H
No indications of child H or brother being distressed
Day of child H’s death: conflicting accounts by mother & Ms FX; Police enquiries later revealed (from mobile records) long-standing sexual relationship and latter’s hatred of child H

23. Review Period Following criminal trial, father’s account sought
Delays in progression of private law proceedings apparently because of internal court difficulties
Cafcass & then Children’s Social Care concerned about emotional consequences to eldest child

24. Findings
Sensitive & well-informed work by Cafcass family court adviser
Sensitive & proportionate response in Children’s Social Care to referral from Cafcass
Parent support adviser role needs better definition & supervision

25. Conclusions
Death of child H was neither predictable nor preventable by local agencies
Review of professional work has identified areas for improved practice amongst local agencies & elsewhere (reflected in existing recommendations)
Methodology adopted expedited learning

26. Implications for Your Agency / Practice