1. Wirral Safeguarding Children Board
Case
Reviews
Summary Briefing
`Right Service
Right Time`
WIRRAL SAFEGUARDING CHILDREN BOARD

2. Session Objectives To understand the purpose of Serious Case Reviews
Case Review Briefing
Session Objectives
To understand the purpose of Serious Case Reviews
To reflect on learning from both National and Local cases

3. What are Serious Case Reviews?
Case Review Briefing
Undertaking SCR’s is a statutory function of LSCB’s.
Working Together states a Serious Case Review should be undertaken when:
(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 concern about the way agencies have worked together to safeguard the child
If a case does not reach the threshold for a SCR but there are lessons to be learnt from the case a learning review should be undertaken.
The final decision about undertaking a SCR is made by the Independent Chair and approved by the National Panel for SCR’s

4. The Purpose of Serious Case Reviews
Case Review Briefing
“…when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children.”
Source: Working Together to Safeguard Children (HM Government)
RIGOROUS - very detailed process looking at all contact professionals have had with the family – a detailed multi-agency chronology is prepared
OBJECTIVE - chronology is not completed by front line practitioner but by someone removed from the case each SCR is chaired by an independent author who does not work in the same area
ANALYSIS - based on the SCIE systems approach so as to analyse what happened at each point – Emphasis on systems approach – Not just what, but why?
Emphasis on actions resulting in lasting improvements
Transparency and independence
Systems methodology looks beyond learning at an individual practitioner level, to understand the deeper systems issues that may have contributed to the child’s death or harm, while setting this understanding within the wider context of the case

5. National Learning
Case Review Briefing
The 2016 DfE triennial report on learning from SCR’s presented the following significant learning points:
1 in 5 SCR’s is undertaken on a child currently or previously on a child protection plan
About 60% of children are/have been known to children’s social care
43% of all SCR’s are undertaken on babies less than 1 year old (most vulnerable group)
Teenagers (14-18) are the second most vulnerable group
Neglect is an underlying feature in over 60% of all SCR cases
Poor information sharing and ineffective multi-agency working are a feature of almost all SCR’s
Statistics from the DfE report on a total of 293 SCRs relating to incidents which occurred in the period 1 April March 2014.
1 in 5 SCR’s is undertaken on a child currently or previously on a child protection plan – sometimes plans are closed too quickly
43% of all SCR’s are undertaken on babies less than 1 year old (most vulnerable group) – What makes them vulnerable
Teenagers (14-18) are the second most vulnerable group – Why? Because often this groups are more independent and can seem hard to engage (as in the case of Hannah Windsor)
Poor information sharing and ineffective multi-agency working are a feature of almost all SCR’s – certainly as highlighted in the case of Victoria

6. National Learning – Key Themes
Case Review Briefing
Domestic Abuse
Neglect
Teenagers
Child Exploitation
Define contextual safeguarding and check that everyone understands and is happy with the information
Thematic national learning from SCR briefings are helpfully published in one document on the WSCB website

7. Domestic Abuse 54% of families had current or previous domestic abuse
Case Review Briefing
54% of families had current or previous domestic abuse
Understanding the roles of men in the family
Seeing the mother alone
Avoiding an over-reliance on the mother’s ability to protect their children
Seeing the bigger picture
Maintaining a healthy scepticism
Talking about domestic abuse between agencies
Understanding the complex nature of domestic violence relationships
Understanding the impact on children
Helping the mother to understand the impact on the children
Understanding the roles of men in the family - the invisible male is a recurring theme in SCRs
Any assessment should include information about all members of the household, including biological fathers, new partners or ex-partners who are back in the picture. Information about who lives in the home and who has contact with the children should be verified and kept up-to-date. The identity of any unknown males in the home should be investigated.
Seeing the mother alone
Agencies must do their utmost to provide suitable opportunities for women to disclose in private. Contacting women at work is not an appropriate way of doing this, as the work environment is rarely a place where women can discuss details of their home life.
Using text messages to communicate with vulnerable service users is not appropriate either. A controlling partner can easily pick up messages so that they know about appointments, or can cancel or re-arrange appointments to suit them. It is not possible for professionals to know whether text messages are from the intended recipient or from someone else.
Avoiding an over-reliance on the mother’s ability to protect their children
Where men refuse to engage with services, there is the danger that child protection plans focus too much on the mother’s ability to protect her children. This can lead to an over-optimistic view of the mother’s parenting ability. When men are not part of the child protection plan, the danger is that the risks they pose are then overlooked..
Seeing the bigger picture
One-off incidents of domestic violence or physical injury may not meet the threshold for child protection procedures. However, these incidents need to be seen within the context of what else is known about the family. This usually means ensuring that relevant and up-to-date information has been gathered from all agencies in contact with the family. Failure in professional practice arises when a series of “one offs” are not put together to see the bigger picture
Maintaining a healthy scepticism
Disguised compliance is a common factor in families living with domestic abuse. In some cases, the mother tells agencies that she is no longer in touch with her ex-partner. Only too late does it become apparent that he is still seeing her and/or the children.
Talking about domestic abuse between agencies
Terminology used to talk about domestic abuse can be quite subjective. The danger of recording incidences as “family problems” or “arguing with partner” by some agencies minimises the seriousness of domestic violence and may lead to it not being identified as a high risk by other agencies.
Understanding the complex nature of domestic violence relationships
Some domestic abuse relationships are characterised by separations and reconciliations. Professionals must be alert to the possibility that a separated couple may be back together and should not rely on a previous claim that the relationship had permanently ended.
Even where alternative accommodation has been provided to enable escape from an abusive partner, in some cases the mother will still let her partner know where she and the children are. In some cases where the police are called out, the mother will later retract the allegation, minimising or justifying the attack.
Victims of domestic abuse are afraid of the consequences of speaking out and seeking help.
Understanding the impact on children of living with domestic violence Any professional who sees mothers who are victims of domestic violence, should make a child protection referral to children’s services. Often violence against the mother is not recognised as a child protection issue, so assessments focus on the needs of the mother, rather than the safety of the children.
Helping the mother to understand the impact of living with domestic violence Information should be provided to mothers regarding the possible impact of domestic abuse, both emotionally and physically, on the children.

8. Neglect Neglect is a factor in 60% of serious case reviews
Case Review Briefing
Neglect is a factor in 60% of serious case reviews
Be aware of children who are more vulnerable to neglect
Monitor missed appointments
Be vigilant to accidents and injuries
Effectively assess parental capacity and ability to change
Understand the long-term impact of neglect
Evidence-based Assessment and Intervention Work using assessment tools
Focus on improved outcomes for the child’s daily lived experience a
Avoid Case Drift
Be Aware of Children who are more Vulnerable to Neglect
 Newborn babies, premature babies and children with ongoing health needs and developmental difficulties are particularly vulnerable.
 Teenagers’ needs can be missed especially where there are younger siblings. Professionals should understand the impact of long term neglect on a teenager’s emotional wellbeing and consider the risk of self-harm or suicide.
Unmet health needs – head lice dental decay failure to thrive developmental delay esp speech delay
Monitor Missed Appointments
Professionals in all agencies should understand the significance of missed medical appointments for children. In one case the only indication of a sudden change in parenting capability was an emerging pattern of non-attendance at appointments.
A system should be in place that allows:
 missed appointments to be monitored
 professionals to know what action to take when there are concerns.
Pay Attention to Accidents and Injuries
Frequent accidents may be an indicator of poor quality parenting through lack of supervision or living in an unsafe home.
 Repeated visits to A&E should raise concern.
 Lack of supervision may include inappropriate supervision such as unacceptably young babysitters or unsuitable adults.
Have the Confidence and Knowledge to Effectively Assess parental Capacity and Capability to Change
 Be clear with parents about what needs to change and by when. Parents should be respectfully challenged when they fail to follow formal agreements.
 When there’s no long term positive change, the lead professional should co-ordinate support and services. Doing this will help agencies work effectively together.
 Warm relationships between parents and children shouldn’t override concerns about neglect.
 Maintain focus on the best interests of the child rather than the immediate needs of a parent who may be dominant or very needy.
 Improvements to poor home conditions should be regularly reviewed, especially if the family is unlikely to sustain them.
 Be aware of the possibility of disguised compliance.
See the Bigger Picture and Understand the Long-term Impact of Neglect – avoid start again syndrome
 Always take the full history of the family into account and patterns of previous episodes of neglect. Include background information of the parents’ own childhood to better assess parenting capability.
 Record all circumstances which may affect the level of care the child receives, for example substance misuse, and establish any patterns of care, such as the child being left with neighbours.
 As well as ensuring a healthy physical environment, make sure the child is helped to build healthy relationships.
 Alongside proactive case management and decision-making, identify and record all incidents of neglect to build a picture of what is going on in the child’s life.
 Emotional neglect is particularly difficult to evidence
 GPs and other GP practice staff should be actively curious when engaging with a family where there are concerns about neglect.
Support Families through Early Evidence-based Assessment and Intervention use the GCP
The Graded Care Profile (GCP) provides a structure for assessing the type and level of neglect so it can be addressed in a timely and appropriate way.
 Where there’s risk of neglect, families should be supported within a model of early intervention.
 Compile a multi-agency chronology of key events.
 Invite health professionals such as the health visitor or school nurse to meetings.
 Thresholds for intervention should be clearly understood across agencies so that professionals can challenge each other with confidence.
 Ensure terminology is free from jargon and clearly understood by the family and all professionals involved.
 Roles and responsibilities must be clearly understood.
 When undertaking multi-agency assessments all agencies must be aware of which agency is leading and what action is being taken.
 Where families refuse to engage with early assessments, this shouldn’t prevent professionals from sharing information or making referrals about child protection concerns.
 Where neglect coexists with physical or sexual abuse, a criminal prosecution for abuse shouldn’t be viewed as the only means of child protection. Where criminal cases don’t result in a prosecution, child protection proceedings may still be necessary to keep the children safe from harm.
Keep Focus on the need to Improve Outcomes for the Child’s Daily Lived Experience
Feelings of hopelessness in families experiencing neglect for a long time may also be felt by professionals. Where there is no change for the better, professionals may sometimes struggle to know how to proceed. The reviews show that sometimes cases were transferred to a colleague, or even closed.
 A review should always take place before a case is closed or transferred.
 Interventions must be linked to specific improved outcomes. Professionals should undertake regular reviews to check improvements are being made. Where improvements are not being
sustained, professionals must decide whether legal proceedings are necessary to protect the child.
Use Staff Supervision to avoid Case Drift
Hope for change for families must be balanced with the absolute need to avoid case drift.
Effective and reflective supervision should enable practitioners to assess children’s development and behaviours in families with high levels of need.
 If a case becomes ‘stuck’ there should be a process where practitioners can escalate the situation to senior managers. This may help to provide a fresh, objective approach to address the problems.
 There should be an opportunity to stop and review the whole case. Supervision should assist practitioners with the discipline of reflective thinking.
 The main focus should always be whether the child’s needs are being met and how that can be achieved to prevent significant harm.
Monitor progress using GCP

9. Teenagers Teenagers (14-18) are the second most vulnerable group
Case Review Briefing
Teenagers (14-18) are the second most vulnerable group
Listen to what young people are trying to say: Disclosure; lead practitioner and advocate: self harm or suicide; balancing wishes with best interests
Keeping the focus on the young people: Treating year olds as children; helping young people access services; understand risky and challenging behaviour; keep clear chronologies
Service provision: Early intervention; accommodation provision; sexual health provision.
Listening to what young people are trying to say
 Disclosure Young people’s disclosure of abuse and suicidal thoughts should be taken seriously and acted upon accordingly. Retractions should be taken as seriously as accusations.
 Lead practitioner and advocate Multi agency responses should be coordinated by a lead practitioner who has built up a relationship with the child. Similarly, young people should be provided with an advocate to explain their rights and represent their best interests.
 Self harm or suicide Incidents involving self harm or suicide should be treated as child protection as well as mental health issues. Young people should not be discharged from hospital following a suicide attempt without an assessment of their child protection needs.
 Balancing wishes with best interests Despite the apparent independence and maturity of some young people, professionals should not be too quick to act in accordance with a young person’s expressed wishes. In some cases these wishes are in direct conflict with their best interests. For Child G she was chatty and interactive but this disguised the extent of her learning difficulties
Keeping the focus on the young people
 Treating year olds as children in need Young people aged between 16 and 17 are still children, and need the same level of support.
 Helping young people access services Failure to attend appointments should not be equated with a lack of desire to receive support, and may be a reflection of the chaotic lifestyles some vulnerable young people lead. Cases should not be closed purely on the strength of poor attendance. Professionals should persevere to ensure that young people receive the services they need.
 Risky and challenging behaviour Professionals should consider the causes of young people’s risky and challenging behaviour, rather than focusing on the behaviours themselves.
 Chronologies All agencies should be aware of, and continue to add to the young person’s chronology. Agencies should be aware of and reflect on the impact long term abuse and neglect has on the young people involved to ensure that the appropriate level of support is provided.
Service provision
 Early intervention Interventions should take place as early as possible. Young people should not be exposed to long term, on-going abuse and neglect.
 Accommodation provision Teenagers taken into care should be placed in accommodation appropriate to their age and needs. In cases where they were subject to a child protection plan before being taken into care, families should be assessed for child protection concerns before young people are allowed to return home. Child G was in a placement where her needs and vulnerabilities were not communicated or understood
 Sexual health provision When an underage girl requests contraception it should prompt a full assessment of social circumstances and risk of sexual exploitation. Assessments of sexual activity should reflect on a girl’s emotional and intellectual maturity as opposed to just their level of understanding of the treatment (i.e. contraception).
Case of Child G – long history of parental neglect and abuse, bullying at school drug and alcohol misuse; challenging and criminal behaviour; self-harm. Was made more vulnerable by the fact she was aggressive and hard to engage so professionals moved away from offering her the support she needed.
At a young age, it was recognised that Child G had learning difficulties and she was later diagnosed as having Attention Deficit Hyperactivity Disorder (ADHD). Child G attended mainstream primary and secondary school, before transferring to a specialist school in Year 9. When she left school, she attended a local further education college for a term. At the time of her death, Child G was living in supported accommodation for young people aged
Child G was murdered by her boyfriend (BfG) in May 2012: Child G was 17 years old and BfG was 18 at that time. In view of the circumstances of Child G’s death and the involvement that both young people had had with local agencies and organisations, Wirral Local Safeguarding Children Board (LSCB) undertook to conduct a serious case review in respect of Child G.
The extent of Child G’s vulnerabilities was not understood by professionals working with her
Child G’s relationships and behaviours were not always understood in the context of both her learning difficulties and of the adversity she had suffered at home
Service provision was diffuse and lacked co-ordination
Child G was not sufficiently diverted from harmful activities

10. Child Sexual Exploitation/ CE
Case Review Briefing
Have an awareness of the warning signs
Use a comprehensive assessment
Draw on knowledge from different agencies
Understand the ‘capacity to consent’
Balance the young person's rights with the risks posed.
Perseverance and patience
Maintain a child-centred approach
On-going support
Sexual exploitation of children is not a ‘new’ issue – sexual abuse rings were studied from
the late 1970s organised abuse and abuse in institutions in the 1980s and 1990s
Identifying and assessing child sexual exploitation
 Practitioners must be aware of the warning signs of potential sexual exploitation and grooming, including: underage sexual activity; sexual health concerns; teenage pregnancy; getting involved in crime; concerning relationships, especially with unknown adults; alcohol and drug misuse; going missing from home or placement; truancy, exclusion and disengagement from school.
 Professionals providing sexual health services (including contraception) should consider the child protection implications of possible abuse or exploitation whenever they become aware of underage sexual activity.
 An early and comprehensive assessment should be carried out otherwise practice becomes task focussed with individual incidents being addressed eg. sexual health concerns, and the bigger picture of child sexual exploitation is missed.
 Assessment should draw on knowledge from different agencies so that a complete picture can be established in cases where sexual exploitation is suspected.
 Any assessment of child sexual exploitation must also include issues of 'capacity to consent', taking into account the grooming process and issues of coercion which may be experienced by victims of child sexual exploitation. 
Interventions
 Practitioners need to balance the young person's right to make their own decisions and assess their own risk, with the need to protect the young person from exploitation. Even when a young person is unaware or doesn't accept that they are at risk, or when risks to the young person's safety arise from their own behaviour and the decisions they make, professionals still need to intervene to prevent exploitation.
 Practitioners need perseverance and patience to help disengaged young people engage with and remain involved with services aimed at protecting and supporting them.
 Services need to embed a child-centred approach where children at risk of exploitation are viewed as vulnerable children in need of protection. Children need to be listened to and their experiences accepted, so trust can develop and young people can feel supported and able to disclose their experiences.
 Victims of sexual exploitation may need on-going support to ensure they are protected from further exploitation in the future
Mention of Child H?

11. CSE learning posters published on the WSCB website
Case Review Briefing
CSE learning posters published on the WSCB website
WSCB publishes 20+ learning posters on its site
Draw attention to distilled learning posters on the WSCB website. CSE ones are displayed but many others are on website.

12. Local Reviews
Case Review Briefing
The WSCB also reviews cases which don’t meet the threshold for a SCR but are reviewed as they may elicit learning. A summary of 12 cases reviewed on the Wirral between tells us:
There was an equal split between boys and girls as subjects of the reviews
Over half of the reviews undertaken were on children 16 or older. 25% of reviews on children under 3 years old
Neglect featured in over half the cases
MLD, criminal behaviour and exploitation, domestic abuse and transition issues were common features.
Case Review committee undertakes multi-agency learning reviews for cases where learning is likely but the case doesn’t meet the SCR criteria.
Anyone can refer a case, but should consult with their safeguarding lead first.

13. Learning Summaries
Case Review Briefing
Learning summaries (for SCR’s and local reviews), posters etc. are published on the WSCB website:
For each local review undertaken we publish a learning summary. This includes a summary of what happened, what the learning is and any recommendations.
The summaries also include key questions for agencies such as:
Are your staff familiar with, and do they use the GCP?
We have ten such summaries published with two more due to be published within the next couple of months.

14. What are Local Reviews Telling Us?
Case Review Briefing
Over half our reviews have been about teenage boys and a number of common themes emerged:
Long term neglect;
Lack of positive male role models;
Dysfunctional families – DV, Drug Alcohol Misuse, PMH
ADHD/ ASD/ MLD
Behavioural concerns – usually identified at Primary School
Escalating anti-social behaviour – often related to deteriorating school attendance
Criminal behaviour – criminal exploitation
Poor outcomes
Most of our recent reviews have been undertaken in respect of teenage boys.
Analysis of the findings from these reviews identifies a number of common features such as:
Long term neglect, which started very early in their lives, most often pre-birth;
Lack of positive role models – absent male is a feature as are males involved in criminal behaviour;
Dysfunctional families where adults are involved in all of or a combination of DV, drug abuse, alcohol misuse and/or parental mental ill-health. Families are usually difficult to engage with;
Behavioural concerns which are usually first identified at primary school – we don’t tend to dig too deeply into the underlying causes;
Behaviour with develops, as the boys get older into anti-social and often criminal behaviour. More of a recent focus on whether these boys are being criminally exploited;
All of this leads to poor outcomes with involvement with youth justice and criminal justice services

15. Case Review Briefing
Learning poster about boys on website.
Need to not lose sight of the vulnerability of teenage boys

16. Future Statutory Changes
Case Review Briefing
Act will replace LSCB’s with new local arrangements by Sept (1st Sept. in Wirral)
In the new arrangements SCR’s are replaced by Local Child Safeguarding Practice Reviews
New National Child Safeguarding Review Panel will consider all notifications of serious incidents and commission any National Reviews
Safeguarding partners are required to undertake a rapid review within 15 working days following any notifications
Child Safeguarding Practice Panel will be consider the case and makes a decision on whether an SCR is undertaken at either a national or local level.
From June 2018 Las must begin transition from LSCBs to new SG partner and CDOP arrangements – to be completed by Sept 2019 – grace period of 12 months to complete and publish outstanding SCRs
During the transition LSCBs have ongoing duty to commission and publish SCRs
The rapid review is designed to gather the facts of the case and consider whether a detailed review is required. Consider the need for immediate action needed to ensure child’s safety

17. End of Presentation
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