1. 2019 Triennial Analysis of Serious Case Reviews Messages for Early Help Professionals

2. Workshop objectives
Review main learning from the report in three key areas:
Neglect and poverty
Vulnerable adolescents
Multi-agency working
Identify implications for Early Help teams
Support staff to develop their knowledge, skills and practice to keep children and young people safe
See for further information

3. Key themes Findings based on:
Quantitative analysis of 368 SCRs notified to DfE
Detailed analysis of 278 SCR reports that were available for review
Qualitative analysis of a sample of 63 SCR reports
Complexity and challenge: complexity of the lives of children and their families, and challenges faced by practitioners seeking to support them
Service landscape: challenges of working with limited resources, high caseloads, high levels of staff turnover and fragmented services
Poverty: the impact of poverty, which created additional complexity, stress and anxiety in families
Child protection: once a child is known to be in need of protection the system generally works well

4. Safeguarding and early help
More than half (55%) of SCRs were open to Social Care
Individual incidents (eg, self- harm, going missing) often elicited a response
Earlier recognition of issues underlying the eventual serious harm could have led to a more holistic response much earlier in the child’s life
The impact of austerity on the availability and configuration of local services is evident in the SCRs
Early help assessments should:
Aim to understand the issues underlying the presenting problems
Explore the complexity of family issues
Collate information held by partners across universal services

5. Neglect and poverty Neglect featured in 75% of all the SCRs examined
Neglect is the most common category of abuse for children on child protection plans
Poverty leads to additional complexity, stress and anxiety and can heighten the risk of neglect
Most children living in poverty do not experience neglect. However the co-existence of poverty and neglect can escalate adverse outcomes
Recognition of poverty and its impact on parenting was often missing. If recognised it was often perceived as an outcome not a cause of a family’s needs and difficulties
Practitioners working in deprived communities can become desensitised when working with families in poverty and accept lower standards or care

6. Adverse family circumstances in cases of neglect
Table 1: Parental and family adversity in SCRs where neglect was a feature (Rates are likely to be an underestimate as they depend on whether a factor was recorded in the SCR report; in some cases the question may not have been asked, in others the SCR author may not have felt the factor was relevant.)

7. Learning points
Practitioners can be reluctant to name neglect. A multi-agency approach to identification and assessment is key:
Practitioners need to be alert to the warning signs of neglect such as poor physical care, smelly and dirty clothes, or poor dental care
Poverty is associated with feelings of shame, stigma and having fewer resources to call upon. A positive consistent relationship with a practitioner can offer vital support
Immediate responses to the physical manifestations of poverty and a chaotic lifestyle do not equate with children being safe. The child and their wellbeing should be the primary focus of any assessment
Language is key to developing empathic practice. Reflective supervision supports practitioners to recognise the importance of their language
Concerns reported by wider family, neighbours or anonymously should be accurately recorded and triangulated with other sources of information
Practitioners need to be mindful of the link between experience of early and ongoing neglect and behaviours in adolescence

8. Early help for adolescents
There is increased potential for extra-familial risk and harm during adolescence - virtual and local communities provide spaces for exploitation
Nearly one in three SCRs involved children aged 11 and over
Most common causes of serious harm were (i) risk-taking/violent behaviour by the young person, and (ii) child sexual exploitation
Adolescents with safeguarding concerns will often have had early experiences of abuse and neglect, time in care and separation or loss
Practice responses to earlier harmful experiences can influence young people’s confidence in services
Professionals working with adolescents who have a history of disturbing and disturbed behaviour may become reactive rather than proactive, focusing on individual incidents rather than considering past experiences

9. Adolescent risk Extra-familial risks include: Going missing
Criminal exploitation (eg, moving drugs (county lines), violence, gangs, trafficking)
Child sexual exploitation (CSE)
Harmful sexual behaviour (HSB)
Radicalisation
Social media and technology-assisted harm
Suicide and self-harm
Loneliness

10. Complex and Contextual Safeguarding (Firmin et al, 2019)
Complex Safeguarding
This encompasses a range of safeguarding issues related to criminal activity involving vulnerable children or adolescents, where there is exploitation and/or a clear or implied safeguarding concern.
Includes child criminal exploitation, county lines, modern slavery including trafficking and child sexual exploitation (CSE).
Contextual Safeguarding
This is an approach to safeguarding children and young people which responds to their experience of harm outside the home – for example, online, in parks or at school.
It provides a framework for local areas to develop an approach that engages with the extra-familial dynamics of risk in adolescence.

11. Learning points
Children who have experienced trauma are not quickly made safe. Adolescent SCRs demonstrate the need for:
Prolonged and persistent engagement
Developing a trusting relationship
A balance of preventative work and crisis management
Looking beyond immediate presenting behaviours - young people involved in criminal exploitation should be seen as victims and safeguarded accordingly.
Voluntary agencies are sometimes better placed to encourage engagement through mentoring and mutual experiences
Non-fatal self-harm is strongly associated with suicide so referrals to health services should be made
Loneliness can be exacerbated for young carers and a young carer assessment may be helpful
It is important to offer ongoing training and support for professionals working with complex issues affecting adolescents

12. Multi-agency working
Systems and services around families can be fragmented and uncoordinated. Professionals who work with adults do not always consider the impact of risk for the children
Multi-agency Safeguarding Hubs (MASH) provide opportunities for key agencies to work together and establish appropriate criteria for meeting thresholds
Co-location of services can increase opportunities for informal liaison
Current and historical information sharing between services remains a key issue. Professionals may be less able to safeguard adolescents when schools/universal services try to manage incidents in-house

13. Learning points
Early help practitioners need to have an understanding of the roles and responsibilities of different organisations, how to refer on and share information with these agencies
Effective early help work requires a lead professional to act as key contact and coordinate service responses
Clear multi-agency plans are central to effective working
Referral forms, assessment tools, incident-logging tools should encourage the use of language that describe issues in ways that do not dilute impact/harm, and express the reality of life for the child
IT systems should be reviewed regularly to ensure they do not present barriers to the progress of referrals or to effective information sharing
Partnership working should be collaborative and open to ‘professional challenge’

14. Reflective questions
What development activities are available to support practitioners’ understanding of parents’ ‘resistance’ or ‘failure to engage’ with support offered?
What access do Early Help practitioners have to multi-agency group supervision?
How is service mapping kept up to date in your local area?
Does service mapping include communicating on multi-agency safeguarding responsibilities and local child protection thresholds and referral routes?

15. Further reading
Brandon M, Sidebotham P, et al (2019) Complexity and Challenge: A Triennial Review of Serious Case Reviews London: Department for Education.
Firmin C, Horan J, Holmes D and Hopper G (2019) Safeguarding during adolescence – the relationship between Contextual Safeguarding, Complex Safeguarding and Transitional Safeguarding. Dartington: Research in Practice.
HM Government (2018) Working together to safeguard children. London: Department for Education.