1. What can we learn? -Analysing child deaths and serious injury through abuse and neglect A summary of the biennial analysis of SCRs 2003-05 Brandon et al. Nicky Brownjohn Designated Nurse Safeguarding Children

2. Profile of cases Nature of injury 39% singular event 36% previous concerns Type of injury 35% physical assault 21% neglect 16% head injury/SBS Perpetrator 19% mother 19% father 19% mother & father 13% self 20% other

3. Profile of Cases Age 47% under 1 year (43% under 6 months) 20% 1-5 years 7% 6-10 years 16% 11-15 years 9% 16 + years 55% female 45% male 74% white british 12% black/black asian 6% mixed 6% asian /asian british 1%other

4. Emerging themes Child factors/experiences Very young babies Illness in babies Older child, hard to help Sexual exploitation Going missing Bullying Suicide Disability, chronic illness Family and environmental factors Domestic violence Substance misuse Mental ill health Fathers, hostility, criminal convictions Patterns of hostility and compliance History of neglect Previous child death Poverty Poor living conditions Frequent house moves Accidents

5. Emerging themes Practice /professionals, agency factors Agency context, capacity and ‘organisational climate’ Preoccupation with thresholds e.g cp threshold not met Professional anxiety and reluctance to act Professional challenge Supervision Ethnicity challenges Understanding and dealing with neglect – ‘start again syndrome’ Communication Keeping track of families Child not seen/heard

6. Key Themes Neglect Physical injuries Dv/substance misuse/mental health Older children Organisational climate

7. Neglect Child Factors linked to the younger child Prematurity/low birth weight Last in long series of pregnancies Resulting in stillbirth or miscarriages Factors linked to older children Long term neglect Self harm Suicide Factors linked to mother History of neglect by own mother History of being in care Frequent house moves Sexual abuse Leaving home early Multiple pregnancies Mental health problems Own father rarely mentioned Factors linked to father History similar to mother, or No history available Criminality Violence Uncontrolled /denied drug or alcohol misuse Factors linked to environment Poverty Poor housing Social isolation Engagement with agencies Avoidance of agencies Avoidance of families by agencies Lack of continuity of workers Optimism

8. Physical injuries Child Factors linked to the child Prematurity Persistent crying Numerous infections Colic Previous admission to hospital High number of contacts with primary health care Factors linked to mother DV history or present History of mental health issues LD “poor temper control”/immature Concealed identity /frequent moves Factors linked to father DV Behavioural problems as a child Current links with probation and mental health Past links with social care Factors linked to environment Volatile atmosphere Financial problems Multiple moves Engagement with agencies More contact with low level and universal services Mental health Difficult to engage Lack of awareness of police and health to risks of DV

9. 3 fold parent Violence Mental health issues Substance misuse 4 (9%) 6 (13%) 7 (15%) 16 (34%) 3 (6%) 3 (6%) 2 (4%)

10. Older children History of rejection, loss and usually severe maltreatment over long periods of time History of long term intensive involvement from multiple agencies –YOT, CSC, CAMHS Parents with their own history of abuse and rejection, misuse of substances and mental health difficulties Difficult to contain in school By adolescence, self harm and misuse of substances Self neglect Numerous placement breakdowns Running away and going missing Going missing increased risk of sexual exploitation and risky sexual activity – significant concern in a number of reviews At times these young people were placed in specialist therapeutic settings/secure units, but the were often discharged home because of persistent running away, so that at the time of the incident which prompted the scr they may have been receiving low level services only

11. Key Messages Early intervention levels 1 and 2 Interagency links Thresholds Working with neglect Supervision

12. Early intervention Early detection of parenting difficulties is crucial so that timely help can be offered Patterns of help seeking can be warning signs of parenting difficulties and abuse Accessible early intervention e.g sure start for stress in families with less severe problems, intensive, focused intervention for the families with more severe problems ‘Hard to reach’ families need flexible, individually tailored services For older children, including ‘hard to reach’, the effects of early maltreatment and trauma need to be acknowledged and addressed by all agencies working with young people and their networks

13. Be compassionate, Be sceptical Key message