1. Julie Daly, Head of Service, Safeguarding and Quality Assurance Yvonne Onyeka, BSCB Business Manager Learning from the findings of Serious Case Reviews

2. Objectives of the Seminar To enable participants to reflect on the findings of Serious Case Reviews and strengthen their practice and management Three reviews in Bromley conducted 2008 – 2010 (summaries on the BSCB website) A briefing on the main findings of the detailed review of the findings of 268 SCRs 2007 – 2009

3. The Purpose of Serious Case Reviews Public enquiries into child deaths Chapter 8 of Working Together 2010 - when to conduct a case review - how to go about it Learning from cases Accountability –to the LSCB –to the community (via the local authority and other agency boards) –to central government and the general public

4. The Process (1) Internal agency reviews Appoint a reviewer Secure the written and computer records Prepare a chronology Interview staff Write the agency management review Submit the material to the safeguarding children board SCR panel

5. The Process (2) LSCB overview report Appoint a SCR panel Appoint an independent chair and report author Produce a joint chronology Scrutinise the individual agency reports Evaluate the practice and agree the ‘lessons learnt’ Write the overview report Recommendations and an action plan

6. Dissemination of the findings Feedback for staff involved Learning for other staff and managers Local agency boards and the council Reports submitted to central government –Department for Education –Strategic Health Authority Publication of the Full Report

7. Main themes from the latest review of SCRs

8. References Brandon, Bailey & Belderson: Building on the learning from serious case reviews: a two year analysis of child protection database notifications 2007- 2009 – 268 SCRS M Brandon et al, Understanding Serious Case Reviews and their impact – A Biennial Analysis Of Serious Case Reviews 2005-7, (2009) DCSF and Families / University of East Anglia Peter Reder and Sylvia Duncan, Lost innocents – a follow up study of fatal child abuse, 1999, Brunner-Routledge An overview of 55 cases subject to serious case review and reported to government in one year Peter Reder, Sylvia Duncan, Moria Gray, and Olive Stevenson, Beyond Blame: Child Abuse Tragedies Revisited,1993, Routledge An earlier review of a less representative sample of cases M Brandon et al, Analysing child deaths and serious injury through abuse and neglect - what can we learn? A biennial analysis of SCRs 2003 – 2005, Department for Children Schools and Families, 2008.

9. The Review of Reviews SCRs in England 189 in 2003-2005 161 in 2005–2007 268 in 2007-2009 2007-2009 675 SINs to Ofsted 152 (57%) died 116 (43%) serious harmed

10. Some population characteristics Characteristics generally consistent over years. Half of all SCRs are babies under 1 (importance of universal services) 45% 23% (1-5 years) (26%) Quarter are older children – who pose a risk to themselves &/ others and needs not recognised (25%) Three quarters killed or harmed at home 72% white (slight under representation) 13% mixed parentage (slightly over represented) 8% black / black British (slightly under represented)

11. Population characteristics Characteristics generally consistent over years. 2007-2009 Under 1 year 281(45%)* 1-5 years136 (22%) 6-10 years54(9%) 11-15 years81(13%) 16 +66(11%)

12. Population characteristics cont. Ethnicity White 421(75%) Mixed54(10%) Black/Black British54(10%) Asian/Asian British27(5%) Other 8(1%)

13. Population characteristics cont. Male331 (54%)* Females286(46%) Disabled 21(8%) Incident type Fatal 381 (62%) Serious 237 (38%) Injury

14. Case characteristics Parents Domestic Violence34% Mental Health27% Drug misuse22% Alcohol misuse22% Child of teen pregnancy7% Parent history of being in care7%

15. Case characteristics Child More than one child abused19% Serious iIlness7% Drug/Alcohol misuse –child7% Mental health problems – child6%

16. Themes: Legal and care status 16% subject to a child protection plan 13% had been previously subject to a plan 23% listed multiple categories of abuse (nationally only 8% of CP Plans are multiple) 4% were accommodated under s20 7% subject to a care or supervision order 5% residence order

17. Case characteristics Relevant Factors Physic abuse55% Long standing neglect25% Recent neglect18% Sexual abuse14% Emotional abuse11% Shaken Baby Syndrome8%

18. Themes: Most frequent cause of death / injury 39% subject to physical assault (24% head injury to baby under age one) 16% died of neglect (fires, ingesting drugs, accidents) 12% adolescent suicide

19. Children who were missing or invisible Emotionally rejected by carers Not spoken to or kept away from professionals Specific vulnerability not appreciated (e.g. low birth weight, developmental delay) Siblings of the child wrongly thought to be most at risk Unable to speak through trauma, disability or fear So professionals need to see the child, know the child and see the world through the eyes of the child!

20. Chaotic, overwhelmed and unsupported families Physically and emotionally overwhelmed 45% had moved very frequently Negative relationships with extended family and others such as neighbours Deprivation and environmental dangers Pattern of low expectations held by families and by professionals Half in families characterised by domestic violence and almost two thirds in a family with a mental illness (past or current)

21. Large families & neglect 1 in 5 reviews on families with 4 or more children. Long standing concerns about older children not considered relevant in present time assessment of parental capacity for change needed ‘Start again syndrome’ Focus on individual child can be lost

22. Community Context 35 aged 11+ killed /harmed in community context mainly older teenagers. Professionals increased awareness of the harmed caused by gangs/youth violence. Some victims were siblings of gang members Absconding (running away regularly) Alcohol and drug excessive use Aspects of unsatisfactory or neglectful care of a disabled child –in/formal arrangements of care

23. Findings from the earlier 2003 – 2007 review of SCRs Significance of mental disorder, violence and substance misuse in the earlier sample Cumulative risk: –34% of cases had 3 of these risk factors –34% had two –(so 68% had 2 or more) –19% had one –but 13% had none at all

24. A hazardous and frightening home life Substance misuse, mental ill health, domestic violence and poor living conditions Don’t always predict serious harm but these factors hugely increase risk to children Points to the need for a holistic assessment

25. The need for dynamic assessment Stresses the importance of assessment based on ‘dynamic analysis’ as opposed to ‘description’ Risk produced by the interaction of experience, current environment, the challenge of parenting, family and personal history and relationships Developing and testing hypotheses about care and the child’s safety Identifying areas where change is needed Predicting capacity to change and care effectively Analytical assessment leads to safer practice

26. Risks from organisations cont Lack of capacity / resources was not always a feature of the review Some individual professionals and organisations were overwhelmed by the nature and the volume of the work Some families can drain the capacity to think and see clearly This can contribute to lowered expectations Refusal of some professionals to be ‘judgemental’ Attention focused in one professional or organisational ‘silo’

27. Risks from organisations and professionals …. Fixed views about the family (not responsive to signs of deterioration) Risks associated with certain types of parenting were underestimated (e.g. ‘rough handling’) Underestimating the need for high level support for carers - foster care mother & baby placements A need for respectful uncertainty & dogged professional challenge

28. The assessment and involvement of men Dearth of information (some organisations and professionals collude in this) Failure to involve men in assessment Fear of some aggressive men shaped practice Rigid and fixed thinking – men seen as either ‘good’ or ‘bad’

29. Significance of supervision and management in this context Critical and challenging thinking about: position and needs of the child history and circumstances of the family actions and attitudes of the worker functioning of the professional network as a whole

30. Bromley Serious Case Reviews Julie Daly Head of Safeguarding and Quality Assurance, LBB

31. Findings from the Bromley SCR in relation to baby ‘P’

32. Key facts 3 month old Black African baby girl 3 older half siblings were looked after by the local authority due to mother’s mental ill health Abandoned by her mother after her mental health deteriorated seriously Injured in the incident, but not badly

33. Concerns pointing to the need for review No pre-birth assessment Limited collaborative working between agencies and no pre-birth conference Social care staff had not taken actions required by the procedures (and staff from other agencies had not challenged this) An opportunity to review working relations between mental health and children’s staff

34. Agencies involved Children’s Social Care Services Bromley PCT Bromley Hospitals Oxleas NHS Foundation Trust Metropolitan Police

35. Positive findings about practice As far as the mother herself was concerned and taken in isolation from one another provision by midwife, health visitor and mental health services was good Services were very responsive to ethnicity and cultural background

36. Key findings Weak assessment by social care staff failed to take into account key factors Rapid turnover of staff dealing with the case Management input failed to identify weaknesses and prevent drift Mother misled some professionals and facts weren’t checked

37. Key findings (2) Inappropriate optimism based on mother’s current presentation No challenge over referrals not responded to and actions not taken by other agencies Mental health service worked from the assumption that mother would be able to care for the baby CPA meetings did not consider the baby’s needs Lack of curiosity about background and history Level of interagency contact was far too low

38. Key recommendations Review of staffing and provision in social care referral service Routine joint planning between professionals and changes in the CPA approach in such cases Review and implementation of the peri-natal mental health protocol Review of joint training on mental health issues Revised procedures for use of mother and baby placements in such cases

39. Findings from the Bromley SCR in relation to baby ‘C’

40. Key facts 3 month old mixed-race UK baby girl Development impairment following head injury in 2009 while at home with her mother Other injuries included old fractures of ribs, legs, knee cap, hand & fractures of skull Parents both had histories of depression, mother self-harmed, father had a cognitive impairment

41. Concerns pointing to the need for review Both parents received treatment for depression from same GP practice Two notifications from police & evidence from midwives, health visitor of unstable parental relationship Reports that mother self-harmed & expressed distress & frustration to health visitor & midwives about child’s crying Father’s head injury impacted on his cognitive functioning Health visitor and midwives identified poor parenting capacity

42. Agencies involved Children’s Social Care Services Bromley PCT Metropolitan Police Service Local Authority Adults & Community Services Two Hospital Trusts Ambulance Service Voluntary Agency

43. Positive findings about practice Health staff, having identified concerns, challenged the CSC manager regarding the decision not to undertake an assessment. Evidence of good supervision in health to consider different options for taking the case forward with CSC.

44. Key findings (1) Police and ACS fail to identify & share information with CSC on father’s risk to others GPs did not share information with ante-natal services CSC’s poor analysis of referral information leading to poor decision making. CSC’s fail to make full use of the London Procedures & risk assessment matrix The quality of the referral in relation to child protection

45. Key findings (2) Failure to pass on information by CSC to a voluntary organisation Pressure of workload and inexperience of staff in CSC leading to inappropriate allocations Lack of timeliness in progressing assessments Failure to assess and mobilise potential source of support in the extended family Lack of any formal planning processes or meetings

46. Key findings (3) Themes Weaknesses in the quality of risk assessment: The relationship between adult and children’s services: The experience and confidence of staff coupled with level of demand

47. Key recommendations Review the effectiveness of the multi-agency risk assessment training Continued training on domestic abuse Improved information sharing by and with police Front line staff feel able to openly discuss and escalate concerns Agencies aware of the need to make timely referrals to Police CAIC out of hours service Practice Standards Board to keep practice & information sharing between adult and children’s service under review. Review progress on the implementation of actions from previous SCRs.

48. Recommendations CSC to reduce the impact of demand and workload on frontline staff & managers CSC to review effectiveness of arrangements with commissioned services to ensure they work within their remit..

49. Findings from the Bromley SCR in relation to Child D and Child B’

50. Key facts Two white British boys aged 5 and 6 years old Brought into care after one of the boys found to have injuries, said to be caused by father Substantial contact between the boy’s family and agencies in Bromley Continuing concerns about neglect over a period of five years

51. Concerns pointing to the need for review Mother’s presented very late with pregnancy and second child born at home a ‘surprise’ birth Mother was adopted & a period in care. She alleges that she was sexually abused Father reports that ill health causing increasing problems for him. Children’s growth and development showed signs of delay reported by many professionals Several attempts to refer to children’s social care Parents various un/co-operative with agencies involved.

52. Agencies involved Bromley Access and Inclusion Services Bromley PCT Children’s Social Care Services Metropolitan Police Service Pre-school School Two Hospital Trusts Voluntary Agency

53. Key findings (1) CSC did not recognise the signs that the children were in need. No CSC assessment undertaken. Agencies did not adequately challenge the decision by CSC Insufficient emphasis on direct work with the children No comprehensive assessment of the needs of this complex family.

54. Key findings (2) Supervision arrangements did not challenge sufficiently the failure to make an enduring improvement to the circumstances of the children. Collective failure to intervene - possible negative effect from the involvement of many agencies Affirms the particular complexity of working with neglectful families

55. Key recommendations Safeguarding concerns must lead to thorough assessment and rigorous review of families. Assessment must be child focussed Responding to the challenges of working with unco-operative families Local procedures on concealed pregnancy Multi agency training on neglect All agencies to review safeguarding supervision to ensure it is challenging Agencies must follow up referrals to other agencies in writing as In LCPP. Services provided within specific catchment areas to have clear guidance on boundaries

56. Key recommendations 2 LB Bromley must ensure adequate staffing to meet statutory responsibilities. A multi-agency review of Common assessment framework LA should be satisfied with safeguarding arrangements at the school Education Welfare Service provision must be flexible enough to address safeguarding Early Years Service to support small scare private providers with safeguarding advice and assistance Bromley PCT to review Community Paediatric Services’ processing, prioritising and review of referrals School nursing services reminded to take individual action when concerned about a child

57. SUMMARY

58. Professional qualities, attitudes and behaviours to make a difference (1) 1.Do everything you can to obtain and understand the history 2.As well as evaluating what you do know - be extremely aware of possible gaps in your knowledge 3.Be alert about aspects of the children’s needs outside of your own specific brief that may not be being met

59. Professional qualities, attitudes and behaviours to make a difference (2) 4.Be aware of the needs of other children in the family, make referrals and seek relevant information 5.Don’t accept one positive sign of progress as being the equivalent of numerous negative ones (avoid undue optimism) 6.Be prepared to listen to and challenge others – especially when action that was agreed has not been taken

60. Professional qualities, attitudes and behaviours to make a difference (3) 7.Take much more pro-active responsibility for information sharing  think pro-actively about the potential value of information you have for others  think about the information that others may have that may be of use to you 8.Develop more effective working relationships with mental health and substance misuse services for adults 9.Ensure the agency insists on pursuing the right course of action with avoidant and aggressive families

61. www.bromleysafeguarding.org