1. Surrey Wide CCG Safeguarding Children Team Surrey Wide CCG Safeguarding Children Team Safeguarding Children & Young People Learning from Serious Case Reviews

2. This presentation presents information from selected recent Surrey Serious Case reviews. Surrey Wide CCG Safeguarding Children Team Introduction

3. Surrey Wide CCG Safeguarding Children Team Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and Improve intra- and inter-agency working to better safeguard and promote the welfare of children. Purpose of a Serious Case Review

4. Regulation 5 (1) (e) and (2) of the LSCB Regulations Sets out an LSCB’s function in relation to serious case reviews, namely: Regulation (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. Surrey Wide CCG Safeguarding Children Team Serious Case Reviews – LSCB Regulations 2006

5. (2) For the purposes of paragraph (1) (e) a serious case is one where: (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 is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Surrey Wide CCG Safeguarding Children Team Serious Case Reviews – LSCB Regulations 2006

6. Young Person Hiers 2013 - age 14: suicide Child S, 2011 – baby (8 weeks): head and other injuries Child X, 2012 – baby (4 weeks): bruising and multiple injuries Surrey Wide CCG Safeguarding Children Team Surrey Serious Case Reviews

7. Came to the UK in 2010 and lived in a bedsit in a shared house with his mother Started school in year 7, limited English initially but was considered to be progressing well Mother returned to China in 2013 to settle some family affairs. Young Person Hiers did not want to return with her so stayed in the UK with arrangements made for the landlord and other residents to keep an eye on him. Mother provided him with adequate food and money. School were unaware of this arrangement Surrey police were contacted by the NSPCC to say that the young person had been left home alone. Police attended home address and carried out welfare checks on 23 rd April Surrey police received a telephone call from the ambulance service to inform them that the young person had been pronounced dead at the home address Surrey Wide CCG Safeguarding Children Team Young Person Hiers

8. Surrey Wide CCG Safeguarding Children Team Young Person Hiers- Practice Issues that Emerged

9. Surrey Wide CCG Safeguarding Children Team Read through the case study of Child S. In pairs/groups, list what you think are the main lessons that emerged from this SCR? Feedback Case Study

10. Surrey Wide CCG Safeguarding Children Team Inadequate recognition by a number of professionals of the significance of interacting risk factors including: failure to engage with services lack of antenatal care substance misuse domestic violence ambiguous feelings towards two pregnancies and a troubled parental history as a child Child S – practice issues that emerged

11. Surrey Wide CCG Safeguarding Children Team Practitioners did not fully appreciate the implications of parental misuse of alcohol and take action to reduce risk to the children. Practitioners in Children’s Social Care and Health did not recognise the significance of bruising/injuries in non-mobile babies. Practitioners did not ensure that when a child on a Child Protection Plan sustains an injury this is examined by a paediatrician. Accessing mother’s historical records presented challenges to the review team and this lack of access also impacted on practitioners Child S – practice issues (continued)

12. Surrey Wide CCG Safeguarding Children Team Child X Case Synopsis The baby aged just 4 weeks lived with her young parents aged 18 and 20 years There were no obvious warning factors prior to birth; but following the review it emerged that the mother and her family were known to children services The mother had declined universal services – CAF, parent education and support with housing and finance. School nursing records suggest mother may have learning difficulties Little was known about the father Maternity inform children’s services after the mother is ejected from parental home. However, there was confusion whether this was a referral or information sharing, lead to children’s services taking no further action

13. Surrey Wide CCG Safeguarding Children Team Child X (continued) In the first 3 weeks of the baby’s life professionals had noted several bruises on different parts of the body and bilateral conjunctival haemorrhages The baby was seen by 5 different health disciplines and no one considered the bruising to be caused by abuse. The injuries were believed to have a medical cause and no one challenged this hypothesis The baby was admitted to hospital by ambulance following a seizure and a medical cause prevailed. Following transfer to a regional unit and following further medical investigation the baby was found to have suffered serious injuries including, sub-dural haematoma, leg & foot fractures and multiple rib fractures Both parents have been convicted and are serving custodial sentences

14. Surrey Wide CCG Safeguarding Children Team Practice issues that emerged Failure to follow child protection procedures due to lack of awareness of procedures, including bruising protocol No consultation with safeguarding leads or safeguarding supervisors Lack of effective communication & information sharing between all professionals involved which may have supported the prevailing hypothesis Poor recording keeping. Poor recording of facts, no body map of bruises, incorrect entries Significant administration weaknesses. Delay in transferring records, failure to send information in a timely fashion, incorrect information sent. Key information between health visitors was either not sent, or not received

15. Surrey Wide CCG Safeguarding Children Team Practice issues that emerged (continued) Lack of consistent involvement by the same professional in all areas of the baby’s care Overwhelming professional tide of optimism leading to rigid mind set and flawed professional judgement about the parents shifted the focus away from the child Lack of professional challenge – either to parents or to other professional colleagues

16. Recognising Neglect

17. Surrey Wide CCG Safeguarding Children Team Recommendations for practice Recommendations therefore aim to improve: Skills & Training Management and organisational support Assessment & recognition of risk

18. Surrey Wide CCG Safeguarding Children Team Multi-agency Child Protection Procedures and Guidance Multi-agency procedures – website: www.sscb.proceduresonline.com www.sscb.proceduresonline.com Surrey Safeguarding Children Board www.surreycc.gov.uk/safeguarding

19. Surrey Wide CCG Safeguarding Children Team Resources & Further Reading Ten pitfalls and how to avoid them http://www.nspcc.org.uk/inform/publications/downloads/tenpitfalls_wdf48122.pdf Working Together to Safeguard Children 2015 https://www.gov.uk/government/publications/working-together-to-safeguard- children Surrey Serious Case Reviews http://www.surreycc.gov.uk/social-care-and-health/childrens-social- care/information-for-child-social-care-professionals/safeguarding- children-serious-case-reviews

20. Surrey Wide CCG Safeguarding Children Team Early Help www.surreycc.gov.uk/earlyhelp Serious Case Review into abuse at Little Ted’s Nursery http://www.plymouth.gov.uk/homepage/.../littletednurseryreview.htm Children’s Needs – Parenting Capacity. Child Abuse: Parental mental illness, learning disability, substance misuse and domestic violence (Cleaver et al) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182095/ DFE-00108-2011-Childrens_Needs_Parenting_Capacity.pdf Serious Case Review - Published January 2012 - The Abuse of Pupils in a First School (North Somerset SCB) http://www.northsomersetlscb.org.uk/uploads/files/282.pdf

21. Surrey Wide CCG Safeguarding Children Team Domestic Violence – Child Protection and impact on Children https://www.nspcc.org.uk/Inform/policyandpublicaffairs/northernireland/briefings/DVbriefin g_wdf64606.pdf Victoria Climbie Enquiry https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/57 30.pdf Victoria Climbie summary report http://lx.iriss.org.uk/sites/default/files/resources/113A.%20The%20Victoria%20Climbie%2 0Inquiry%20-%20Summary-Report.pdf Peter Connelly – first SCR report https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182527/firs t_serious_case_review_overview_report_relating_to_peter_connelly_dated_november_2 008.pdf

22. Surrey Wide CCG Safeguarding Children Team SCR – Keanu Williams http://www.lscbbirmingham.org.uk/images/stories/downloads/executive- summaries/Case_25__Final_Overview_Report_02.10.13.pdf SCR Daniel Pelka Overview Report http://www.coventrylscb.org.uk/files/SCR/FINAL%20Overview%20Report%20%20DP %20130913%20Publication%20version.pdf What to Do if You’re Worried a Child in Being Abused 2006 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/190604/ DFES-04320-2006-ChildAbuse.pdf Information Sharing Guidance for Practitioners and Managers https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/277834/i nformation_sharing_guidance_for_practitioners_and_managers.pdf

23. Surrey Wide CCG Safeguarding Children Team For advice or to make a referral: North East Referral Hub: 0300 123 1610 South East Referral Hub: 0300 123 1620 North West Referral Hub: 0300 123 1630 South West Referral Hub: 0300 123 1640 Emergency Duty team: 01483 517898 Surrey Police: 101 (or 999 in an emergency) Referrals should be made to Children's Service using the Multi-Agency Referral Form (MARF). If the referral is urgent and is made verbally it must be followed up by the MARF within 48 hours. Children’s Services