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

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Surrey Wide CCG Safeguarding Children Team

Surrey Wide CCG Safeguarding Children TeamSafeguarding Children & Young PeopleLearning from Serious Case Reviews

This presentation presents information from selected recent Surrey Serious Case reviews.

Surrey Wide CCG Safeguarding Children TeamIntroduction

Surrey Wide CCG Safeguarding Children TeamEstablish 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 ReviewSerious Case Reviews are not inquiries into how a child dies or who is to blame. These are matters for coroners and for criminal courts.

Discuss impact on staff who are part of the process, need for support, updated regularly on progress


Regulation 5 (1) (e) and (2) of the LSCB RegulationsSets out an LSCBs function in relation to serious casereviews, 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 TeamSerious Case Reviews LSCB Regulations 2006Statutory requirement and the legal framework for undertaking SCRs4(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 TeamSerious Case Reviews LSCB Regulations 2006Expand on Working Together 2015 and further definition of seriously harmedCame from recommendation made by Independent panel of experts5Young 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 TeamSurrey Serious Case Reviews6Came 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 23rd 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 TeamYoung Person Hiers 7

Surrey Wide CCG Safeguarding Children TeamYoung Person Hiers- Practice Issues that Emerged


Surrey Wide CCG Safeguarding Children TeamRead through the case study of Child S.

In pairs/groups, list what you think are the main lessons that emerged from this SCR?

FeedbackCase Study

Surrey Wide CCG Safeguarding Children TeamInadequate recognition by a number of professionals of the significance of interacting risk factors including: failure to engage with serviceslack of antenatal caresubstance misusedomestic violenceambiguous feelings towards two pregnancies and a troubled parental history as a child

Child S practice issues that emerged

Surrey Wide CCG Safeguarding Children TeamPractitioners did not fully appreciate the implications of parental misuse of alcohol and take action to reduce risk to the children.

Practitioners in Childrens 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 mothers historical records presented challenges to the review team and this lack of access also impacted on practitioners

Child S practice issues (continued)Practitioners did not fully appreciate the implications of parental misuse of alcohol and take action to reduce risk to the children.Practitioners in Childrens Social Care and Health did not recognise the significance of bruising/injuries in non-mobile babies.This case has features similar to those found in previous serious case reviews in: engaging with fathers, recognising the significance of family history, risk assessment in situations of domestic violence, substance misuse and working with resistant families.Working with resistant families requires practitioners to have highly developed interpersonal skills supported by effective supervision which addresses the emotional impact of such work .When the case was closed to Children's Social Care there were missed opportunities for a more structured approach to the assessments undertaken and help given to the family.


Surrey Wide CCG Safeguarding Children TeamChild X Case SynopsisThe 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 childrens services after the mother is ejected from parental home. However, there was confusion whether this was a referral or information sharing, lead to childrens services taking no further action


Surrey Wide CCG Safeguarding Children TeamChild X (continued)In the first 3 weeks of the babys 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

Surrey Wide CCG Safeguarding Children TeamPractice issues that emergedFailure 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

Surrey Wide CCG Safeguarding Children TeamPractice issues that emerged (continued)Lack of consistent involvement by the same professional in all areas of the babys 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 colleaguesExpand on the rule of optimism, what this means. Dingwall et al

Commonly identified in SCRs (Brandon)

Failure to revise judgements. One of the common problematic tendencies in human cognition is our failure to review judgements and plans once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture. (Fish, Munro & Bairstow 09). Stop, look and listen, and look again Professional curiosity15

Recognising NeglectIf time permits could discuss similarities from other SCRsChild Y, 2013 baby (6 weeks): bruising and head injuries, neglect inter-relating risk factors, DA, parental substance misuse, criminalityU&V filicide suicideJ&K filicide Q drowning, professionals not recognising neglect issues and inter-relating risk factors, DA, depression, criminality

Many of the SCRs showed professionals focused on parental needs diverting attention away from the needs of children. Often not seen, or their wishes and feelings not heard

Could expand on step down/ step up process. Need for professional challenge and escalation process if needed16

Surrey Wide CCG Safeguarding Children TeamRecommendations for practiceRecommendations therefore aim to improve:Assessment & recognition of risk:Improving risk assessment, analysis and management of risk, use of specific risk assessment tools

Improved use of specific assessments tools, alcohol drug misuse, DA, CSE neglect assessment tools graded care profile. Mental health

Improved use of access to historical records

Effective use of early help assessments and step down process

Discuss tools can be found in multi-agency procedures/SSCB website

Assessment is a dynamic process its not just a gathering of information exercise, its about understanding and analysing the information to determine need, harm and risk and formulating an action plan that is reviewed regularly. Assessments should always be revised when new and changing information is received. Failure to revise judgements is frequently sited in SCRs (Brandon et al) As is the rule of optimism

Skills & Training:Professional responsibility to ensure you are update with your safeguarding practice

Access specific safeguarding training, working with disguised compliance, and resistance, drug and alcohol misuse, working with fathers, CSE, DA etc

Learning from SCRs

Know how to access policy and procedures, multi-agency and your own organisations

Know who contact if you have concerns and how to refer to statutory authorities

Make use of the GP prompt cards

Be prepared to challenge constructively the views of others including parents

Ensure records are up to date and inline with recording keeping policies, standards

Management and organisational support:Ensure you receive regular effective safeguarding supervision. Supervision should include critical and reflective practice.

System/process in place for flagging children on CPP, families causing concern

System/process in place for tracking DNAs

Good record keeping systems

System/process for sharing of relevant information with others

Easy access to policies/procedures

Dissemination of safeguarding information and learning from SCRs CRs

Understand barriers to learning, why doesnt change happen? how do you support staff and colleagues in managing complex cases, dealing with resistance

Whistle blowing, escalation policies, supporting staff to challenge and to raise questions and report concerns


Surrey Wide CCG Safeguarding Children TeamMulti-agency Child Protection Procedures and GuidanceMulti-agency procedures website:

Surrey Safeguarding Children

Surrey Wide CCG Safeguarding Children TeamResources & Further ReadingTen pitfalls and how to avoid them

Working Together to Safeguard Children 2015

Surrey Serious Case Reviews

Surrey Wide CCG Safeguarding Children TeamEarly Serious Case Review into abuse at Little Teds Nursery Childrens Needs Parenting Capacity. Child Abuse: Parental mentalillness, learning disability, substance misuse and domestic violence(Cleaver et al)

Serious Case Review - Published January 2012 - The Abuse of Pupils in a First School (North Somerset SCB)

Surrey Wide CCG Safeguarding Children TeamDomestic Violence Child Protection and impact on Children

Victoria Climbie Enquiry

Victoria Climbie summary report

Peter Connelly first SCR report

Surrey Wide CCG Safeguarding Children TeamSCR Keanu Williams SCR Daniel Pelka Overview Report

What to Do if Youre Worried a Child in Being Abused 2006

Information Sharing Guidance for Practitioners and Managers

Surrey Wide CCG Safeguarding Children TeamFor advice or to make a referral:North East Referral Hub: 0300 123 1610South East Referral Hub: 0300 123 1620North West Referral Hub: 0300 123 1630South West Referral Hub: 0300 123 1640Emergency Duty team: 01483 517898Surrey Police: 101 (or 999 in an emergency)

Referrals should be made to Children's Service using the Multi-AgencyReferral Form (MARF). If the referral is urgent and is made verbally itmust be followed up by the MARF within 48 hours.Childrens Services


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