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

Surrey Wide CCG Safeguarding Children Team


Safeguarding Children & Young PeopleLearning from Serious Case Reviews

This presentation presents information from selected recent

Surrey Serious Case reviews.


Introduction


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

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.


Serious Case Reviews – LSCB Regulations 2006

(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.


Serious Case Reviews – LSCB Regulations 2006

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 Serious Case Reviews

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 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


Young Person Hiers- Practice Issues that Emerged


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


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


• 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)


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

Surrey Wide CCG Safeguarding Children TeamChild 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


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


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

Recognising Neglect


Recommendations for practice

Recommendations therefore aim to improve:

Skills & Training

Management and organisational

support

Assessment &

recognition of risk


Multi-agency Child Protection Procedures and Guidance

Multi-agency procedures – website: www.sscb.proceduresonline.com

Surrey Safeguarding Children Board

www.surreycc.gov.uk/safeguarding

http://www.sscb.proceduresonline.com/

http://www.surreycc.gov.uk/safeguarding


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









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

http://www.surreycc.gov.uk/earlyhelp

http://www.plymouth.gov.uk/homepage/.../littletednurseryreview.htm



http://www.northsomersetlscb.org.uk/uploads/files/282.pdf


Domestic Violence – Child Protection and impact on Children

https://www.nspcc.org.uk/Inform/policyandpublicaffairs/northernireland/briefings/DVbriefing_wdf64606.pdf

Victoria Climbie Enquiry

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/5730.pdf

Victoria Climbie summary report

http://lx.iriss.org.uk/sites/default/files/resources/113A.%20The%20Victoria%20Climbie%20Inquiry%20-%20Summary-Report.pdf

Peter Connelly – first SCR report

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182527/first_serious_case_review_overview_report_relating_to_peter_connelly_dated_november_2008.pdf











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/information_sharing_guidance_for_practitioners_and_managers.pdf










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

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