What can we learn? -Analysing child deaths and serious injury

through abuse and neglectA summary of the biennial analysis of SCRs

2003-05 Brandon et al.Nicky Brownjohn

Designated Nurse Safeguarding Children

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

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

Emerging themesChild 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

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

Key Themes

• Neglect

• Physical injuries

• Dv/substance misuse/mental health

• Older children

• Organisational climate

Neglect

Child

Factors linked to the younger child•Prematurity/low birth weight•Last in long series of pregnanciesResulting 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

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

3 fold parentViolence

Mental health issuesSubstance misuse

4(9%)

6(13%)

7(15%)

16(34%)

3(6%)

3(6%)

2(4%)

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

Key Messages

• Early intervention levels 1 and 2

• Interagency links

• Thresholds

• Working with neglect

• Supervision

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

Be compassionate, Be sceptical

Key message