Learning from Serious Case Reviews2010 - 2011

Child B

Introduction Statutory basis: Working Together to Safeguard

Children- A guide to inter-agency working to safeguard and promote the welfare of children. March 2010, Chapter 8 p233

Purpose: to examine the actions of agencies, determine if anything could have been done differently to avoid what occurred, to implement change if required.

After the S.C.R: Single agency and Multi-agency actions plans and Learning

Evaluation and Inspection: Ofsted. Proposed changes by Munro Review of Child Protection. Munro. May 2011

March 2010- publication Overview Report and Executive summary.

National Learning Biennial Analyses England 2003-2009 (618 SCRs)

and Wales (18 SCRs) Some patterns evident Known to CSC ? Just under half of children not

known at the time of incident but ¾ known to CSC in the past

Age of child? Nearly half under 1, nearly quarter 1-5, nearly quarter 11-17, (less than 10% aged 6-10)

Proportions of serious harm cases rising- formed 40% of all SCR in 2007-2009( although numbers of SCRs are dropping post publication decision in june2010)

Local LearningThere have been 2 SCRs in Newcastle over thelast 4 yearsAre these SCRs unique or part of a pattern? Both

1. Known to CSC and many other professionals2. CP Plan ? Both considered as vulnerable.3. 17 year old females4. Drug and alcohol misuse5. Criminal behaviour6. Died from drug overdose

Circumstances leading to the Serious Case Review of Child B Child B was admitted to hospital from

home on 22nd March 2010 in a collapsed state and was found to be in multi organ failure brought on by paracetamol ingestion. Despite intense efforts to save her including a liver transplant she died on the 23rd March 2010

Initial information indicated that Child B took the tablets on 19th March and was ill at home for 3 days prior to medical attention being sought on 22nd March. Initial enquiries indicated no other person’s culpability for Child B’s death.

A criminal investigation followed an allegation that Child B’s mother had been aware of the overdose throughout the weekend and failed to seek medical assistance. Subsequent enquiries suggested that her Father and sister were also aware of her condition.

Family Themes: Teenage pregnancy Absent fathers Drug and alcohol misuse/dependency Non school attendance / No educational achievement Young carer Poor medical health care Economic deprivation Leaving home at young age Aggressive behaviour from young age Misguided expectations from female members of the

family Mistrust of professionals and lack of engagement

generationalgenerational

generational

generational

generationalgenerational

generational

Practitioners Themes: Not recognising generational themes or cultural values

and beliefs Lack of historical perspective Not sharing information at the right time Incomplete paper exercise assessments Focus on mother not seeing the children’s needs behind

the adults Low expectations / desensitisation Starting again Misguided expectations What is good enough parenting? Totality of adolescent neglect

Learning good practice:

Referred to appropriate services

(timing and consistency) Identified as vulnerable

(early intervention key)

Learning cont…. Effective multi-agency planning and practice Knowledge, skills and confidence in working with

families where neglect is a feature (adolescent neglect)

Recognise the potential risks to children of alcohol misuse and the need for early identification

Strategies and skills for working with ‘hard to change’ or ‘highly resistant’ families

Learning cont….

Importance of alternative education provision Strengthening of formal admission and transition

arrangements involving schools Importance of support for the child and family

whilst excluded from school Reinforces the message about the potential

dangers of drugs that contain paracetamol Greater focus on issues of equality and diversity

within case work and delivery of services

Next steps:

Take learning back to your workplace for discussion and suggestions to improve practice and front line delivery

Implement monitor and review

Practice improvement is a

Continuous activity

Learning from what works Always focus on the child Serious Case Review

Learning (National) NSCB Appreciative Enquiry

Model Signs of Safety Family Group Conferences Involvement of Families

Any questions