Learning From Serious Learning From Serious Case ReviewsCase Reviews

Prity Patel LLB (Hons)Prity Patel LLB (Hons)

Independent ConsultantIndependent Consultant

September 2011September 2011

LearningLearning Outcomes Outcomes• To develop an understanding of the purpose and process of

conducting a Serious Case Review (SCR)• To gain a better understanding of the Practice Guidance

governing a SCR• To understand key ways of promoting action learning within the

SCR process have knowledge about the purpose, process and outcomes of serious case reviews

• To receive the findings of two local SCRs (Baby F and Child G) and one Case Audit (Case W) and some themes from national learning from SCRs

• To have the opportunity to discuss how the learning from these cases should influence inter-, and intra-, agency working in Bournemouth and Poole 

• Practice across all agencies will reflect on the learning from these cases

Working PrinciplesWorking Principles

• Each individual has a valid contribution to make Each individual has a valid contribution to make which will be valued and listened towhich will be valued and listened to

• Confidentiality should always be observedConfidentiality should always be observed

• There will be mutual respect within the group for There will be mutual respect within the group for individuals and their experiencesindividuals and their experiences

• Naive questions will be considered the norm!Naive questions will be considered the norm!

Serious Case ReviewSerious Case ReviewThe Purpose Of A SCRThe Purpose Of A SCR

• Prime purpose for agencies and individuals to learn Prime purpose for agencies and individuals to learn lessons to improve the way in which they work both lessons to improve the way in which they work both individually and collectively to safeguard and promote individually and collectively to safeguard and promote welfare of childrenwelfare of children

• Identify clearly what those lessons are both within and Identify clearly what those lessons are both within and between agencies- What changes in practice need to be between agencies- What changes in practice need to be mademade

• Lessons learned should be disseminated effectivelyLessons learned should be disseminated effectively

• Recommendations should be implemented in a timely Recommendations should be implemented in a timely mannermanner

Serious Case ReviewSerious Case ReviewThe Purpose Of A SCRThe Purpose Of A SCR

• Where possible lessons should be acted upon quickly Where possible lessons should be acted upon quickly without necessarily waiting for the SCR to be completedwithout necessarily waiting for the SCR to be completed

• SCRs are not inquiries into how a child died or was SCRs are not inquiries into how a child died or was harmed or form part of any disciplinary process harmed or form part of any disciplinary process

Serious Case ReviewSerious Case ReviewWhen To Conduct A SCR?When To Conduct A SCR?

Working Together sets out the requirement for SCRsWorking Together sets out the requirement for SCRs

A LSCB should A LSCB should always always undertake a SCR:undertake a SCR:• When a child dies and abuse or neglect is known or suspected to be a When a child dies and abuse or neglect is known or suspected to be a

factor in the death. factor in the death.

A LSCB should A LSCB should consider consider whether to undertake a SCRwhether to undertake a SCR::• A child sustains a potentially life threatening injury or serious and A child sustains a potentially life threatening injury or serious and

permanent impairment of physical and/or mental health and development permanent impairment of physical and/or mental health and development through abuse or neglect; orthrough abuse or neglect; or

• A child has been seriously harmed as a result of sexual abuse; orA child has been seriously harmed as a result of sexual abuse; or

• A parent has been murdered; A parent has been murdered; oror

• A child has been seriously harmed following a violent assault perpetrated A child has been seriously harmed following a violent assault perpetrated by another child or an adult by another child or an adult and there is concern about how local and there is concern about how local services were delivered by professionals involved with the family.services were delivered by professionals involved with the family.

Serious Case ReviewSerious Case ReviewSCR PanelSCR Panel

• Ensuring membership of SCR Panel is vital - should Ensuring membership of SCR Panel is vital - should include at least representatives from relevant Partner include at least representatives from relevant Partner agencies. (WT 8.14) Panel will define the scope of the agencies. (WT 8.14) Panel will define the scope of the Terms of Reference for the SCRTerms of Reference for the SCR

• Independent Chair and Overview Author (WT 8.16)Independent Chair and Overview Author (WT 8.16)

• Health - Designated Leads or Named Nurse for Health - Designated Leads or Named Nurse for SafeguardingSafeguarding

• Health Overview Author - required to prepare Health Health Overview Author - required to prepare Health Overview ReportOverview Report

Serious Case ReviewSerious Case ReviewIMR - PreparationIMR - Preparation

Each agency involved in a case will write their own Each agency involved in a case will write their own Individual Management ReviewIndividual Management Review

• Review records and filesReview records and files• Develop initial facts/chronology and Develop initial facts/chronology and analysis• Interview staff- always keep a record. (WT 8.38)Interview staff- always keep a record. (WT 8.38)• Re-read filesRe-read files• Finalise Chronology and genogramFinalise Chronology and genogram• Finalise Factual InformationFinalise Factual Information• Finalise AnalysisFinalise Analysis• Identify the Lessons LearnedIdentify the Lessons Learned• Make RecommendationsMake Recommendations

Serious Case ReviewSerious Case Review The Purpose Of an IMR The Purpose Of an IMR

• To look openly and critically at organisational practiceTo look openly and critically at organisational practice

• To identify and analyse the context within To identify and analyse the context within which people people were workingwere working

• To indicate if the case identifies that improvements could To indicate if the case identifies that improvements could or should be madeor should be made

• To identify how those changes can be brought aboutTo identify how those changes can be brought about

Serious Case ReviewSerious Case ReviewIMR - ContentsIMR - Contents

• IMR and chronology is completed using templates from IMR and chronology is completed using templates from the LSCBthe LSCB

• Basic details and methodologyBasic details and methodology

• Contextual Background - demographics of Contextual Background - demographics of population you you are providing a service for, is there anything particular to are providing a service for, is there anything particular to your geographical area that may impact on how a service your geographical area that may impact on how a service is provided or meeting service user’s needs ?is provided or meeting service user’s needs ?

• IMRs and SCRs are anonymised IMRs and SCRs are anonymised • A factual summary of the agency’s involvement is set out A factual summary of the agency’s involvement is set out

and analysis of this is undertakenand analysis of this is undertaken• A genogram and family composition is suppliedA genogram and family composition is supplied

Serious Case ReviewSerious Case ReviewIMR- AnalysisIMR- Analysis

• Consider decisions made and the actions taken or not taken• Consider what best practice should be and how the service

should have been delivered• If practice has changed since the incident that led to the

SCR, this should be outlined• Were judgements made, or actions taken which indicate that

practice or management could be improved?• Gain an understanding of not only what happened but also

why? • Significant learning can be gained from probing beyond the

surface. A good IMR should reflect this

Serious Case ReviewSerious Case ReviewIMR - AnalysisIMR - Analysis

• Statements will be corroborated with effective examples Statements will be corroborated with effective examples to support your analysisto support your analysis

• Analysis is related to procedures and policies in respect Analysis is related to procedures and policies in respect of your agency and LSCB of your agency and LSCB

• Criticism needs to be constructiveCriticism needs to be constructive

• The Terms of Reference sets out the areas for focus The Terms of Reference sets out the areas for focus within the IMR as identified by the SCR Panel and WT within the IMR as identified by the SCR Panel and WT (8.39WT)(8.39WT)

Serious Case ReviewSerious Case ReviewIMR - AnalysisIMR - Analysis

• The IMR will reference Local and National Professional Standards/Guidance and learning from previous SCRs from your LSCB, and the Biennial Analysis of SCRs

• It will flag up Good Practice - Over and beyond what was necessary to meet the child’s needs NOT what is expected practice

Serious Case ReviewSerious Case ReviewIMR- RecommendationsIMR- Recommendations

• Identify Lessons Learned Identify Lessons Learned

• List Agency Recommendations- Make them SMARTList Agency Recommendations- Make them SMART

• Be succinct!Be succinct!

• Focus on a few key areasFocus on a few key areas

• Link to Lessons LearnedLink to Lessons Learned

• Recommendations WILL NOT be about what Recommendations WILL NOT be about what professionals should already be doingprofessionals should already be doing

Serious Case ReviewSerious Case ReviewAction PlanAction Plan

• Action Plan = Actual or Recognised Learning. Identify:Action Plan = Actual or Recognised Learning. Identify:

• the action the action • who will have lead responsibility within the agency to who will have lead responsibility within the agency to

ensure action is fully implementedensure action is fully implemented• the timescale to achieve completion of the the timescale to achieve completion of the

recommendation – Be Realistic but not foolish!recommendation – Be Realistic but not foolish!• What will be the desirable outcomeWhat will be the desirable outcome• How can the outcome be evidenced/measured? How can the outcome be evidenced/measured? • Individual Agency Action Plan will form part of Individual Agency Action Plan will form part of

Composite Action Plan that LSCB will monitor until all Composite Action Plan that LSCB will monitor until all actions completed and can be signed offactions completed and can be signed off

• Endorsement by Chief Officers of the agencyEndorsement by Chief Officers of the agency

Serious Case ReviewSerious Case ReviewTimescalesTimescales

• A SCR to be completed within 6 months (WT 8.23)A SCR to be completed within 6 months (WT 8.23)

• SCR Chair will prepare a timetableSCR Chair will prepare a timetable

• Important to meet deadlines- Failure to do so impacts Important to meet deadlines- Failure to do so impacts upon the whole SCR processupon the whole SCR process

• OFSTED feedback from previous SCR’s- Delay in OFSTED feedback from previous SCR’s- Delay in meeting timescales has been a significant factor in poor meeting timescales has been a significant factor in poor ReviewsReviews

Serious Case ReviewSerious Case ReviewLearning-FeedbackLearning-Feedback

• Learning needs to be implemented and acted upon – Learning needs to be implemented and acted upon – needs to be timelyneeds to be timely

• Dissemination of Learning- Consideration to be given to Dissemination of Learning- Consideration to be given to what type and level of information needs to be what type and level of information needs to be disseminated and to whomdisseminated and to whom

• Staff directly involved in the case need to have Staff directly involved in the case need to have feedback, may require supportfeedback, may require support

Serious Case ReviewSerious Case ReviewIMR FormatIMR Format

• Summarise the salient points of the key themes that you Summarise the salient points of the key themes that you have identified in your analysis, including good and poor have identified in your analysis, including good and poor practicepractice

• Highlight any progress that has already been made Highlight any progress that has already been made regarding implementing change in practiceregarding implementing change in practice

• This will be an opportunity for SCR Panel Members to This will be an opportunity for SCR Panel Members to raise questions with you- make sure you read your IMR raise questions with you- make sure you read your IMR before presenting it including informing the Panel of any before presenting it including informing the Panel of any updating information that may be relevant to the reviewupdating information that may be relevant to the review

Serious Case ReviewSerious Case ReviewPresenting the IMRPresenting the IMR

The SCR Panel scrutinises all the IMRs and will interview The SCR Panel scrutinises all the IMRs and will interview each IMR author at a SCR Paneleach IMR author at a SCR Panel

• The Panel is an opportunity for SCR Panel members to The Panel is an opportunity for SCR Panel members to raise questions with the authorraise questions with the author

• It is very likely that the author will be asked to make It is very likely that the author will be asked to make amendments and additions to the IMR as the information amendments and additions to the IMR as the information from other agencies may indicate gaps or areas to be from other agencies may indicate gaps or areas to be explored againexplored again

• The IMR is re-submitted following this workThe IMR is re-submitted following this work

Serious Case ReviewSerious Case ReviewOutstanding IMR’sOutstanding IMR’s

• Comprehensive history and chronologyComprehensive history and chronology• Good depth of detail/clear family historyGood depth of detail/clear family history• Staff/Managers interviewed to support file reviewStaff/Managers interviewed to support file review• Identification of strengths and good practiceIdentification of strengths and good practice• Keeping the child the focus of the IMRKeeping the child the focus of the IMR• Focussed recommendations linked to the analysisFocussed recommendations linked to the analysis• Clear and SMART action plan which identifies lessons Clear and SMART action plan which identifies lessons

already learnedalready learned

Serious Case ReviewSerious Case ReviewThe Health Overview ReportThe Health Overview Report

• To provide a critical overview of To provide a critical overview of all all health serviceshealth services

• They will not repeat information already provided in the They will not repeat information already provided in the Health IMRs – they will identify where there may be gaps Health IMRs – they will identify where there may be gaps in the analysis which needs to be included to tell the in the analysis which needs to be included to tell the story from Health’s perspectivestory from Health’s perspective

• Summarise salient learning points identified in Health Summarise salient learning points identified in Health IMRs- Always ask “ Why and so what?”IMRs- Always ask “ Why and so what?”

• Comment upon Health IMR recommendations- identify Comment upon Health IMR recommendations- identify gaps if any, make further SMART recommendations if gaps if any, make further SMART recommendations if appropriateappropriate

Learning From Serious Case Learning From Serious Case ReviewsReviews

• Last 15 months Bournemouth & Poole Local Last 15 months Bournemouth & Poole Local Safeguarding Children Board (B&PLSCB) has conducted Safeguarding Children Board (B&PLSCB) has conducted several reviewsseveral reviews

• 2 SCRs - Baby F and Child G2 SCRs - Baby F and Child G

• 1 Independent Case Review – Case W1 Independent Case Review – Case W

• Bournemouth & Poole Adult Safeguarding Board Bournemouth & Poole Adult Safeguarding Board conducted a SCR May 2008conducted a SCR May 2008

• Overlap of key learning from both child and adult reviews Overlap of key learning from both child and adult reviews involving Professionals from all agenciesinvolving Professionals from all agencies

Baby F - Baby F - BackgroundBackground

• Baby F born in summer 2009- Unplanned first babyBaby F born in summer 2009- Unplanned first baby

• Parents 18 and 17 yrs respectivelyParents 18 and 17 yrs respectively

• Parental relationship- known each other 8 monthsParental relationship- known each other 8 months

• Mother articulate and engaging with services initially. Mother articulate and engaging with services initially. Father has a history of CAMHS and YOT historyFather has a history of CAMHS and YOT history

• Incident of abuse when baby F 5 weeks oldIncident of abuse when baby F 5 weeks old

• MARAC thresholdMARAC threshold

• Father bailed - conditions no contact with mother – baby Father bailed - conditions no contact with mother – baby not specifiednot specified

• CP Inquiry, no CP ConferenceCP Inquiry, no CP Conference

Baby F – Baby F – Background (cont.)Background (cont.)

• Mr A breached bail conditionsMr A breached bail conditions

• Further bruising on mother Further bruising on mother

• CP Conference – emotional categoryCP Conference – emotional category

• Father convicted of assault on motherFather convicted of assault on mother

• Bruise to face – aged 4 months – no actionBruise to face – aged 4 months – no action

• Bruise discussion aged 5 months at Core GroupBruise discussion aged 5 months at Core Group

• January 2010 admitted with serious injuries bruising to January 2010 admitted with serious injuries bruising to face and parts of body, torn fraenulum, 3 fractures to one face and parts of body, torn fraenulum, 3 fractures to one leg possible broken legsleg possible broken legs

Themes From the CaseThemes From the Case

• Assessment/PlanningAssessment/Planning

• Domestic Violence – impact on childrenDomestic Violence – impact on children

• Engaging Fathers/Significant Males within the householdEngaging Fathers/Significant Males within the household

• Record keepingRecord keeping

Assessment/PlanningAssessment/Planning• Quality of assessment impacts on outcomes for the childQuality of assessment impacts on outcomes for the child

• Drawing on historical informationDrawing on historical information

• Child Protection Plans- Need to be SMART (Specific, Child Protection Plans- Need to be SMART (Specific, Measurable, Achievable, Realistic and Timely) and Measurable, Achievable, Realistic and Timely) and robustly monitoredrobustly monitored

• Include fathers/significant malesInclude fathers/significant males

• Explore parents’ own accountsExplore parents’ own accounts

• Assessment needs to be child focussed at all timesAssessment needs to be child focussed at all times

• Multi-agency – what information can be collated from Multi-agency – what information can be collated from other Professionalsother Professionals

• Assessment needs to have a Assessment needs to have a holistic approach.holistic approach.

Assessment of InjuriesAssessment of Injuries• Know your own agency procedures on seeking medical Know your own agency procedures on seeking medical

opinionopinion

• Timing of medical opinion crucialTiming of medical opinion crucial

• Observation- physical and behaviouralObservation- physical and behavioural

• History taking and reactionsHistory taking and reactions

• Rooted in Child development e.g.; non mobile babiesRooted in Child development e.g.; non mobile babies

• Appropriate recording - use of Skin MapsAppropriate recording - use of Skin Maps

• Referral and further investigationReferral and further investigation

Domestic ViolenceDomestic Violence• Cycle of abuseCycle of abuse

• Impact on childImpact on child

• Deceit / manipulation- disguised co-operationDeceit / manipulation- disguised co-operation

• Reliance on bail conditions and Written AgreementsReliance on bail conditions and Written Agreements

• Protective measuresProtective measures

• Contact arrangements- consider supervised or not, Contact arrangements- consider supervised or not, frequency, duration and reviewfrequency, duration and review

• Recording of injuries to both adult and child, taking a Recording of injuries to both adult and child, taking a holistic approachholistic approach

• Direct questioning. An Investigative style of questioning Direct questioning. An Investigative style of questioning needs to be developed. needs to be developed. Probe below the surface, do Probe below the surface, do not take at face valuenot take at face value

• MARAC to include planning for childMARAC to include planning for child

Engaging Fathers/Significant MalesEngaging Fathers/Significant Males• Meet with fathers/significant males in as many assessments as Meet with fathers/significant males in as many assessments as

possiblepossible

• Don’t let them be invisible!Don’t let them be invisible!

• May have to make suitable arrangements with working males- Offer May have to make suitable arrangements with working males- Offer alternative appointmentsalternative appointments

• Learn about their role in the family- how does it impact upon the Learn about their role in the family- how does it impact upon the childchild

• Record their viewsRecord their views

• Explore their historyExplore their history

• Understand the strengths they bring to the family and identify the Understand the strengths they bring to the family and identify the risksrisks

• Talk to other Professionals Talk to other Professionals

• Consider them in analysis and assessmentConsider them in analysis and assessment

Engaging Fathers/Significant Engaging Fathers/Significant Males(2)Males(2)

• Fatherhood Research Summary Fatherhood Research Summary

“…“…..If professionals systematically gather the young man’s ..If professionals systematically gather the young man’s details by, for instance, routinely asking the mothers for details by, for instance, routinely asking the mothers for them in early pregnancy, develop Interagency working them in early pregnancy, develop Interagency working while making child outcomes the focus of their work and while making child outcomes the focus of their work and mainstream engagement through the service” ( e.g. mainstream engagement through the service” ( e.g. teenage pregnancy service, “While keeping good records teenage pregnancy service, “While keeping good records and comprehensively assessing the young men's needs, and comprehensively assessing the young men's needs, substantial numbers of young fathers can be reached with substantial numbers of young fathers can be reached with interventions that make a real difference…..”interventions that make a real difference…..”

Record KeepingRecord Keeping

• Record observations of child, verbal and non-verbalRecord observations of child, verbal and non-verbal• Records to be child focussed- child’s perspectiveRecords to be child focussed- child’s perspective• Record parents’ account in detailRecord parents’ account in detail• All recordings must be accurate and evidence based!All recordings must be accurate and evidence based!• Maintaining good records assists reflective PracticeMaintaining good records assists reflective Practice

Child G - BackgroundChild G - Background

• SCR conducted following a case of filicide/suicide. Child SCR conducted following a case of filicide/suicide. Child G 6 years old when killed by his father in summer 2010. G 6 years old when killed by his father in summer 2010. Father killed himself at the same timeFather killed himself at the same time

• Coroner’s Inquest makes Finding - Child G unlawfully Coroner’s Inquest makes Finding - Child G unlawfully killed and Mr G, father, took his own lifekilled and Mr G, father, took his own life

• Child G living with both parents at time of birth. Parents Child G living with both parents at time of birth. Parents separate, at time of death Child G spending considerable separate, at time of death Child G spending considerable time with both parentstime with both parents

• Mother had little previous involvement with services. Mother had little previous involvement with services. Father had significant involvement. He carried out several Father had significant involvement. He carried out several suicide attempts and experienced suicidal ideation over a suicide attempts and experienced suicidal ideation over a 30 year period preceding the incident30 year period preceding the incident

• Father involved with mental health services and GPFather involved with mental health services and GP

Child G Background(2)Child G Background(2)• Child G diagnosed with diabetes 3 years prior to incidentChild G diagnosed with diabetes 3 years prior to incident• Child G’s parents engage well with appropriate health services. Child G’s parents engage well with appropriate health services.

There is good liaison between health and school services. Child G There is good liaison between health and school services. Child G receives support from the local speech and language servicereceives support from the local speech and language service

• During acrimonious separation father alleges he informed mother During acrimonious separation father alleges he informed mother he wanted to commit suicidehe wanted to commit suicide

• Police called to family home as mother has concerns about child’s Police called to family home as mother has concerns about child’s safety, father having taken Child G from school unexpectedlysafety, father having taken Child G from school unexpectedly

• Police attend family home. Police judge Child G to be safe in care Police attend family home. Police judge Child G to be safe in care of father. Mother also present at family home. Police treat as a of father. Mother also present at family home. Police treat as a domestic violence incidentdomestic violence incident

• Court application made by father. Court adjourns substantial Court application made by father. Court adjourns substantial hearing, further enquiries to be made by CAFCASS. Interim hearing, further enquiries to be made by CAFCASS. Interim Residence granted to fatherResidence granted to father

• Child G dies before matter returns to CourtChild G dies before matter returns to Court

Themes From the CaseThemes From the Case

• Suicide/FilicideSuicide/Filicide

• Domestic Violence/DV1 NotificationsDomestic Violence/DV1 Notifications

• The Court ProcessThe Court Process

• Compliance/Information SharingCompliance/Information Sharing

Suicide/FilicideSuicide/Filicide• Suicide/Filicide very rare Suicide/Filicide very rare • By it’s nature a deliberate and thought-out act with limited By it’s nature a deliberate and thought-out act with limited

research available - impossible to predictresearch available - impossible to predict• Historic events regarding adult mental health, significance Historic events regarding adult mental health, significance

of these need to be retained and viewed as a continued riskof these need to be retained and viewed as a continued risk• Professionals to develop a style of Practice to ask Professionals to develop a style of Practice to ask

questions directly of suicide and suicidal intentions questions directly of suicide and suicidal intentions expressed. Critical to any assessment of riskexpressed. Critical to any assessment of risk

• Parental separation - If suicide threats made, do not regard Parental separation - If suicide threats made, do not regard as common place, take seriouslyas common place, take seriously

• Consider implications of suicidal threats on child as part of Consider implications of suicidal threats on child as part of any risk assessmentany risk assessment

• Consider previous triggersConsider previous triggers• Seek Management adviceSeek Management advice

Domestic Violence/DV1 ReferralsDomestic Violence/DV1 Referrals

• Police oversight of DV1 notifications requires a Police oversight of DV1 notifications requires a knowledge of children’s safeguarding issuesknowledge of children’s safeguarding issues

• DV1 notifications – A Multi- agency assessment is likely DV1 notifications – A Multi- agency assessment is likely to lead to a more comprehensive assessment leading to to lead to a more comprehensive assessment leading to better outcomes for the childbetter outcomes for the child

• Role of GP pivotal to identification and management of Role of GP pivotal to identification and management of potential risk of DV. GP a good source of information potential risk of DV. GP a good source of information and support for the child/family following a DV incidentand support for the child/family following a DV incident

The Court ProcessThe Court Process• The Private Law Programme (April 2010) at the first hearing the The Private Law Programme (April 2010) at the first hearing the

Court should consider risk identification and the impact of any Court should consider risk identification and the impact of any known risk on a child’s welfare  known risk on a child’s welfare  

• The Court initially is dependent on being informed by the The Court initially is dependent on being informed by the Officer’s of the Court (CAFCASS reporting officers) to make Officer’s of the Court (CAFCASS reporting officers) to make appropriate safeguarding enquiries about the family , appropriate safeguarding enquiries about the family , highlighting any concerns or risks that the Court needs to be highlighting any concerns or risks that the Court needs to be made aware ofmade aware of

• Roles and responsibilities of Court Officers need to be clear to Roles and responsibilities of Court Officers need to be clear to avoid insufficient attention being given to assessing risks to a avoid insufficient attention being given to assessing risks to a childchild

• The Judiciary need to keep abreast of Safeguarding TrainingThe Judiciary need to keep abreast of Safeguarding Training

Compliance/InformationCompliance/Information Sharing Sharing

• Failure to comply with procedures undermines effective Failure to comply with procedures undermines effective risk assessment of childrenrisk assessment of children

• Organisations have a responsibility to ensure staff are Organisations have a responsibility to ensure staff are able to comply with procedures and able to access able to comply with procedures and able to access necessary training. Needs to be a regular part of necessary training. Needs to be a regular part of management support and monitoringmanagement support and monitoring

• Procedures are less likely to be followed or less Procedures are less likely to be followed or less stringently applied potentially leaving children at riskstringently applied potentially leaving children at risk

• Difficulties in communication and sharing of relevant Difficulties in communication and sharing of relevant information between agencies hinders effective risk information between agencies hinders effective risk assessmentassessment

Case Review W- BackgroundCase Review W- Background• 3 young people, aged between 14-16 years of age from the 3 young people, aged between 14-16 years of age from the

Poole area found guilty of manslaughter. Their victim, a man Poole area found guilty of manslaughter. Their victim, a man sleeping rough in Westbourne in April 2009sleeping rough in Westbourne in April 2009

• All of the young men were remanded to a Young Offender All of the young men were remanded to a Young Offender Institute (YOI). The trial at Winchester Crown Court Institute (YOI). The trial at Winchester Crown Court concluded a year after the offence, when all three accused concluded a year after the offence, when all three accused were found guilty of manslaughter. They are all due for were found guilty of manslaughter. They are all due for release in 2011release in 2011

• All 3 young people and their families known to agencies due All 3 young people and their families known to agencies due to a number of welfare concernsto a number of welfare concerns

• The circumstances of the case did not meet the criteria for a The circumstances of the case did not meet the criteria for a Serious Case ReviewSerious Case Review

Themes From the CaseThemes From the Case

• Engagement/Intervention of AgenciesEngagement/Intervention of Agencies

• Professional Judgement/AssessmentsProfessional Judgement/Assessments

• Multi-Agency WorkingMulti-Agency Working

• Peer Pressure/Anti-Social BehaviourPeer Pressure/Anti-Social Behaviour

• Family IssuesFamily Issues

• Communications/Information SharingCommunications/Information Sharing

• Record KeepingRecord Keeping

Engagement/Intervention of Engagement/Intervention of AgenciesAgencies

• Opportunities for agencies to intervene at early stages not Opportunities for agencies to intervene at early stages not consistently taken- missed opportunitiesconsistently taken- missed opportunities

• Hard to engage familiesHard to engage families

• Need to work with the families and be more challenging of Need to work with the families and be more challenging of information presented to identify risk factors information presented to identify risk factors

• Need to work together and not in isolation. Assessments may be Need to work together and not in isolation. Assessments may be conducted, but are not effective if information not shared with conducted, but are not effective if information not shared with other Professionalsother Professionals

• Investigative style needs to be adopted. Do not be too accepting Investigative style needs to be adopted. Do not be too accepting of responses families give i.e. do not need any support of responses families give i.e. do not need any support

• Planning required. Exit strategies for young people need to be in Planning required. Exit strategies for young people need to be in placeplace

Engagement/Intervention of Engagement/Intervention of Agencies(2)Agencies(2)

• Consider the need to have specialist workersConsider the need to have specialist workers

• All Professionals need to be clear about roles and All Professionals need to be clear about roles and responsibilities in the plan devised for the young person- responsibilities in the plan devised for the young person- could lead to better engagement from familiescould lead to better engagement from families

• Need to understand a young person’s needs. Youth Need to understand a young person’s needs. Youth services play a pivotal role in ensuring there is services play a pivotal role in ensuring there is appropriate engagement with a young personappropriate engagement with a young person

• Young person needs to feel empowered for effective Young person needs to feel empowered for effective engagement.engagement.

Professional Professional Judgements/AssessmentsJudgements/Assessments

  

• Assessments- crucial to take a history from families as Assessments- crucial to take a history from families as part of risk assessment. Likely to highlight triggers which part of risk assessment. Likely to highlight triggers which inform services and support providedinform services and support provided

• Use of the CAF still requires clarity. Professionals need Use of the CAF still requires clarity. Professionals need to know when to use and in what context. Confusion in to know when to use and in what context. Confusion in use of CAF can lead to lack of appropriate interventionuse of CAF can lead to lack of appropriate intervention

• The Southwark Judgement( May 2009) obliges The Southwark Judgement( May 2009) obliges Children's Services to provide accommodation and Children's Services to provide accommodation and support to homeless 16 and 17 year olds. support to homeless 16 and 17 year olds.

Multi- Agency WorkingMulti- Agency Working

• Professionals need to work proactively in a multi-agency arena to Professionals need to work proactively in a multi-agency arena to gain the families’ engagement in order to help support them in their gain the families’ engagement in order to help support them in their care of young peoplecare of young people

• Consider the need for a multi-agency risk assessment. Can lead to a Consider the need for a multi-agency risk assessment. Can lead to a more coherent and comprehensive assessment with better outcomesmore coherent and comprehensive assessment with better outcomes

• Multi- agency meetings- Need to ensure Multi- agency meetings- Need to ensure allall relevant Professionals relevant Professionals attend to increase chances of a robust multi- agency risk assessmentattend to increase chances of a robust multi- agency risk assessment

• Collaborative thinking by Professionals required!Collaborative thinking by Professionals required!

• Professionals need to follow through on referrals to another agency. Professionals need to follow through on referrals to another agency. Check referral has been actionedCheck referral has been actioned

Peer Pressure/Anti- Social Peer Pressure/Anti- Social BehaviourBehaviour

• Lack of understanding by agencies including the School, Lack of understanding by agencies including the School, Police, Anti Social Behaviour Team and Youth Offending Team Police, Anti Social Behaviour Team and Youth Offending Team involved with the young people regarding the escalation in involved with the young people regarding the escalation in destructive behaviourdestructive behaviour

• DCSF Guidance on working with young people affected by DCSF Guidance on working with young people affected by group anti social behaviour in the community will be available group anti social behaviour in the community will be available with relevant risk assessment toolwith relevant risk assessment tool

• There was a lack of reference or understanding of the misuse There was a lack of reference or understanding of the misuse by young people of alcohol and drugs Substance abuse was by young people of alcohol and drugs Substance abuse was not considered as part of any assessment of risk not considered as part of any assessment of risk

• The use of Restorative Justice Procedures could have been The use of Restorative Justice Procedures could have been used more broadly with the young peopleused more broadly with the young people

Family IssuesFamily Issues

• Vital to consider all members of the family as part of risk Vital to consider all members of the family as part of risk assessment including any significant males. All three assessment including any significant males. All three boys had difficult family upbringings and appeared to boys had difficult family upbringings and appeared to lack consistent positive male role modelslack consistent positive male role models

• Consider what support networks are in place for the Consider what support networks are in place for the family, particularly if main carer is a sole carer family, particularly if main carer is a sole carer

• All risk assessments need to consider cultural and All risk assessments need to consider cultural and literacy issues to inform adequate and appropriate literacy issues to inform adequate and appropriate planning. Failure to do so impacts on outcomes for planning. Failure to do so impacts on outcomes for young personyoung person

CommunicationCommunication

  • Communication needs to be clear, concise and requires Communication needs to be clear, concise and requires

the use of simple language. Professionals need to make the use of simple language. Professionals need to make sure what they are saying is easily understood. Use of sure what they are saying is easily understood. Use of an interpreter/ translator where English is not the first an interpreter/ translator where English is not the first languagelanguage

• Communication needs to occur both inter- and intra- Communication needs to occur both inter- and intra- agency. Lack of information sharing leads to missed agency. Lack of information sharing leads to missed opportunities opportunities

Record KeepingRecord Keeping

• Good practice to ensure chronologies/summaries always Good practice to ensure chronologies/summaries always reflect the depth of history of the families and the number reflect the depth of history of the families and the number of contacts. Need to make sure the information is used to of contacts. Need to make sure the information is used to inform assessments about the “here and now”.inform assessments about the “here and now”.

  

• Ensure records are accurate, evidence based and can be Ensure records are accurate, evidence based and can be accessed easily. Important to be able to access historical accessed easily. Important to be able to access historical records, crucial information may be missed if not accessed records, crucial information may be missed if not accessed as part of a risk assessment.as part of a risk assessment.

Adult SCR Case A- BackgroundAdult SCR Case A- Background• Mrs A an elderly widowed lady aged 83 years.Mrs A an elderly widowed lady aged 83 years.• Mrs A murdered by her son-in law in 2008.Mrs A murdered by her son-in law in 2008.• Mrs A’s daughter and son-in-law had a history of mental Mrs A’s daughter and son-in-law had a history of mental

health and known to have a violent relationship. They were health and known to have a violent relationship. They were also known to Probation and received considerable support.also known to Probation and received considerable support.

• Both moved in and out of Mrs A’s home on several occasions. Both moved in and out of Mrs A’s home on several occasions. It was alleged both were violent and abusive to Mrs A.It was alleged both were violent and abusive to Mrs A.

• Mrs A told her GP she was frightened of her son- in –law and Mrs A told her GP she was frightened of her son- in –law and stressed by them both.stressed by them both.

• Referrals had been made by neighbours and a family Referrals had been made by neighbours and a family member to the Police about concerns for Mrs A’s welfare.member to the Police about concerns for Mrs A’s welfare.

• Agencies had information on their records about concerns for Agencies had information on their records about concerns for Mrs A, however the information was not shared.Mrs A, however the information was not shared.

Themes From the CaseThemes From the Case

• Identification of Safeguarding issues.Identification of Safeguarding issues.

• Domestic Violence.Domestic Violence.

• Communication/Information Sharing.Communication/Information Sharing.

• Compliance.Compliance.

Identification of Safeguarding Identification of Safeguarding IssuesIssues

• Multi- agency partners need to understand the definition Multi- agency partners need to understand the definition of a “vulnerable adult”of a “vulnerable adult”

• Trigger signs need to be recognised by Professionals of Trigger signs need to be recognised by Professionals of adult abuseadult abuse

• The same significance needs to be given to a vulnerable The same significance needs to be given to a vulnerable adult experiencing abuse as a child experiencing abuse.adult experiencing abuse as a child experiencing abuse.

• A holistic approach is required. Looking at the “A holistic approach is required. Looking at the “bigger bigger picture”picture”

• Multi- agency risk assessment leads to better outcomesMulti- agency risk assessment leads to better outcomes

Domestic ViolenceDomestic Violence

• Consider the pattern of DV reported. Look at the historical Consider the pattern of DV reported. Look at the historical information held on records to give context to DV occurring. information held on records to give context to DV occurring. Do not look at DV incidents in isolationDo not look at DV incidents in isolation

• Consider the impact of DV on all persons within the household Consider the impact of DV on all persons within the household even though they may not be a direct recipient of the DVeven though they may not be a direct recipient of the DV

• Ensure that the scene of potential violence is safe for the Ensure that the scene of potential violence is safe for the vulnerable personvulnerable person

Communication/Information Communication/Information SharingSharing

• Discuss/contact other Professionals regarding any Discuss/contact other Professionals regarding any referrals or significant information held on your records referrals or significant information held on your records where there are safeguarding concernswhere there are safeguarding concerns

• Consider the use of multi- agency meetings to exchange Consider the use of multi- agency meetings to exchange relevant informationrelevant information

• Lack of communication leads to poor outcomes for Lack of communication leads to poor outcomes for service user. Significant missed opportunities can have service user. Significant missed opportunities can have serious consequencesserious consequences

• Ensure all communication is accurately recordedEnsure all communication is accurately recorded

ComplianceCompliance

• Failure to follow either your own internal policies and Failure to follow either your own internal policies and procedures or local agreed protocols can lead to poor procedures or local agreed protocols can lead to poor service deliveryservice delivery

• In order to effectively execute your safeguarding role In order to effectively execute your safeguarding role and responsibility it is your duty to ensure you are and responsibility it is your duty to ensure you are familiar with relevant inter and intra agency guidance familiar with relevant inter and intra agency guidance and Practice locallyand Practice locally

Recurring ThemesRecurring Themes

Clearly there are recurring themes from all reviewsClearly there are recurring themes from all reviews

conducted both children and adult matters:conducted both children and adult matters:

• AssessmentsAssessments

• Communication/Information SharingCommunication/Information Sharing

• Multi- agency workingMulti- agency working

• ComplianceCompliance

• Record KeepingRecord Keeping

Making A Difference!Making A Difference!

• Why are there recurring themes?Why are there recurring themes?

• What can you do inter and intra agency to change your What can you do inter and intra agency to change your Practice from today?Practice from today?

• How can How can you you make a make a realreal difference?difference?

Making a Difference! (2)Making a Difference! (2)

• Good news! - Both B&PSCB and the Adult Safeguarding Good news! - Both B&PSCB and the Adult Safeguarding Board have already started implementing learning from Board have already started implementing learning from reviews conductedreviews conducted

• Combined agency Action Plans with close scrutiny by Combined agency Action Plans with close scrutiny by relevant Boards regarding progress of each action relevant Boards regarding progress of each action identifiedidentified

• Achieving improved Practice across all agencies in Achieving improved Practice across all agencies in Bournemouth and Poole areasBournemouth and Poole areas