Improving Safeguarding Practice: Messages from Serious Case Reviews

1. Improving Safeguarding Practice: Messages from Serious Case Reviews James Blewett Making Research Count, King’s College London Hillingdon 15th October 2009

2. Aims • To consider the messages in relation to safeguarding practice emerging from national evaluations of serious case reviews • To look at the learning that can be derived from a local independent management review in the case of a child death

3. Serious Case Review Background • ‘Serious Case Reviews’ are undertaken when a child dies or is seriously injured and abuse or neglect are suspected to be a factor andthere are lessons to be learnt about inter-agency working to protect children. Regular reports to Ministers from Ofsted. • In addition, DCSF commissions an analysis of these Reviews every 2 years – the fourth national study analysis 2005-7 has just been published.

4. Context • A difficult population to study and learn from - ‘hard cases make bad laws’ • Public scrutiny - high profile cases, media interest, court involvement, uncertainty, confidentiality, data protection etc • Professional anxiety about scrutiny – can reduce morale • Findings can be misinterpreted

5. Challenging times • Baby Peter--A series of concerns—Doncaster, Birmingham Sheffield etc • The credibility of professional practice under scrutiny • Pressure on public spending • Long standing debates re the role of the state and safeguarding • Childhood and risk

6. 11 million children in England. • 200,000 children live in households where there is a known high risk case of domestic abuse and violence (55 died last year) • 235,000 are ‘children in need’ and in receipt of support from a local authority • 60,000 are looked after by a local authority • 37,000 are the subject of a care order • 29,000 are the subject of a Child Protection Plan • 1,300 are privately fostered • 300 are in secure children’s homes

7. Understanding serious case reviews and their impact (Brandon et al, 2009) • The chaotic behaviour in families was often mirrored in professionals’ thinking and actions. • Many families and professionals were overwhelmed by having too many problems to face and too much to achieve. These circumstances contributed to the child being lost or unseen.

8. Themes and learning points • The capacity to understand the ways in which children are at risk of harm is complex and requires clear thinking. • Practitioners who are overwhelmed, not just by the volume of work but also by its nature, may not be able to do even the simple things well. • Good support, supervision and a fully staffed workforce is crucial.

9. Themes (contd) • Reluctant parental co-operation and multiple moves meant that many children went off the radar of professionals. • However, good parental engagement sometimes masked risks of harm to the child. • Looked at 189 cases using a transactional ecological appraoch

10. The children • 2/3 were under 5 • ½ were under 1 • Minority aged 6-10 • ¼ over 11 • 11% over 16

11. What happened to the children • 2/3 of 189 children died • 1/3 seriously injured or harmed • The highest risk of maltreatment related deaths and serious injury are in the first five years of life • Physical assault was the major cause of death • Most of the older adolescents died through suicide

12. Continued • Issues of neglect were often present in those children who died. • Sexual abuse was the prime concern in 1 in 12 cases.

13. Were there known child protection risks? • 17% of the children were the subject of a child protection plan (mostly neglect) • In a third of the 189 families there were known child protection risks as either the index child or a sibling were at some time the subject of a child protection plan • Just over half of the children were known to children’s social care at the time of the incident

14. continued • Neglect was the most common pre-existing factor in those children or siblings who had been previously known to children’s social care • The needs and distress of the older young people were often missed or too challenging or expensive for services to meet. .

15. A local example • A good source of learning • All agencies learnt lessons—the management review conducted across to LA s in a climate of openness • There was much good practice • However themes emerged that resonate with Brandon’s findings

16. Case summary • A young care leaver with a traumatic personal history who had 2 young children. The younger child aged 1 died of SIDS (“a potentially avoidable death”) • The father was not visible much of the time and there were considerable concerns • Issues of childhood sexual abuse, ongoing concern around domestic violence and substance misuse. • Neglect

17. Key themes • The importance of understanding the impact of psycho social history on parenting • Working with men • Substance misuse • Working together to manage risk • Assessment, care planning and review • The importance of high quality supervision

18. The importance of understanding the impact of psycho social history on parenting • The “vulnerable adolescent” versus the “needy parent” • The importance of a high quality social history that identifies the relationship between childhood trauma and abuse the capacity to parent • Acknowledging the horror and pain of some peoples’ pasts • Joining up the past and present at the conceptual and practical levels

19. Working with men • Fixed thinking about men (Brandon) • Absence and presence—”off the radar” • Domestic violence • Not engaging with either the man or the issue

20. Substance misuse • The impact of chaotic drug use in pregnancy and on parenting of young children • Mother and baby units and residential treatment • The role of testing • The meaning of closing a case • The importance of protocols for transferring cases. Sharing information between community drug treatment teams in different boroughs

21. Assessment, care planning and review • Importance of good quality case transfers • The meaning of compliance • The role of core groups and child protection plans [Local Guidance on Core groups] • The danger of a “fresh start” • Very easy to reflect the “stuckness” of the family • Levels of professional activity increased in proportion to rising levels of concern

22. Working together to manage risk • Multi disciplinary working in cases such as this is complex and difficult • Exacerbated by moves • Importance of adult focused/ children services working together • Meeting together is not enough • Need for robust processes for escalating (Acting) interagency communication when practitioners remain concerned about families

23. The importance of high quality supervision • The work is complex, demanding and emotive • The mother and father were challenging, frightening and at times engaging • People who have had high levels of professional contact can become skilled in managing (avoiding) professionals

24. Final thoughts • Keeping the child in focus • The complexity of partnership working in cases of high levels of risk • Developing a non defensive learning culture (leads to better outcomes)