Sue Dunstall Chairperson Havering Local Safeguarding Children Board

1. Sue Dunstall Chairperson Havering Local Safeguarding Children Board

3. Serious Case Reviews: Learning the Lessons • Background • Research and other evidence • Key themes • Havering Serious Case Reviews • Key themes • Training • Requests /suggestions • The future

4. Background • Some evidence that numbers and rates of fatal maltreatment in England have fallen (Pritchard et al, 2008) • 1-2 children per week continue to die from maltreatment (Brandon et al., 2008) • Deaths are often difficult or impossible to predict (Sidebotham, et al 2010) Pritchard, C., & Sharples, A. (2008). Violent deaths of children in England and Wales and the major developed countries 1974-2002: possible evidence of improving child protection? Child Abuse Review, 17(5), 297-312. Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth, J., et al. (2008). Analysing Child Deaths and Serious Injury through Abuse and Neglect: What can we Learn? A Biennial Analysis of Serious Case Reviews 2003-2005. London: Department for Children Schools and Families. Sidebotham P, Brandon M, Powell C, Solebo C, Koistinen J, Ellis C, (2010), Learrning from serious case reviews: Report of a research study on the methods of learning lessons nationally from serious case reviews. London: Department for Children Schools and Families

5. What is a Serious Case Review? • A serious case review is a study by the local safeguarding children board of the circumstances of a child who dies or sustains a serious injury.

6. Serious Case Reviews - Why? • To establish what lessons are to be learned about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • To 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 • To improve intra- and inter-agency working and better safeguard and promote the welfare of children.

7. Serious Case Reviews - When? • When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected • When a child has been seriously harmed e.g. • Where a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect; or • a child has been seriously harmed as a result of being subjected to sexual abuse; • a parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004146; or • a child has been seriously harmed following a violent assault perpetrated by another child or an adult

8. What isn’t a Serious Case Review? • SCRs are not inquiries into how a child died or was seriously harmed, or into who is culpable. These are matters for coroners and criminal courts, respectively, to determine as appropriate. • Nor are SCRs part of any disciplinary inquiry or process relating to individual practitioners.

9. Key Themes … • CAF • The ‘toxic’ trio: • Domestic abuse • Mental health • Substance and alcohol misuse

10. WORKING TOGETHER … • SCRs should include situations where a child has been killed by a parent, carer or close relative with a mental illness, known to misuse substances or to perpetrate domestic abuse Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children (2010) retrieved November 2011 @ https://www.education.gov.uk/publications/.../DCSF-00305-2010

11. BIENNIAL REVIEW 2007-2009 • Approximately half of all serious case reviews are in relation to babies under one year of age, underlining the importance of effective universal services provision for young children …” Building on the learning from serious case reviews: A two-year analysis of child protection database notifications 2007-2009 Research Report DFE-RR040 Retrieved November 2011 @ https://www.education.gov.uk/publications/standard/publicationdetail/page1/DFE-RR040

12. BIENNIAL REVIEW 2007-2009 • Substance misuse, domestic violence and parental mental ill health pose significant risks factors for children. Previous reviews have emphasised that it is the combination of these factors which is particularly “toxic”. Building on the learning from serious case reviews: A two-year analysis of child protection database notifications 2007-2009 Research Report DFE-RR040 Retrieved November 2011 @ https://www.education.gov.uk/publications/standard/publicationdetail/page1/DFE-RR040

13. OFSTED • Of the 194 children who were the subject of the reviews, a majority were five years old or younger at the time of the incident. There were 69 under one year old and 47 between one and five years old. • The most common issues were domestic violence, mental ill-health, and drug and alcohol misuse. Frequently, more than one of these characteristics were present. Learning lessons from serious case reviews 2009–2010 Ofsted’s evaluation of serious case reviews from 1 April 2009 to 31 March 2010 Retrieved November 2011 @ http://www.ofsted.gov.uk/resources/learning-lessons-serious-case-reviews-2009-2010

14. MUNRO • “Babies and young children are particularly vulnerable, and they are at increased risk of being maltreated when they are growing up in families affected by parental substance misuse, domestic violence and mental ill health”. The Munro Review of Child Protection: Final Report A child-centred system Retrieved November 2011 @ http://www.education.gov.uk/munroreview/firstreport.shtml

15. BUT…

16. Learning from Serious Case Reviews 2010 • Focusing solely on aspects of interagency working, to the exclusion of other factors, including factors in the child, parents, family, and wider environment, that may have contributed to risk, may fail to identify issues that could be addressed at a wider community level (Sidebotham et al, 2010)

17. Havering Serious Case Reviews Child D Under-1 Child B Under-1 Child N Under 1

18. Recommendations • When working with parents who have mental health, substance abuse or similar problems all agencies must ensure that they specifically take account of and plan for the needs of children. • All appropriate agencies must ensure that their staff understand how and when to make use of the Common Assessment Framework

19. The LSCB should implement arrangements for monitoring the extent and quality of use of the Common Assessment Framework • The issue of parental substance misuse and its implications for the child’s safety was not given sufficient weight • This case again provides evidence of the link between domestic violence and child abuse.

20. TRAINING http://www.havering-lscb.org.uk/prof_training.html

21. Inspectors “The CAF is not well established and is not used effectively by all services. As a result families do not always have access to well coordinated early intervention and support. As a consequence some children and young people are referred to children’s service unnecessarily because appropriate support has not been put in place at a sufficiently early stage”. Inspection of safeguarding and looked after children services London Borough of Havering @ www.ofsted.gov.uk/local-authorities/havering and Retrived November 2011

22. … and they weren’t over the moon with the LSCB either … “Progress has been made in achieving most of the identified priorities but further work is needed on key areas such as embedding the use of the CAF and improving understanding of thresholds”. Inspection of safeguarding and looked after children services London Borough of Havering @ www.ofsted.gov.uk/local-authorities/havering and Retrived November 2011

23. WORKSTREAM 1Supporting Chaotic and Barely Coping Families WORKSTREAM 3Developing Identification, Assessment and Referral Processes WORKSTREAM 2Supporting Coping Families Four Workstreams With thanks to Jane Smithson, LBH Transformation Programme

24. Workstream 3The Role of the LSCB Identification, referral and assessment has, historically, been too local authority ‘owned’ • ‘critical friend’ to this strand of work / planning / implementation • Provide CAF training within the multi-agency suite of training • Promote use of CAF amongst LSCB partners • Monitor progress, and • Act as the link with the Referral & Assessments work stream

25. CONCLUSION • “ … children’s services have been hit disproportionately by spending cuts … The message from the front-line is that Councils are trying to avoid closing services for children wherever possible, especially in child protection where local authorities have statutory responsibilities to fulfil. As a result, cuts are inevitably falling on preventative services, universal services are being scaled back or targeted on the most vulnerable and ‘non-essential’ functions such as monitoring and quality assurance are particularly at risk”. Smart Cuts? Public spending on children’s social care (2010). A report produced by the Chartered Institute of Public Finance and Accountancy (CIPFA) for the National Society for the Prevention of Cruelty to Children (NSPCC) @ www.nspcc.org.uk/inform and retrieved November 2011.

26. Common Assessment Framework • Early Identification of Need • Munro: The Way Forward • Grooming and exploitation • Top 100 Families