2019 Triennial Analysis of Serious Case Reviews

1. 2019 Triennial Analysis of Serious Case Reviews Messages for Local Safeguarding Partnerships

2. Workshop objectives • Review main learning from the report concentrating on four key areas: • Neglect and poverty • Vulnerable adolescents • Multi-agency working • Enabling children to have a voice • Identify implications for local safeguarding partnerships

3. Key themes • Findings based on: • Quantitative analysis of 368 SCRs notified to DfE 2014-2017 • Detailed analysis of 278 SCR reports that were available for review • Qualitative analysis of a sample of 63 SCR reports • Complexity and challenge: complexity of the lives of children and their families, and challenges faced by practitioners seeking to support them • Service landscape: challenges of working with limited resources, high caseloads, high levels of staff turnover and fragmented services • Poverty: the impact of poverty, which created additional complexity, stress and anxiety in families • Child protection: once a child is known to be in need of protection the system generally works well

4. Complexity and challenge 1. Complexity of children’s and families’ lives: • Neglect in context of poverty • Cumulative harm • Emerging extra-familial threats in adolescence • Better assessments for children’s long-term care and in court processes 2. Challenges facing professionals: • Lack of reflective supervision • Enabling discussion of different views in multi-agency working • Using chronologies effectively • Fragmented working

5. Neglect and poverty • Neglect was the category of abuse in 75% of all SCRS and in 50 out of 84 children were subject to a child protection plan • SCR findings associated with neglect include: poor dental hygiene; incomplete vaccinations; missed appointments; poor school attendance; developmental delay • Poverty leads to additional complexity, stress and anxiety and can heighten the risk of neglect • Most children living in poverty do not experience neglect • The impact of poverty is not always fully understood or captured in recording or assessments • Parents living in poverty often have fewer resources to draw upon (social, emotional and physical). Shame and hopelessness can be barriers to seeking/accepting help

6. Adverse family circumstances in cases of neglect Table 1: Parental and family adversity in SCRs where neglect was a feature (Rates are likely to be an underestimate as they depend on whether a factor was recorded in the SCR report; in some cases the question may not have been asked, in others the SCR author may not have felt the factor was relevant.)

7. Learning points • Links between domestic abuse, substance misuse and poverty are complex and often inter-dependent. It is not enough to address a single issue without addressing the underlying issues • Normalisation and desensitisation: • Professionals who work in areas of high deprivation may no longer notice the warning signs of poverty and neglect • Supervision/case management is crucial in supporting practitioners to identify poverty and work proactively • Professionals can be reluctant to name neglect: • Often seen as a barrier to family engagement • A multi-agency approach allows for the triangulation of differing views and perspectives • Many families were living in unstable and inadequate housing • Housing services may have valuable information to offer

8. Adolescent neglect • The link between adolescent neglect and complex adolescent behaviour is not well understood across the multi-agency network: • This leads to fragmented and reactive responses, leaving young people at risk • When each involvement with a family is treated as a discrete event, information is not accumulated and professionals do not develop a comprehensive understanding of the child’s life experiences • The report identifies the need for: • Joint working agreements for adolescents with complex health needs, especially around transition to Adults’ Services • Better transition protocols that contain sufficient details to identify young people not in receipt of support from disabled children teams

9. Vulnerable adolescents • Local neighbourhoods were a source of significant risk • Young people were often not in school, going missing and seeking a sense of belonging away from the family home • Emerging threats outside the home include: • Going missing • Criminal exploitation (eg, moving drugs, violence gangs, trafficking) • Child sexual exploitation • Harmful sexual behaviour • Radicalisation • 115 (31%) of the 368 SCR notifications involved children aged 11 and over • 65 of those SCRs related to deaths and 50 involved serious harm • 47 deaths (72%) were maltreatment related • Risk-taking/violent behaviour by the young person and child sexual exploitation (CSE) were the most common causes of serious harm in adolescent cases

10. Complex and Contextual Safeguarding (Firmin et al, 2019) • Complex Safeguarding • This encompasses a range of safeguarding issues related to criminal activity involving vulnerable children or adolescents, where there is exploitation and/or a clear or implied safeguarding concern. • Includes child criminal exploitation, county lines, modern slavery including trafficking and child sexual exploitation (CSE). • Contextual Safeguarding • This is an approach to safeguarding children and young people which responds to their experience of harm outside the home – for example, online, in parks or at school. • It provides a framework for local areas to develop an approach that engages with the extra-familial dynamics of risk in adolescence.

11. Learning points • It is important to recognise the relationship between adolescents’ prior experiences and their risk of harm • An adolescent going missing is a powerful signal that all is not well. Timely multi-agency responses and effective return home and prevention interviews are needed • Prolonged and persistent professional engagement is needed to support adolescents, including: • A balance of preventative work and crisis management • Trauma-informed and relationship-based practice • Agencies should find ways to understand and record patterns in adolescent group and individual behaviour • Practitioners can feel unprepared for working with adolescents. Relevant up-to-date training is essential • Criminal activity may be an indicator of wider exploitation and vulnerability. Responses need to recognise vulnerability and not focus solely on criminal processes

12. Multi-agency working • The number of different agencies involved in delivering care can result in fragmented and uncoordinated services. ‘Silo-working’ may occur within and between agencies • Information sharing is crucial: • Some SCRs show a reluctance among practitioners to pass on information and confusion about what they can and cannot share • When families move area, key information from Adults’ and Children’s Services may be lost/not passed on • The police held information about parents/families with a history of criminal convictions, but this was not routinely shared • It is important to have a lead professional who acts as the main contact for the child or family and coordinates interventions • Effective multi-agency plans depend on all relevant agencies being represented at meetings • Referral forms, assessment tools and incident-logging tools should use language that explicitly depicts issues in ways that do not dilute impact and harm

13. Care and court cases • There are many competing imperatives within care proceedings: • The principle of ‘no order’ • A duty to protect children from harm • A legal priority to place children with kin • The increasing number of care proceedings and speeding up the process have had some negative impacts on outcomes for children • Timescales should not undermine the need for a thorough assessment of all carers, including kinship carers • Some professionals had limited understanding of the legal framework and were unclear about their roles/responsibility for children on supervision orders

14. Enabling children to have a voice • The absence of the child’s voice and their lived experience is a recurrent theme in the report • Understanding the emotional world of a child requires a rounded rather than incident-led approach • Children have more contact with adults as they enter school. School staff need to inquire what lies behind changes in a child’s behaviour • Ethnicity may be recorded but the implications for the day-to-day lives of the children are often not explored: • Professionals should be supported to be confident in exploring cultural and spiritual beliefs to fully understand the daily life for the child • Practitioners need to be alert to when a pregnant mother’s circumstances may put the baby at risk, and consider how best to safeguard mother and baby before and after delivery

15. Implications for the future commissioning of local child safeguarding practice review (LCSPRs) • The following were considered important for reviews: • Considering from the outset what the partnership is trying to achieve • Not just applying one model to every review • Effective involvement of family members and practitioners • The skills and quality of the lead reviewer • Multi-agency training and the distribution of briefings or bulletins were the most popular methods of dissemination • LCSPR/SCR recommendations: • need to be specific, contextual and at a systems level • were felt to have most impact when they were either targeted at single agencies or clearly at a multi-agency level • mattered less than having a committed, motivated team or champion to take them forward

16. Impact and change • It was rare to find evidence of national change resulting from SCRS • Demonstrating change was challenging; evidence came primarily from audits and action plans • Learning was thought to have added weight and be easier to embed when it came from a local review • Keeping learning real, local and close to home was helped by involving practitioners in the review process • SCRs were thought to act as an accountability check on the system and the quality of leadership and practice • Barriers to achieving impact included: • A preoccupation with process • Action plans that prompt a tick-box response rather than a focus on systemic change • Organisational change and a depleted organisational memory • Shifting priorities

17. Reflective questions (strategic) • How are local safeguarding partners working effectively across partnerships? • Do local strategic plans and service commissioning take account of the local picture of child poverty and neglect? • Are these delivered in a way that enables practitioners to support families living with an increased risk of neglect, alongside other complex needs? • How are local data and knowledge being used to provide a more effective safeguarding service? • What processes are in place to ensure that new or revised protocols are embedded in practice? • Are you clear about your role in commissioning and quality assurance?

18. Reflective questions (practice) • Do agency assessments take into account how poverty is impacting on families? • Do multi-agency practitioners have the tools to help them recognise and respond to neglect? • How well embedded are reflective supervision / case management processes in the key agencies? • How effective are local transition processes between children and adult services? How do you monitor this? • How successful is the role of lead professional in your area? • How are you evidencing the lived experiences of infants who are pre-verbal, and children and adolescents with speech and language difficulties?

19. Further reading • Brandon M, Sidebotham P, et al (March 2019) Complexity and Challenge: A Triennial Review of Serious Case Reviews 2014-2017. London: Department for Education. • Firmin C, Horan J, Holmes D and Hopper G (2019) Safeguarding during adolescence – the relationship between Contextual Safeguarding, Complex Safeguarding and Transitional Safeguarding. Dartington: Research in Practice. • Research in Practice (2019) Neglect in the context of poverty and austerity: Frontline briefing. Dartington: RiP.

20. Contact details www.rip.org.uk ask@rip.org.uk @researchIP