2019 Triennial Analysis of Serious Case Reviews Messages for Health Professionals

1. 2019 Triennial Analysis of Serious Case ReviewsMessages for Health Professionals

2. Workshop objectives • Review main learning from the report in three key areas: • Neglect and poverty • Vulnerable adolescents • Multi-agency working • Identify implications for health professionals • Support staff to develop their knowledge, skills and practice to keep children and young people safe • See https://seriouscasereviews.rip.org.uk/ for further information

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. Neglect and poverty • Neglect featured in 75% of SCRs. It is the most common category of abuse for children on child protection plans • Poverty leads to additional complexity, stress and anxiety and can heighten the risk of neglect • Most children living in poverty do not experience neglect • However the co-existence of poverty and neglect can escalate adverse outcomes • Pathways to serious harm through neglect include: • Severe deprivational neglect • Medical neglect eg, dental caries, incomplete vaccinations, missed appointments • Accidents • Physical abuse • Suicide and self harm • Vulnerable adolescents harmed through risk taking behaviour and/or exploitation • Sudden unexplained death in infancy (SUDI)

5. 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.)

6. Learning points • Recognition of poverty and neglect was often missing in SCRs: • Understanding and responding to neglect is a partnership requirement and not just the responsibility of children’s social care • Health visitors, nursery nurses, school nurses and GPs are especially involved in health assessment during child’s early years. All need to be curious and explore children’s development by talking and listening to children and observing nonverbal children • Immediate responses to the physical manifestations of poverty and a chaotic lifestyle do not equate with children being safe. The child and their wellbeing should be the primary focus of any assessment • Use clear, straightforward and respectful language to effectively describe difficult issues; do not dilute severity of the circumstances • Acknowledgement of cumulative risk should be embedded in all responses • Poverty is associated with feelings of shame, stigma and having fewer resources to call upon. A positive consistent relationship with a practitioner can offer vital support

7. Learning Points • Poor mental health was the most prevalent parental characteristic reported in neglect cases: • Mental health need may be acute for refugee/asylum seeking people. Ascertaining and applying knowledge about past experiences, culture, religion and beliefs is vital in assessment and planning for all children • Nine in ten SCRs related to a child less than one year old: • Most common category of death was SUDI: often involved co-sleeping plus other risks (eg, parental alcohol or drug misuse) • Some SCRs found health visitor assessments focused on weighing/ measuring baby, observing bonding between mother and baby • Health professionals need to consider how best to safeguard mother and baby prior to and following delivery • Fathers/father figures are often overlooked when assessing a child’s circumstances: potential risks and protective factors can be missed

8. Vulnerable Adolescents • One in three SCRs involved children aged 11 and over • There is increased potential for extra-familial risk and harm during adolescence – virtual and local communities were a source of significant risk • Most common causes of serious harm were (i) risk-taking/violent behaviour by the young person, and (ii) child sexual exploitation • Young people were often not in school, going missing and seeking a sense of belonging outside their family Threats outside home include: • Going missing • Criminal exploitation eg, moving drugs (county lines), violence, gangs, trafficking • Child sexual exploitation (CSE) • Harmful sexual behaviour (HSB) • Radicalisation • Social media and technology- assisted harm

9. 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.

10. Learning Points • Outside infancy, suicide was the most common category of death related to maltreatment: • Non-fatal self-harm is strongly associated with completed suicide and should be referred for specialist assessment • It is important to take a holistic approach to understanding underlying causes of problems, as well as reacting to immediate crises • Professionals were slow to recognise vulnerability to CSE, especially for males: • Multi-agency collaboration is essential for tackling CSE • Practice responses to earlier harmful experiences can influence young people’s confidence in services • School nurses/sexual health nurses are in a good position to identify and support young people at risk of/experiencing harm • The report emphasises the importance of trauma-informed practice across all professions

11. Learning points • Young people involved in criminal exploitation should always be seen as victims and safeguarded accordingly • Children with HSB are likely to have experienced poly-victimisation: • Being a victim and a perpetrator can be very closely related, particularly when offences are committed as part of a group • There must always be a therapeutic and/or safeguarding response in addition to any criminal justice response • Joint working agreements are needed in the transfer of young disabled people with complex health needs to adult services: • Health professionals play a vital role in ensuring children with disabilities are seen and heard, and that multi-agency partners cooperate effectively

12. Multi-agency working • Effective information sharing and communication is crucial: • When each involvement with a family is treated as a discrete event, information is not accumulated and professionals fail to develop a comprehensive understanding of the child’s life experiences • Good quality record keeping and communication helps identify patterns of events, concerns, strengths and unmet needs • Silo working should be avoided; there should be clear understanding of roles/responsibilities of different organisations • Clear multi-agency plans are key to effective working • Assessment and planning tools must be carefully designed to facilitate communication of concerns across agencies • Undertaking cross-service chronologies can be helpful • Information solutions need to be identified at systems level, eg, flags/triggers in IT systems, embedding information sharing into practice • Partnership working should be open to ‘professional challenge’

13. Reflective questions • How can information about a family’s experience be shared with other professionals in a way that does not add to parents’ feelings of shame or stigma? • How can health professionals be supported to recognise that ‘resistance’ on the part of families is not a justification for withdrawing support? • What attention is given to the experiences, wellbeing and safety of children of parents who present with mental health concerns? • How can health professionals help ensure that health-harming behaviours (exhibited by young people and parents) do not obscure their underlying needs and vulnerabilities? • How are practitioners supported to provide consistent support and cross-agency connectivity?

14. Further reading • Brandon M, Sidebotham P, et al (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. • IRMHA (2018) Modernising the Mental Health Act: Increasing choice, reducing compulsion, Final report of the Independent Review of the Mental Health Act 1983. London: Department of Health and Social Care.

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