Learning from Serious Case Reviews 5 th May 2010 Tomlinson Centre, London Sarah Wright

1. Learning from Serious Case Reviews 5th May 2010 Tomlinson Centre, London Sarah Wright Safeguarding Group Manager Serena Tommasino CHSCB Project Manager

2. Content of today • What is the Safeguarding Children Board? • What is a Serious Case Review? • National Findings and Research • Serious Case Reviews in Hackney • Questions and discussion next step…sharing the learning

3. What is the Safeguarding Children Board ?

4. What is the Legal Framework? • Formerly ACPC – Area Child Protection Committee • Lord Laming Victoria Climbié Inquiry Report and Every Child Matters Green Paper 2003 • Section 13 of the Children Act 2004 requires each children’s service local authority to establish a Local Safeguarding Children Board involving key local partners • Working Together to Safeguard Children 2006 – Chapter 3 sets out guidance on how LSCBs should operate: “LSCB is the key statutory mechanism for agreeing how the relevant organisations in each local area will co-operate to safeguard and promote the welfare of children in that locality, and for ensuring the effectiveness of what they do”

5. CHSCB Objectives and Functions To co-ordinate what is done by each person or body represented on the Board for the purpose of safeguarding and promoting the welfare of children and young people • Developing policies and procedures • Participating in the planning of services for children • Communicating the need to safeguard children • Ensuring a coordinated response to unexpected child deaths To ensure the effectiveness of what is done by each such person or body for that purpose • Monitoring effectiveness of what is to done to safeguard children • Undertaking Serious Case Reviews • Collecting and analysing information about child deaths

6. Who sits on the Board? • Children and Family Court Advisory and Support Service • Children and Young People’s Services - Hackney Council • City and Hackney Primary Care Trust • City of London • East London NHS Foundation Trust • Hackney Community and Voluntary Service • Homerton University Hospital NHS Trust • Metropolitan Police Service • Safer Communities Service – Hackney Council • The Learning Trust

7. What is the structure of the CHSCB? City & Hackney Safeguarding Children Board City of London Sub-Committee Finance Sub-Committee Quality Assurance Sub-Committee Training & Development Sub-Committee Child Death Overview Panel Serious Case Review Sub-Committee

8. Who is in the CHSCB team? Independent Chair -Fran Pearson Safeguarding Group Manager & Local Authority Designated Officer Sarah Wright Professional Advisor to the CHSCB & Head of Safeguarding Sophie Humphreys Community Partnership Advisor Leethen Bartholomew Safeguarding Project Manager Serena Tommasino Multi-agency Training Co-ordinator To be recruited Board Co-ordinator Alice Tomlinson Child Death Overview Panel & Rapid Response Co-ordinator Lia Gett

9. 2. What is a • Serious Case Review?

10. What is the legal framework? Regulation 5 of the ‘Local Safeguarding Children Boards (LSCB) Regulations 2006’ requires LSCBs to undertake reviews of serious cases. They should be undertaken in accordance with the processes set out in Chapter 8 of Working Together 2010. (page 233, Chapter 8 - Working Together 2010)

11. When does one take place? • Serious Case Reviews are undertaken when • abuse or neglect of a child is known or • suspected; and, • (b) either the child has died or has been seriously • harmed and there is cause for concern as to the • way in which the authority, their Board partners • or other relevant persons have worked together • to safeguard the child. • (page 233, Chapter 8 - Working Together 2010)

12. Purpose of a Serious Case Review • establish what lessons are to be learned about the way in which professionals and organisations work individually and together; • 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 • improve intra- and inter-agency working and better safeguard and promote the welfare of children. • (p.234, Chapter 8 - Working Together 2010)

13. It is important to note that... • 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 to determine. • SCRs are not part of any disciplinary inquiry or process relating to individual practitioners

14. How to instigate a SCR? • Any professional or agency may refer a case to the CHSCB if they believe that there are important lessons for intra- and/or interagency working to be learned from the case. • The Serious Case Review Sub-committee will consider cases to decide whether or not a recommendation should be made to the Chair of the Board for a SCR to be held.

15. Serious Case Review Process - 1 • Referral made by a professional or agency • Referral considered by SCR Sub-committee • CHSCB Independent Chair initiates a SCR • Ofsted and Government Office informed • Terms of Reference agreed • SCR Panel convened with an Independent Chair and Overview Report Author

16. Who sits on the SCR Panel? • Independent Chair and Independent Author • Professional Advisor to the Board Experts from: • Children and Young People’s Services • Primary Care Trust • The Learning Trust • Metropolitan Police Service Other possible experts: • Paediatrician • East London NHS Foundation Trust • Voluntary, Community and Faith organisations

17. Serious Case Review Process - 2 • 7. Relevant Agencies complete Chronologies and Individual Management Reviews • Single and multi-agency recommendations identified and implemented • SCR Overview Report produced and submitted to Ofsted within timescale (6 months) • Monitoring Action Plans arising from review • Ofsted evaluation received within 3 months • Executive Summary published • Learning disseminated to staff

18. Monitoring and Dissemination • Actions Plans: • SMART (Specific, Measurable, Achievable, Realistic and Time-limited) • Outcome focused • Regularly monitored and reviewed by the SCR Sub-committee • Dissemination: • CHSCB representatives accountable for dissemination of learning within their own agency • Series of multi agency briefing sessions

19. SCR Process Lessons - 1 • Importance of independent chair; SCR panel membership • Importance of being open vs defensiveness • Willingness to critically challenge • Focus is on learning not apportioning blame • “It is not an academic exercise. The real skill is in cascading the lessons to be learnt across all the multi-agency partners.” (Lord Laming, 2009)

20. SCR Process Lessons - 2 • It is essential: • to maximise the quality of learning • that the child’s daily life experiences and understanding of his or her welfare, wishes and feelings are at the centre of the SCR • where possible lessons should be acted upon without waiting for the SCR to be completed

21. 3. National Findings and Research

22. National Findings and Research • Ofsted data • Biennial analysis • New Working Together • Chapter 8 • Sharing findings across authorities • Influencing national policy etc • London SCRs analysis

23. Biennial Analysis 2005-07 • Themes: • Information about men often missing • Information about the child missing in some reviews • Reluctant parental engagement and multiple • moves made it difficult to build a consistent and • reliable picture • BUT good parental engagement often masked risks

24. Biennial Analysis 2005-07 • Family features (NB. not causal link): • Two thirds of children under 5 and almost half under 1 • 30% were under 3 months and 15% were less than 1 month • 45% of families highly mobile • Half parents had criminal convictions • Three quarters had past or current Domestic Violence, • Mental Health , or Substance Misuse (often co-existing) • Three quarters did not co-operate with services

25. Biennial Analysis 2005-07 • Agency involvement: • 17% subject to CP plan (major category neglect) • One third of families there were known CP risks • Just over half known to Children’s Social Care (mostly for neglect) • 13% Looked After Children • One third had history of missed health appointments

26. Biennial Analysis 2005-07 • Practice issues: • Needs and distress of older young people often missed or too challenging or expensive for services to meet • Practitioners and managers often unclear about what they could or should do about confidentiality • Assumptions often made that others were visiting the family or seeing the child • Enthusiasm for strengths based approach precluded recognition of risks • Focus on one issue (typically neglect) often prevented consideration of other forms of harm

27. Biennial Analysis 2005-07 • Practice issues (cont): • Injuries sometimes seen as less serious acts of careless parenting rather than indicator of more serious concerns about physical injury • Failure to take fathers into account; rigid thinking about fathers as ‘good’ or ‘bad’; perceived as a threat to workers • Unrealistic expectations sometimes placed on staff with low level qualifications (who sometimes struggled to challenge other professionals) • Profound and long-lasting impact on practitioners involved in these cases

28. London SCR analysis April 2006 – Sept 2009 • Approximately 15% involved new immigrants • 70% known to Children’s Social Care • 19% had CP plan • 13% receiving Child in Need services • 17% Looked After

29. London SCR analysis April 2006 – September 2009 • 60% of families had a parent with a mental health problem • Domestic Violence in 47% of families • 26% of families included adult with a history of (non-DV) violent • 40% families considered highly mobile • 47% had rent arrears, had been evicted or were on verge of eviction • 23% featured alcohol misuse • 28% featured drug misuse • 21% problems with ante-natal care • 32% problems post natally (prematurity, PND, feeding problems)

30. London SCR analysis April 2006 – Sept 2009 Practice issues: • Failure to ascertain family history • Decisions and judgements over optimistic • Fixed thinking • Practitioners failing to recognise importance of information (lack of adequate analysis) • Some cases where failure to recognise ‘rehearsal incidents’

31. London SCR analysis April 2006 – Sept 2009 Some key learning points identified: • Best predictor of future behaviour is past behaviour –importance of comprehensive background information & chronologies • Male household members and visitors as important as female • Importance of clear well-understood thresholds and continuum of services • Importance of addressing high mobility and housing problems • Recognising violence of all types as a risk • Importance of early relationships • Vulnerability of adolescents

32. 4. Serious Case Reviews in Hackney Case example

33. Serious Case Reviews in Hackney Case example • Child F (concluded December 2008) • It was not judged that, if the recommendations of the SCR had already been enacted the child would not have died.

34. Child F • Male child aged 20 months died as result of amitryptiline (prescribed to mother) in blood stream. Mother later pleaded guilty to ‘Causing or Allowing the Death of a Child’. Currently serving prison sentence. • Mother had complicated and problematic childhood. Presented with multiple health problems, including reporting extensive problems to ante-natal services • Child F and sibling generally healthy, no CSC involvement • One incident when mother suggested possible sexual abuse of child (not supported by medical judgement) reported to EDT by hospital staff but no further records

35. Child F • Key lessons: • Health professionals should have been more curious and more thorough in exploring reported medical history • Primary health services should have been more proactive in supporting young, relatively unsupported, mother • Improvements needed in processing referrals between Emergency Duty Team and CSC • Avoidable delays in making long-term plans for surviving child

36. 5. Questions and Discussion

37. How to spread the learning • Allocating time for learning from SCR’s • Attending CHSCB training • Lunch time seminars (e.g. e-safety) • Seeking advice from your safeguarding lead

38. Safeguarding is Everyone’s Business • Critical role for universal services • Lessons from SCRs do not just relate to agencies whose work involves responsibility for CP • Everyone that has direct or indirect contact with families where there are children has a responsibility to those children and should raise concerns if they have them • …“It is simpler to lift the telephone than live with the regret of not doing so” ( SCR Baby P)

39. Useful references and links • Chapter 8 – Working Together March 2010 • CHSCB SCR Procedures 2009 – currently under revision • DCSF Bi-annual analysis of SCRs - www.dcsf.gov.uk • London SCRs analysis 2006–09 - www.londonscb.gov.uk • Centre for Excellence Outcomes in Children & Young People’s Services - www.C4EO.org.uk • Research in Practice - www.rip.org.uk • Social Care Institute for Excellence - www.scie.org.uk

40. Contact details City & Hackney Safeguarding Children Board Hackney Service Centre, 1 Hillman Street, London E8 1DY 020 8356 3661 / Fax: 020 8356 4734 www.chscb.org.uk Sarah Wright Safeguarding Group Manager sarah.wright@hackney.gov.uk 020 8356 6824