Serious Case Reviews

1. Serious Case Reviews Local Lessons & Actions www.hertsdirect.org/safeguardingchildren

2. Why do we undertake SCRs? Regulation 5 of the LSCB Regulations 2006 states: “(1)The functions of a LSCB in relation to its objective ....are as follows- (e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.”

3. When do we undertake SCRs? When a child dies andabuse or neglect is known or suspected to be a factor in the death, the LSCB should alwaysconduct a SCR into the involvement of the organisations and professionals in the lives of the child and family. (Working Together, 2010)

4. When do we consider undertaking SCRs? • When a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse; or • A child has been seriously harmed as a result of being subjected to sexual abuse; or • A parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004; or • A child has been seriously harmed following a violent assault perpetrated by another child or an adult; AND The case gives rise to concerns about the way local professionals and services worked together to safeguard the children.

5. What is the purpose of a SCR? • To establish what lessons there are about the way professionals and organisations worked individually and together. • To identify how theses lessons will be acted on; in what timescale; and what is expected to change • To improve intra- and inter-agency working & therefore better safeguard children.

6. What would the role of the school be? • An Individual Management Review would be completed by Standards & School Effectiveness • This would look at he role & involvement of all educational staff, including school employees • The report author would review school records & interview relevant staff • The aim would be to establish if there are lessons to be learnt in respect of how the school contributed to safeguarding the child

7. The national picture Understanding Serious Case Reviews and their Impact A Biennial Analysis of Serious Case Reviews 2005-07 M Brandon, et al, 2009

8. The Children www.hertsdirect.org/safeguardingchildren • 30 % were aged 0-3 months • 45% were under 1 year old • 67% were 5 years old or younger • 25% were over 11 • 17% were subject to a child protection plan • About half were known to children’s social care

9. The Families 45% Families had had frequent house moves 53% Domestic Violence (current or past) 33% Substance Misuse (current or past) 63% Mental Health problems (current or past) 15% Parental learning disability 45% Parent with criminal conviction 75% of children had lived with domestic violence, parental mental ill health or substance misuse www.hertsdirect.org/safeguardingchildren

10. The issues Chaotic behaviour in families can be mirrored in chaotic professional thinking and actions Failure to see the child - practice is not ‘child focused’ Efforts not to be judgemental becoming failure to exercise professional judgement Silo practice – professionals not looking at the needs of the child outside their own specific brief. www.hertsdirect.org/safeguardingchildren

11. Issues (cont’d) • ¾ of the families did not co-operate with services – a lack of authoritative child protection practice • Multiple risk factors – parental substance misuse; mental health problems; domestic abuse; poor living conditions • Little or limited information about men • Fixed views of a family • Perceived, or real, difficulty in engaging older children

12. SCR in Hertfordshire 5 SCR completed in past year 3 deaths and 2 serious injuries 3 under 5 years old 1 teenager Parental mental health problem 3 cases Domestic Violence 4 cases Parent with learning disability 1 case Substance misuse 1 case Neglect 5 cases www.hertsdirect.org/safeguardingchildren

13. What were the lessons in Hertfordshire • Keeping a focus on the child • Can/are the parents meeting the child’s needs • Working across adult and children's services • Making best use of expertise • Accessing and taking account of past history • Start again syndrome & the rule of optimism • The need for professionals to escalate concerns where they feel these are not being addressed appropriately www.hertsdirect.org/safeguardingchildren

14. What were the lessons in Hertfordshire • Assessing the impact of cumulative risk factors on parenting ability • Working with complexity • All significant adults should be included in assessments • The absence of fathers, male partners, relatives • Critical and authoritative child protection practice • Family & professional accountability