Cardiff Partnership Board

1. Item 6.3 Cardiff Partnership Board LOCAL SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEWS 24th July 2012

2. Background • In August 2011 the Serious Case Review subgroup of the Cardiff Local Safeguarding Children Board completed four SCRs • In October 2011 three of the SCRs were published • In agreement with Welsh Government the fourth SCR in respect of Child X was not published because of concern about the potential risks to her family • An outstanding recommendation of two of the SCRs was to present the outcomes to the Cardiff Partnership Board

3. Requirement to undertake SCRs • Legal requirement of LSCBs • Criteria are set out in statutory guidance • Guidance includes direction re methodology and timescale • In Wales LSCBs are required to publish anonymised Executive Summaries of reviews • LSCBs are required to submit copies of completed reviews to the Welsh Government • Welsh Government commissions analysis of SCRs so that key learning can be identified on a national basis • Welsh Government are due to publish guidance for new arrangements for Multi-Agency Child Practice Reviews in January 2013

4. Current criteria for SCR The LSCB should undertake a serious case review in all cases where child abuse or neglect are known or suspected and; • A child dies or • A child receives a potential life threatening injury or serious and permanent impairment of health or development, this may include cases where a child has been subjected to particularly serious sexual abuse. Additionally LSCBs should undertake SCRs where: • A child has committed suicide • A child is killed by a parent with a mental illness LSCBs may also undertake SCRs where a child suffers harm that does not meet the criteria set out above but where there may be concerns for example about: • Interagency working • Local policies or procedures

5. Purpose of SCRs To identify steps that might be taken to prevent a similar death or harm occurring and in so doing, to: • Establish whether there are lessons to be learned • Identify what the lessons are and how they should be acted upon • Improve interagency working • Identify examples of good practice • The published summary includes the recommendations for action to implement learning from the review and improve future practice

6. Child A • Child A was three at the time of his death following a road traffic collision near his home • His name was included on the Child Protection Register • Focus of work with the family had been to improve the quality of parental care and supervision • While the review identified areas for improvement in safeguarding practice it concluded that Child A’s death could not have been predicted.

7. Child C • Child C was less than a year old when she died • Her death occurred in the context of her co-sleeping with a parent who had consumed alcohol • Child C’s name was included on the Child Protection Register • The focus of the work with the family had been the protection of children from the impact of domestic violence between adult members of the household • While the review’s consideration of interagency practice highlighted areas for improvement, it concluded that Child C’s death could not have been predicted by professionals.

8. Child D • Child D was 15 when she died and was looked after by the local authority • Post mortem examination found that Child D’s death was caused by a cardiac arrest and that prior to her death she had ingested a volatile substance • The review’s consideration of interagency practice identified lessons for agencies and made recommendations for improvement • The review concluded that Child D’s death could not have been predicted.

9. Child X • Child X was aged 14 at the time of her death • Child X committed suicide following a number of previous attempts • The focus of work had been in respect of her mental ill health and the quality of her parental care • The review made a number of recommendations in respect of multi agency working and risky behaviours in young people • Whilst areas of improvement were identified the review concluded that Child X s death could not have been prevented

10. Conclusions of the Reviews • The children's deaths were tragic events that could not have been predicted by professionals • The consideration of professional practice identified learning that the LSCB has taken forward so that it contributes to improvements in interagency safeguarding practice

11. Key recommendations • Children's Services Core Assessments and Initial assessments • Attendance and contribution of reports from South Wales Police and G.Ps at Child Protection Conferences • Neglect toolkit • Improvements in road safety • Self harm – policy and protocol • Working Together training • Development of third sector network

12. Key recommendations • The work of housing agencies and their awareness of child protection and domestic violence • Availability of services where domestic abuse is a chronic and/or acute issue • Interagency child protection procedures for children and young people where their choices of lifestyle, relationships and living arrangements involve risk of significant harm • Co sleeping • Audit of the Resolution of Professional Differences protocol • Quality Assurance of SCRs

13. Next Steps • The LSCB developed action plans in response to the recommendations from each of the four reviews • Progress against the action plans is being monitored by the LSCB via the SCR sub group