Serious Case Reviews – key recommendations

1. Serious Case Reviews – key recommendations Clare Kershaw Lead Strategic Commissioner – Standards and Excellence

2. Serious Case Reviews • S5 of Local Safeguarding Children’s Board Regulations requires LSCB’s to undertake a SCR where • (a) abuse of neglect of a child is suspected • (b) and either the child has died or have been seriously harmed • Purpose is to advise the board of the lessons learned • Should contain a sound analysis of the case and a review of why and what happened in order to reduce the risk of recurrence • The report should be easily understood and suitable for publication without the need to amendment or redaction • Ryan and Olivia are the last two SCR – both cases involve domestic abuse and drug and alcohol misuse in the families and there were complex family arrangements • Both cases occurred whilst CSC was judged inadequate and subject to intervention • Failings by all agencies were found in both SCR’s

3. Ryan’s story – February 2011 • Ryan and Jordan – cared for by a single mother • Both subject to child protection and child in need plans due to concerns about neglect and the impact of domestic abuse • Lived a chaotic lifestyle – changing adult relationships, substance misuse and changes of accommodation and aggressive behaviour at school by Jordan • 6 domestic abuse incidents over a period of time were reported to the police, only 2 were notified to Children’s Social Care, one did not refer to a child being in the house • Links between the violence in the home and Jordan’s aggressive behaviour

4. Ryan’s story – February 2011 • The primary school referred Jordan to CAMHS 5 months after he joined but the family did not attend the appointments – follow up referrals led to a CP conference • The birth of Ryan exacerbated Jordan’s behaviour – this was not picked up by the Health visitor • At this time the case was closed • Jordan was excluded from school - EP and behaviour support placed Jordan in a special school but this would not address poor parenting nor a poor attachment with his mother • During this time multi agency work was uncoordinated • Mother placed Jordan in private fostering arrangements

5. Ryan - outcomes • Overall the management and effectiveness of the Child Protection process was inconsistent. • The parents were not fully engaged in the process. The Child in Need plans were allowed to drift and did not lead to a multi-agency approach • In respect of the education providers school representation at CPC’s was very good and they clearly had a considerable role with Jordan by ensuring that his mother maintained her commitments to him whilst he was in the residential school. • There were numerous examples of the mother not being able to receive Jordan from school; the response of the agencies was to take Jordan to CSC or the police which caused immense frustration to his school. • There was a very poor exchange of information amongst agencies.

6. Ryan - outcomes • Ryan was a healthy, adaptable baby – though his attendance was poor at nursery. His nursery did not know about the family issues or that Ryan had been subject to a CP plan. • However, there was no distinct link between the domestic abuse and substance misuse and the violence that occurred towards Ryan – it was neither predictable nor preventable • There was however a lack of timely, effective responses to the domestic violence notifications or interventions from CSC. • Private fostering was an issue – this is when a child under 16 lives with someone who is not a parent or close relative for more than 28 days. • Education IMR – meticulous records were kept by the schools.

7. Olivia’s Story – June 2011 • In 2007 Fiona (Olivia’s mother) came to her daughter Gemma’s school tearful – Gemma was 6. She explained that she had had a bad day with her partner and “things were getting out of hand”. • Gemma was always immaculate, well clothed, attended school well and Fiona was a protective parent who attended parents evenings and school events. • Fiona was subject to systematic domestic abuse – she did not reveal this to any agency • 10 domestic violence incidents were recorded by police – they were not joined up by agencies • Eg. School nurse knew of the incidents but the school did not

8. Olivia’s Story – outcomes • When learning lessons in Serious Case Reviews we often find that, instead of learning new ones, the old lessons keep reoccurring. This review contains a number, including: • poor assessments • communication problems • focus on adults not children • failure to listen to children • men not involved in assessments • learning should be used to inform the Community Budgets domestic abuse multi agency working project • learning is reflected in multi agency training and single agency training

9. SCR actions • ECC will combine the actions from Ryan and Olivia into a package in the Autumn term and provide comprehensive summary following the publication of Olivia • Key actions include: • Better understanding by schools about domestic violence and the research behind this • Widely sharing good practice in maintaining safeguarding records • Ensuring CP training records are kept – this follows the ESCB request in Autumn term 2012 for schools to submit records of their safeguarding practice • Ensuring records in schools are legible – Olivia • Discussion around sharing DV1 notifications with schools