Learning from Serious Case Reviews Kate McKenna Associate (SDSA) Anne Partington Nottingham City Safeguarding Children Board Steve Baumber Nottinghamshire Safeguarding Children Board

Objectives To disseminate lessons from the most recent SCR’s in Nottingham City and Nottinghamshire To share learning from other local review processes To share learning from a regional perspective on SCR’s To consider the future SCR process

Setting the national and regional context Munro Review of Child Protection – May 2011  from bureaucracy/compliance to effective help/learning culture  use of research evidence to reach best decisions  “Local multi-agency systems will need to be better at monitoring, learning and adapting their practice”  statutory guidance to reduce prescription  Ofsted to focus on whether the child has been effectively helped by the agencies involved (the child’s journey) Working Together to safeguard children – March 2013  removes prescription, e.g. timescales  more flexibility in completing SCRs – importance of learning lessons Ofsted Inspection framework  proposed new child protection inspection from June replaced with a single inspection framework for child protection and looked after children in September

Learning from Serious Case Reviews The themes

Multi agency working, communication and recording Health Services impact of DNA policy Challenge and escalation procedures Handover discussions to HV and midwife Reporting of observed parenting concerns Involvement of GPs Police Process for handling parents after a child death Liaison with Coroners court where parents have additional needs to ensure advocacy. Bereavement support for parents Impact on professionals Impact of intimidating parents on professionals Communication Between agencies Recording Cross border arrangements Information about men with dangerous histories stored on partner files Transitions

Pregnancy, birth and babies ShakingUnsafe sleeping Midwifery transitions Services for neonatal surgery Death rate from extreme prematurity including maternal BMI

Teenagers Road safety awareness SuicideSelf harmMurder

Parents/Parenting Parenting Preparation for parenting Identification of parental avoidance Family support workers in parenting assessments Concerns resulting from parenting observations need recording by health Parents with Learning disabilities Parent assessments Disguised compliance Mental health and substance misuse Impact of suicidal parents

Domestic Violence Risk assessment tool across agencies Consistency of response to identified risks. Current lack of assessment/invol vement of fathers/perpetrat ors. Holistic risk assessment needed. Processes for escalation of risk e.g. stalking Multi agency management Clear referral pathways Separation as a protection factor

Identification, Assessment, Referral. Assessment and referral Multi agency challenge and escalation Early CAF 20 week referral (pregnancy) Involvement of FSW in parenting assessments Handovers Invisible partners Quality of assessments Thresholds Identification Emotional abuse Sexual abuse Self harm Suicide

Management/access to services Management of children missing from: CareHomeEducation Reflective practice and supervision Access to services Interpreting services Impact of immigration status Responding to allegations of sexual abuse Males Links with alcohol and substance misuse

Case Reviews….WT 2013 Safeguarding Children Board options: Focus of this learning seminar: – Serious Case Review (SCR) – Review of a child protection incident that falls below the SCR threshold (alternative review) Other types of review within the learning and improvement framework: – Child death reviews – Review or audit of practice in one or more agencies Reviews are also carried out through other partnership arrangements

SCR criteria SCR criteria – for every case where abuse or neglect is known or suspected and either: – A child dies: or – A child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child NCSCB/NCSB standing SCR sub groups consider cases that potentially meet the SCR criteria and make recommendations to the Independent Chairs. A National SCR Panel is now in place to advise LSCBs

Principles for all reviews Whichever type of review is conducted the following principles apply: - Reviews should look at what happened in a case, and why, and what action will be taken to learn from the review findings Approach taken to reviews should be proportionate Professionals must be fully involved and invited to contribute their perspectives without fear of being blamed for actions they took in good faith Families and surviving children should be invited to contribute – it is important to ensure that the child is at the centre of the process

Additional principles for SCRs Led by individuals who are independent of the case and organisations whose actions are being reviewed Final reports must be published and include the LSCB’s response to the review findings The learning model adopted may now vary but will always be consistent with the above principles. A Serious Case Review Panel that reflects the agencies involved in the case and will be formed that agrees the learning model and terms of reference

NCSCB & NSCB Reviews reviews undertaken / underway – 6 NCSCB & 7 NSCB – 9 SCRs / 4 alternative reviews – Some reviews are joint with other LSCB’s A number of reviews included more than 1 child Even male / female split 25 White British / case not disclosed or determined 12 children died

2 children on autistic spectrum 2 children physical disability 12 Children in Care 1 subject to Child Protection Plan 17 living at home AgeNumber of Cases Under 57 5 – 10 years8 10 – 16 years11

Domestic Violence in 10 cases Adult Mental Health in 5 cases Adult Substance Use in 5 cases Type of AbuseNumber of Cases Physical Abuse7 Sexual Abuse4 Emotional Abuse5 Neglect1 Multiple Abuse Categories3

Vulnerability of: – Babies – physical abuse / significance of bruises in non mobile babies / prematurity – Teenagers – self harm / suicide / impact of earlier safeguarding issues – Children In Care – isolation / education / placement change / transition between authorities. – Disabled Children – ensure safeguarding concerns are not missed Overview of the Learning

Sexual Abuse: – Lack of disclosure / need to minimise barriers to disclosure – Complexity of assessment and management – Need to minimise the barriers for children disclosing sexual abuse Emotional Abuse: – Lack of disclosure / assessment of parenting and the relationship is essential – Early intervention – Recognition of impact on children

Complexity of parental relationships and the impact on children Identification of non compliance / significance of missed appointments Maintain a focus on the child and the parenting, not the parents Perpetrators linked to a number of families The importance of seeing the parents separately and raising domestic violence as an issue

Managing enquiries and concerns about the behaviour of trusted adults Preparation, support and supervision of foster carers Ensure pre discharge planning takes place and appropriate colleagues are engaged The importance of management oversight and supervision promoting reflective practice All members of the core group must understand the safeguarding risks and be giving the same messages to the family. The importance of multi agency meetings and the potential impact of professionals only attending part of a meeting

Summary Children should be seen frequently by the professionals involved and asked for their views and feelings A respect for family privacy should not be at the expense of safeguarding children Professionals who are concerned about their own safety should consider the implications of risk to children Be aware that the needs of parents can mask children’s needs. The importance of information sharing There is lots of good practice!

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