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

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 2

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

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 4

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. 5

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. 6

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 7

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 8

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 9