1. Cardiff Partnership Board
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 Establish whether there are lessons to be learned
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