1. Thematic Analysis of Sheffield Cases of Concern Completed between December 2005 – April 2012 Sheffield Safeguarding Children Board

2. Introduction The thematic analysis of 12 reviews (including Serious Case (SCR) and Learning Lessons Reviews (LLR)) completed between December 2005 – April 2012. Methods The analysis of the 12 cases has two main aspects: Content analysis to provide details regarding the children at the focus of the reviews and known parent/carer vulnerabilities. A thematic analysis to identify any themes occurring across cases and/or over significant time periods *. *The stages of thematic analysis were adapted from those suggested by Braun & Clarke (2006), ‘Using thematic analysis in psychology’.

3. Results: Content Analysis Details of the children at the focus of the 12 reviews: 8 focused on 1 child, 2 focused on 2 children & 2 involved families. 78% of the children were between 0 – 5 years. There were 4 child deaths. The remaining 8 cases were for serious injury, neglect or sexual abuse/rape. The involvement of Social Care: 67% (8 cases) had had contact with social care in the past. 58% (7 cases) had contact at the time of the incident. None of the children were subject to a Child Protection Plan at the time of the incident.

4. Parental Risks & Vulnerabilities Factors known about the parent’s childhood 7 cases (58%) involved one or more parent/carer that had experienced a difficult/abusive childhood. o 5 cases had known social care referrals/involvement. o 5 parents/carers had been sexually abused as a child. 5 fathers & 9 mothers first became a parent at 20 years or younger. 3 parents/carers had Learning Disabilities, 2 had ADHD & 1 borderline ADHD. Parental vulnerabilities 75% (9 cases) involved one/more parent with mental health difficulties, higher than found nationally. 42% (5 cases) had parental substance misuse, domestic abuse and mental health issues.

5. Results: Thematic Analysis 1. Public Involvement 2. Everything is ok 3. Assessment, Assessment, Assessment 4. Protection 5. Challenge and Responsibilities 6. Professional Knowledge and Support These themes will be considered in more detail on the following slides Thematic analysis is a method of qualitative research which involves searching through data to identify patterns that can be developed into themes. In this case, identifying themes across cases or over time. The thematic analysis produced 6 main themes, each with a number of sub- themes.

6. Theme 1 - Public Involvement Apathy: In 2005 &2008 (in 2 cases) it was shown that members of the public didn’t recognise or report safeguarding concerns. ‘Some relatives and public house regulars were worried about the condition of the living quarters and believed the children were sometimes left alone for long periods…….. It is a matter of great regret that no-one shared this information with the care agencies ’ (2008) Public Concerns: However, in 5 recent reviews (published 2010/11) there was evidence of relatives/the public reporting concerns. However, the response from professionals wasn’t always what they expected. ‘The same health visiting service not following up information from Ms A’s neighbour that she did have a child (2011)

7. Theme 2 - Everything is ok This theme demonstrated how professionals didn’t recognise the safeguarding issues or vulnerabilities that existed. There were 2 main reasons for this: 1. Normal for Community. In 3 cases professionals felt that the children were one of a ‘number of children like this’ in the community: ‘There are lots of other families like this in their practice area so this family would not have stood out. This is of concern… because of the clear level of risk that there was in this family.’ (2011) 2. Misplaced Optimism. There was evidence (in 8 cases) of professionals working with an overoptimistic view of the situation. The most common reason was that they didn’t question, recognise, know or collate the family history or vulnerabilities that exist. ‘Assessments failed to consider the historical information regarding this couple. Agencies failed to consider the multiple risk factors’ (2011)

8. Theme 3 - Assessment, Assessment, Assessment 1.An Assessment Mindset is seeing every encounter with a family as an opportunity to re-evaluate the situation. The lack of this was an issue in 6 cases. 2.Silo Thinking. In 6 cases professionals viewed situations in isolation, were task focused and ‘episodic’. This also highlighted where professionals didn’t consider the possible impact of the parents mental health on their parenting. 3.Downgrading of risk (4 recent cases). In these professionals closed cases when there was no evidence of any new information to inform this decision. 4.Recognition of risk by universal services. 3 cases highlighted that although universal services had contact with a family, they didn’t recognise the circumstances the children were living in. 5.Communication and information sharing was an issue in 10 reviews. This highlights the importance of assessment and the difficulties that arise when this isn’t thoroughly completed.

9. Theme 4 - Protection 1. Loss of Child Focus. In 3 reviews ‘Professionals failed to listen and consider situations from the child’s perspective: they did not see the children, and where possible, talk to them to find out what they thought and felt about issues; and take action based on this information.’ (2010) 2. The vulnerability of the very young. There were 10 reviews that involved children 2yrs or younger at the time of the incident. 4 Cases had earlier injuries judged to be accidental/ explainable & 1 case an older sibling had, had previous injuries. There were examples of professionals accepting unrealistic explanations and working within the assumption that they must be ‘beyond reasonable doubt’ (of Non accidental injury) before taking action. Where professionals failed to keep their focus on the child(ren) and their well being. As very young children (2 yrs or younger) have particular vulnerabilities these are a separate ‘sub theme’:

10. Theme 5 - Professional Challenges & Responsibilities 1.Challenging Parents. Professionals have a responsibility to challenge parents when needed. In 3 cases this didn’t happen. 2. Evasive & Manipulative Parents In 6 reviews professionals had difficulties in keeping parents ‘on side’, parents pressurising professionals to alter reports, refusing access to the child/property or giving incorrect information. 3. Fathers - In 3 reviews the fathers/partners were either not known or their role not fully considered. There were also 2 cases where fathers intimidated the professionals, which led to the fathers controlling the situation. 4. Professional responsibility to challenge other professionals when necessary. There were examples in 6 reviews were this did not happen. 5. Assumptions of responsibility. In 5 reviews professionals made assumptions that others were monitoring the situation or they had made a referral and therefore their responsibility ended.

11. Theme 6 - Professionals Support & Knowledge Knowing your client, what is important? Not holding knowledge or understanding the issues in 2 cases led to difficulties Where were the good practice guidelines? In 7 cases professionals did not follow the guidelines. Support, Supervision & Good Management In 5 reviews there were issues around supervision & 4 cases where management and support issues arose.

12. Conclusion  Themes repeatedly being seen at a national level  The analysis has provided evidence of the issues relevant to Sheffield.  Demonstrates that even though Sheffield agencies have completed action plans (from reviews) in a timely and robust manner, challenges continue.  These issues appear to be ones that will require a cultural change in the way that professionals work and are thus more difficult to achieve

13. For further information please see: www.safeguardingsheffieldchildren.org.uk or contact: Sarah Adams Research & Performance Officer sarah.adams2@sheffield.gov.uk www.safeguardingsheffieldchildren.org.uk

14. References Brandon,M., Bailey,S. & Belderson, P. 2010. Building on the learning from serious case reviews: a two year analysis of child protection notifications 2007 – 2009 – Brief. Department for Education. Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth,J. & Black, J. 2008. Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of SCR 2003 – 5. Department for Children, Schools and Families. Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C. & Megson, M. (2012) New Learning from SCR. A two year report for 2009 – 2011. Department for Education. DFE-RR226 Braun, V. & Clarke, V. 2006. Using thematic analysis in psychology. Qualitative Research in Psychology, 3 (2). Pp. 77 – 101. Burton, S. 2009. The oversight and review of cases in the light of changing circumstances and new information: how do people respond to new (and challenging) information? C4EO. Safeguarding: Briefing 3.

15. References continued Jones, A. 2009. Serious Case Review: Baby Peter. Executive Summary. Haringey Local Safeguarding Children Board & Department for Education: Laming. 2003. The Victoria Climbie Inquiry. Report of an inquiry by Lord Laming. Department of Health: Ofsted. 2009. Learning lessons from serious case reviews: year 2. Ofsted’s second year of evaluating serious case reviews: a progress report (April 2008 to March 2009). Ref 090101. Ofsted. 2010. Learning lessons from serious case reviews 2009 – 2010. Ofsted’s evaluation of serious case reviews from 1 April 2009 to 31 March 2010. Ref 100087. Ofsted 2010b. Learning lessons from serious case reviews: interim report 2009 – 10. Ofsted’s evaluation of serious case reviews 1 April to 30 September 2009. Ref 100033. Ofsted. 2011. The voice of the child: learning lessons from serious case reviews. A thematic report of Ofsted’s evaluation of serious case reviews from 1 April to 30 September 2010. Ref 100224. Ofsted. 2011b. Ages of concern: learning lessons from serious case reviews. A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011. Ref 110080..