Messages from Serious Case Reviews Patrick Ayre Department of Applied Social Studies University of...

Messages from Serious Case Reviews

Patrick Ayre

Department of Applied Social Studies

University of Bedfordshire

Park Square, Luton

email: pga@patrickayre.co.uk

web: http://patrickayre.co.uk

Learning from enquiries

Those who cannot learn from history are doomed to repeat it

(George Santayana)

Plus ça change Every child matters & Keeping children

safe

Jasmine Beckford, Kimberley Carlile, Tyra Henry & Victoria Climbié, Lauren Wright and Ainlee Walker,

Doing the simple things well

Serious Case Reviews

Held when a child has died or suffered serious harm and abuse or neglect suspected

Aim to identify lessons to be learned

Action plan drawn up

Serious Case Reviews

A panel of senior managers drawn from key local agencies

Final report normally written by an experienced external consultant

Examine management reviews prepared by each agency

Serious Case Reviews

Produce overview report and action plan

Executive summary of report becomes a public document

Learning from Past Experience Major themes from SCR reviews of the 90s:

Inter-agency working Limited inter-agency co-operation and service

integration, especially child and adult services Poor communication both between agencies

and within agencies Health services and child protection: variable

levels of knowledge, especially among GPs and those in adult mental health service

Learning from Past ExperienceCollecting and interpreting information Importance of comprehensive family

assessments, especially male figures Need for medical evidence to be

considered within the overall context Receiving, interpreting and dealing with

referrals Understanding thresholds, especially the

importance of neglect and emotional deprivation and the need to accumulate evidence

Capturing chronic abuse

Judging the impact of long-term abuse is an essential component of any assessment but how well do we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event

Capturing chronic abuse

Judging the quality of care is an essential component of any assessment but how well do we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event

Our image of assessment

A ssessm ent

The reality of assessment?

A ssessm ent

Capturing chronic abuse

Judging the quality of care is an essential component of any assessment but how well do we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event

The pattern of neglect: atypical

The pattern of neglect: typical

Intervention Intervention

The pattern of neglect

'G ood enough' level

Intervention Intervention

The pattern of neglect

Intervention Intervention

'G ood enough' level

Intervention ceases

The pattern of neglect

What we would hope to find

T h r es h o ld f o rin te r v en tio n

SEXUAL

ABUSE

PHYSICAL

ABUSE N

EGLECT

NEGLECT

NEGLECT

What we found

T h r es h o ld f o rin te r v en tio n

SEXUAL

ABUSE

PHYSICAL

ABUSE

NEGLECT

NEGLECT

NEGLECT

NEGLECT

What we found

Chronic abuse and the principle of cumulativeness Incidents scattered through files

The problem of proportionality

Acclimatisation

Pitfalls and How to Avoid Them Professionals think that when they have explained something

as clearly as they can, the other person will have understood Parents’ behaviour, whether co-operative or uncooperative, is

often misinterpreted Not enough weight to information from family friends and

neighbours Not enough attention is paid to what children say, how they

look and how they behave Attention is focused on the most visible or pressing problems

and other warning signs are not appreciated When faced with an aggressive or frightening family,

professionals are reluctant to discuss fears for their own safety and ask for help

Information taken at the first enquiry is not adequately recorded, facts are not checked and reasons for decisions are not noted.

In Cleaver, H, Wattam, C and Cawson, P Assessing Risk in Child Protection, NSPCC, 1998

Information handling Picking out the important from a mass of data Interpretation Distinguishing fact/opinion; too

trusting/insufficiently critical Mistrusted source Decoyed by another problem False certainty; undue faith in a ‘known fact’ Discarding information which does not fit First impressions/assumptions

Department of Health (1991) Child abuse: A study of inquiry reports, 1980-1989, HMSO,

Learning from Past Experience

Decision-making Need for shared decision-making,

especially in respect of not taking action or case closure

Moving from data collection and sharing to strategic discussions and clear plans

Planning a co-ordinated response across professionals and agencies

Learning from Past ExperienceRelations with families Dealing with hostile families or those

who withdraw Lack of awareness of the impact of

domestic violence on children and their safety.

Seeing the child as the client, focusing on his or her protection and not being distracted by other problems or by adult or sibling concerns

A child centred approach

The purpose of assessment is to understand what it is like to be that child (and what it will be like in the future if nothing changes)

Learning from Past Experience (2002)

Geographical mobility: breaking contact Common understanding of what triggers

an assessment of need or risk of significant harm?

Information sharing and confidentiality Better identification of children

vulnerable to abuse Understanding the process of change in

public services

ANALYSING CHILD DEATHS AND SERIOUS INJURY THROUGH ABUSE AND NEGLECT (2003-5)

‘Hard to help’ young people

Hesitancy in challenging

Hostile and ‘difficult to engage’ families

‘Start again syndrome’.

Very young children physically assaulted known to universal services or adult services rather than children’s social care

Well over half: domestic violence, or mental ill health, or parental substance misuse

“Hard to Help”: The complexity of the challenge

Young people may be Victims, Perpetrators Parents Any combination of the above

but have the same right to be safeguarded as any other child.

The background

“The reviews showed that state care did not always support these young people fully and that they experienced ‘agency neglect’” Brandon and others (2008).

The young people

Adolescence marks start of serious problems for many children:

– Onset of mental health issues– Family conflict– Drug use, offending– Sexual activity– Running away

The young people (Brandon and others)

History of rejection, loss and, usually, severe maltreatment

Long term intensive involvement from multiple agencies

Parents: history of abuse and current mental health and substance issues

Difficult to contain in school Typically self-harming and misusing

substances, often self-neglect

The young people (Brandon and others)

Numerous placement breakdowns Running away, going missing Risk of dangerous sexual activity

including exploitation Sometimes placed in specialist

settings, only to be withdrawn because of running away

The young people (My experience)

Long involvement, but not always intense Sometimes few placements, but all wrecked

by the young person Common factor that local services just did

not know what to do with them. ‘By the time of the incident, for many of the

young people, little or help was being offered because agencies appeared to have run out of helping strategies’ (Brandon and others, 2008).

The response

Reluctance to identify mental illness and suicidal intent (CAMHS)

Failure to respond in a sustained way to extreme distress manifested in risky behaviour (sex, drugs, suicide attempts)

Arguing between agencies about responsibility and thresholds

Reasons for running not addressed adequately

The response

Running away leads to discharge [More generally, does rejection of

services lead to total abandonment?] Age used as a reason for not imposing

services No proper assessment of competence;

allowed/forced to choose; [Dealing with incidents but failing to

recognise patterns]

The obstacles

Hard to get a purchase on the system Wrong children, wrong adults (Ayre, 2000) Lack of off-the-shelf resources The limited resources are poorly

coordinated and integrated Government targets not child centred or

child driven Different agency agendas and mutual

misunderstanding; falling down the gap

The solutions?

Biehal (2005) recommends adolescent support teams in the community [but is that enough?]

The complexity of the challenge requires flexible collaborative, individualised responses built around the young person

Learning from recent SCRs

Information drawn from:

About 30 Serious Case Reviews and expert witness reports undertaken in local authorities around England since 2003

A ‘review of reviews’ undertaken for one authority

Learning from recent SCRs

Key areas of concern

Assessment practice

Response to overload

Communication and collaboration

Child protection meetings and conferences

Case management

Assessment Practice Great disquiet over assessment

practice Failure to give sufficient weight to

relevant case history Facts recorded faithfully but not

always critically appraised Guidance and thresholds

Assessment Practice

Use of trained staff

Assessment of male carers

Maintenance of a wholly child-centred approach

Formal assessment of risk (How do you do a risk assessment?)

Risk assessment The dangers involved (that is the feared outcomes);

The hazards and strengths of the situation (that is the factors making it more or less likely that the dangers will realised);

The probability of a dangerous outcome in this case (bearing in mind the strengths and hazards);

The further information required to enable this to be judged accurately; and

The methods by which the likelihood of the feared outcomes could be diminished or removed.

Response to overload

Acclimatisation at individual and agency levels

Lack of a strategic multi-agency response

The Child Safeguarding System (nominal)

The Child Safeguarding System (actual?)

Collaboration and communication

Communication generally found to be good but…

Communication with hospitals

– Referrals

– Medical reports

Mental health or drugs issues

Mental health or drugs issues

Working on the same case but not working jointly

Mutual incomprehension and misunderstanding

False expectations and assumptions

Abdicating responsibility

Need for ‘interpreters’

Child protection meetings

Attendance at conferences

Protection plans omit objectives and outcomes

Removal from the register

Use of strategy meetings

Proliferation of meeting types

Case management File management: reading, recording

decisions, auditing

Case closure

Chronologies

CP and teenagers

Effectiveness of Emergency Duty Teams

Training

General disquiet over the level of training in child protection

Specific training for children's services and mental health workers

Enhanced training for conference chairs and or independent professionals

Interagency training to cover the roles and priorities of the key agencies

References Brandon M. et al (2008) Analysing child deaths and serious

injury through abuse and neglect: What can we learn?; London, Department for Children. Schools and Families

Falkov, A. (1996) A Study of Working Together Part 8 Reports: Fatal Child Abuse and Parental Psychiatric Disorder, London: Department of Health

James, G. (1994) Study of Working Together Part 8 Reports, London: Department of Health

Owers, M., Brandon, M. and Black, J. (1999) Learning How to Make Children Safer: An Analysis for the Welsh Office of Serious Child Abuse Cases in Wales, University of East Anglia/Welsh Office

Sinclair, R and Bullock, R (2002) Learning from Past Experience: A Review of Serious Case Reviews, London: Department of Health

Learning from Public Enquiries

The unholy trinity following cp tragedies:

aggressive public pillorying of agencies; ever more detailed recommendations resulting

from public enquiries; increasingly intricately wrought practice

guidance from central government

CLIMATIC CONDITIONS

Climate of fear

Climate of mistrust

Climate of blame

HOW DID WE GET TO WHERE WE ARE NOW? This history may create a system: excessively concerned with identifying and

eliminating danger rather than promoting well-being and undertaking treatment or therapy.

excessively concerned with procedures and process rather than with objectives and outcomes.

defensive, reactive and concerned with the collection of evidence at the expense of the assessment of need and proactive, co-operative, preventive provision.

Trusting procedures

Procedural proliferation

Blaming and training

The myth of predictability

Procedures as a net to catch problems

Procedures as a net to catch problems

Procedures as a net to catch problems

Procedures as a net to catch problems

In itiateaction 1

Tak eaction 1

Tak e ne xt action

As s e s sand e valuateDe cide ne xt

action

Exit s ys te m

Ente r s ys te m Exit s ys te mInitiate

e xit action

Ente r s ys te m

PROFESSIONAL LEV EL

TECHNICAL LEV EL

PROFESSIONAL LEV EL

TECHNICAL LEV EL

Feedforward Control System

Feedback Control System

In itiateaction 2

Tak eaction 2

Controle ve nts

Actions