Serious Case Reviews

Local Lessons & Actions

www.hertsdirect.org/safeguardingchildren

Why do we undertake SCRs?

Regulation 5 of the LSCB Regulations 2006 states:

“(1)The functions of a LSCB in relation to its objective ....are as follows-

(e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.”

When do we undertake SCRs?

When a child dies and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of the organisations and professionals in the lives of the child and family.

(Working Together, 2010)

When do we consider undertaking SCRs?

• When a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse; or

• A child has been seriously harmed as a result of being subjected to sexual abuse; or

• A parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004; or

• A child has been seriously harmed following a violent assault perpetrated by another child or an adult;

AND

The case gives rise to concerns about the way local professionals and services worked together to safeguard the children.

What is the purpose of a SCR?

• To establish what lessons there are about the way professionals and organisations worked individually and together.

• To identify how theses lessons will be acted on; in what timescale; and what is expected to change

• To improve intra- and inter-agency working & therefore better safeguard children.

What would the role of the school be?

• An Individual Management Review would be completed by Standards & School Effectiveness

• This would look at he role & involvement of all educational staff, including school employees

• The report author would review school records & interview relevant staff

• The aim would be to establish if there are lessons to be learnt in respect of how the school contributed to safeguarding the child

The national picture

Understanding Serious Case Reviews and their Impact

A Biennial Analysis of Serious Case

Reviews 2005-07

M Brandon, et al, 2009

The Children• 30 % were aged 0-3 months

• 45% were under 1 year old

• 67% were 5 years old or younger

• 25% were over 11

• 17% were subject to a child protection plan

• About half were known to children’s social care

www.hertsdirect.org/safeguardingchildren

The Families• 45% Families had had frequent house moves

• 53% Domestic Violence (current or past)

• 33% Substance Misuse (current or past)

• 63% Mental Health problems (current or past)

• 15% Parental learning disability

• 45% Parent with criminal conviction

• 75% of children had lived with domestic violence, parental mental ill health or substance misuse

www.hertsdirect.org/safeguardingchildren

The issues• Chaotic behaviour in families can be mirrored in

chaotic professional thinking and actions• Failure to see the child - practice is not ‘child

focused’• Efforts not to be judgemental becoming failure

to exercise professional judgement• Silo practice – professionals not looking at the

needs of the child outside their own specific brief.

www.hertsdirect.org/safeguardingchildren

Issues (cont’d)

• ¾ of the families did not co-operate with services – a lack of authoritative child protection practice

• Multiple risk factors – parental substance misuse; mental health problems; domestic abuse; poor living conditions

• Little or limited information about men• Fixed views of a family• Perceived, or real, difficulty in engaging older

children

SCR in Hertfordshire• 5 SCR completed in past year• 3 deaths and 2 serious injuries• 3 under 5 years old• 1 teenager• Parental mental health problem 3 cases• Domestic Violence 4 cases• Parent with learning disability 1 case• Substance misuse 1 case• Neglect 5 cases

www.hertsdirect.org/safeguardingchildren

What were the lessons in Hertfordshire

• Keeping a focus on the child– Can/are the parents meeting the child’s needs

• Working across adult and children's services– Making best use of expertise

• Accessing and taking account of past history– Start again syndrome & the rule of optimism

• The need for professionals to escalate concerns where they feel these are not being addressed appropriately

www.hertsdirect.org/safeguardingchildren

What were the lessons in Hertfordshire

• Assessing the impact of cumulative risk factors on parenting ability – Working with complexity

• All significant adults should be included in assessments

– The absence of fathers, male partners, relatives

• Critical and authoritative child protection practice

– Family & professional accountability