Case Reviews

With thanks to Stuart Smith, CAIU Essex Police

What is a Case Review SERIOUS CASE REVIEW

- When a child dies and abuse/neglect known or suspected or

- Where there are concerns about inter-gency working to protect children from harm or

- Child sustained potentially life-threatening injury/serious permanent impairment or serious sexual abuse

Reviews• The R case 1999

7 yr old alleging sexual assault by her father

The NG Case 1999

Child with disabilities suffered bruising incidents and a spiral fracture

Reviews• The S Case 1999

Child placed with father who had previous convictions for sexual offences against children

The 1-4 Case 2002

Convicted offender in family – continued abuse whilst assessment and child protection process failed to protect children

Reviews• The Childs Case SCR 2002

Teacher previously investigated for sexual abuse abused number of children within school and social group

The Needs of Children First SCR 2003

Long term issues in family involving number of professionals. Child admitted to hospital with insulin overdose. Concern medical equipment tampered with

Reviews• RE Case SCR 2004

Death of 7 week old child – evidence of shaking & fractures to both legs

• Missing Records Case SCR 2004

Child of asylum seeking family known to number of agencies – physically assaulted by female carer who was not mother

Reviews• KB Case SCR 2005

Baby suffered brain haemorrhaging and retinal damage. Long history professional involvement

DE Case SCR 2005

Death of baby following history of multi-agency involvement

Reviews

• LU Case (Sec. 111 LGA 1972) 2005

Death of teenager who had been looked after child, living independently in supported accommodation

Two current LSCB Reviews

Main areas of concern• Identify needs of children first – 6 reviews• Risk factors/assessments – 4 reviews• Supervision – 4 reviews• Basic training – 4 reviews• Full checks & recording – 3 reviews• Transfer of cases – 3 reviews• Recording of entries – 3 reviews• Interviewing children alone – 3 reviews

Recommendations• Supervisors must be alive to need for

assessments to be child centred• Risk assessment training• Supervisory review of cases prior to closing• Review of training given to professionals – is it fit

for purpose?

Recommendations Details obtained at referral.

All necessary checks completed Chronology/summary sheet at beginning of all agency

files Written record of transfer when a case is reallocated Child seen and spoken to alone Reinforcement of policies and procedures surrounding

post natal depression

LSCB Recommendations• All reviews are retained by a designated person• All review recommendations are subject to action plans• All action plans are subject to LSCB scrutiny and

agencies are accountable for own recommendations• Results of action plans are published and retained with

the relevant reviews• All future reviews are compared to this research to

identify any further duplication of bad practice. Any remedial action is then made subject of review recommendation and action plan

Duplicate recommendations• Identifying needs of child first• Recognition of risk factors/assessments• Full checks and recording• Dating and signing of entries• Chronologies• Children interviewed alone• Basic training and awareness• Supervision of staff• Referral deficiencies• Referrals re: Domestic Violence• Assessment postnatal and general depression• Procedures fit for purpose

What Next?

MONITORING FRAMEWORK

- Quarterly monitoring:

- % of case review recommendations that have been implemented by each agency within timescale

- Safeguarding performance and activity of each agency

- Including training of new/existing staff