Upload
winifred-harper
View
228
Download
2
Tags:
Embed Size (px)
Citation preview
Surrey Wide CCG Safeguarding Children Team
Surrey Wide CCG Safeguarding Children Team
Safeguarding Children & Young PeopleLearning from Serious Case Reviews
This presentation presents information from selected recent
Surrey Serious Case reviews.
Surrey Wide CCG Safeguarding Children Team
Introduction
Surrey Wide CCG Safeguarding Children Team
Establish what lessons are to be learned from the case about
the way in which local professionals and organisations work
individually and together to safeguard and promote the welfare
of children;
Identify clearly what those lessons are both within and between
agencies, how and within what timescales they will be acted on,
and what is expected to change as a result; and
Improve intra- and inter-agency working to better safeguard and
promote the welfare of children.
Purpose of a Serious Case Review
Regulation 5 (1) (e) and (2) of the LSCB Regulations
Sets out an LSCB’s function in relation to serious case
reviews, namely:
Regulation
• (1) (e) undertaking reviews of serious cases and
advising the authority and their Board partners on
lessons to be learned.
Surrey Wide CCG Safeguarding Children Team
Serious Case Reviews – LSCB Regulations 2006
(2) For the purposes of paragraph (1) (e) a serious case is one
where:
(a) abuse or neglect of a child is known or suspected; and
(b) either
(i) the child has died; or (ii) the child has been seriously harmed
and there is cause for concern as to the way in which the
authority, their Board partners or other relevant persons have
worked together to safeguard the child.
Surrey Wide CCG Safeguarding Children Team
Serious Case Reviews – LSCB Regulations 2006
Young Person Hiers 2013 - age 14: suicide
Child S, 2011 – baby (8 weeks): head and other injuries
Child X, 2012 – baby (4 weeks): bruising and multiple injuries
Surrey Wide CCG Safeguarding Children Team
Surrey Serious Case Reviews
Came to the UK in 2010 and lived in a bedsit in a shared house with his mother
Started school in year 7, limited English initially but was considered to be progressing well
Mother returned to China in 2013 to settle some family affairs. Young Person Hiers did not want to return with her so stayed in the UK with arrangements made for the landlord and other residents to keep an eye on him. Mother provided him with adequate food and money. School were unaware of this arrangement
Surrey police were contacted by the NSPCC to say that the young person had been left home alone. Police attended home address and carried out welfare checks
on 23rd April Surrey police received a telephone call from the ambulance service to inform them that the young person had been pronounced dead at the home address
Surrey Wide CCG Safeguarding Children TeamYoung Person Hiers
Surrey Wide CCG Safeguarding Children Team
Young Person Hiers- Practice Issues that Emerged
Surrey Wide CCG Safeguarding Children Team
Read through the case study of Child S.
In pairs/groups, list what you think are the main lessons that emerged from this SCR?
Feedback
Case Study
Surrey Wide CCG Safeguarding Children Team
Inadequate recognition by a number of professionals of the significance of interacting risk factors including: • failure to engage with services• lack of antenatal care• substance misuse• domestic violence• ambiguous feelings towards two
pregnancies and a troubled parental history as a child
Child S – practice issues that emerged
Surrey Wide CCG Safeguarding Children Team
• Practitioners did not fully appreciate the implications of parental misuse of alcohol and take action to reduce risk to the children.
• Practitioners in Children’s Social Care and Health did not recognise the significance of bruising/injuries in non-mobile babies.
• Practitioners did not ensure that when a child on a Child Protection Plan sustains an injury this is examined by a paediatrician.
• Accessing mother’s historical records presented challenges to the review team and this lack of access also impacted on practitioners
Child S – practice issues (continued)
Surrey Wide CCG Safeguarding Children Team
Child X Case Synopsis
The baby aged just 4 weeks lived with her young parents aged 18 and 20 years
There were no obvious warning factors prior to birth; but following the review it emerged that the mother and her family were known to children services
The mother had declined universal services – CAF, parent education and support with housing and finance. School nursing records suggest mother may have learning difficulties
Little was known about the father
Maternity inform children’s services after the mother is ejected from parental home. However, there was confusion whether this was a referral or information sharing, lead to children’s services taking no further action
Surrey Wide CCG Safeguarding Children TeamChild X (continued)
In the first 3 weeks of the baby’s life professionals had noted several bruises on different parts of the body and bilateral conjunctival haemorrhages
The baby was seen by 5 different health disciplines and no one considered the bruising to be caused by abuse. The injuries were believed to have a medical cause and no one challenged this hypothesis
The baby was admitted to hospital by ambulance following a seizure and a medical cause prevailed. Following transfer to a regional unit and following further medical investigation the baby was found to have suffered serious injuries including, sub-dural haematoma, leg & foot fractures and multiple rib fractures
Both parents have been convicted and are serving custodial sentences
Surrey Wide CCG Safeguarding Children Team
Practice issues that emerged
Failure to follow child protection procedures due to lack of awareness of procedures, including bruising protocol
No consultation with safeguarding leads or safeguarding supervisors
Lack of effective communication & information sharing between all professionals involved which may have supported the prevailing hypothesis
Poor recording keeping. Poor recording of facts, no body map of bruises, incorrect entries
Significant administration weaknesses. Delay in transferring records, failure to send information in a timely fashion, incorrect information sent. Key information between health visitors was either not sent, or not received
Surrey Wide CCG Safeguarding Children Team
Practice issues that emerged (continued)
Lack of consistent involvement by the same professional in all areas of the baby’s care
Overwhelming professional tide of optimism leading to rigid mind set and flawed professional judgement about the parents shifted the focus away from the child
Lack of professional challenge – either to parents or to other professional colleagues
Recognising Neglect
Surrey Wide CCG Safeguarding Children Team
Recommendations for practice
Recommendations therefore aim to improve:
Skills & Training
Management and organisational
support
Assessment &
recognition of risk
Surrey Wide CCG Safeguarding Children Team
Multi-agency Child Protection Procedures and Guidance
Multi-agency procedures – website: www.sscb.proceduresonline.com
Surrey Safeguarding Children Board
www.surreycc.gov.uk/safeguarding
Surrey Wide CCG Safeguarding Children Team
Resources & Further Reading
Ten pitfalls and how to avoid them
http://www.nspcc.org.uk/inform/publications/downloads/tenpitfalls_wdf48122.pdf
Working Together to Safeguard Children 2015
https://www.gov.uk/government/publications/working-together-to-safeguard-children
Surrey Serious Case Reviews
http://www.surreycc.gov.uk/social-care-and-health/childrens-social-care/information-for-child-social-care-professionals/safeguarding-children-serious-case-reviews
Surrey Wide CCG Safeguarding Children Team
Early Help
www.surreycc.gov.uk/earlyhelp
Serious Case Review into abuse at Little Ted’s Nursery
http://www.plymouth.gov.uk/homepage/.../littletednurseryreview.htm
Children’s Needs – Parenting Capacity. Child Abuse: Parental mental
illness, learning disability, substance misuse and domestic violence
(Cleaver et al)
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182095/DFE-00108-2011-Childrens_Needs_Parenting_Capacity.pdf
Serious Case Review - Published January 2012 - The Abuse of Pupils in a First
School (North Somerset SCB)
http://www.northsomersetlscb.org.uk/uploads/files/282.pdf
Surrey Wide CCG Safeguarding Children Team
Domestic Violence – Child Protection and impact on Children
https://www.nspcc.org.uk/Inform/policyandpublicaffairs/northernireland/briefings/DVbriefing_wdf64606.pdf
Victoria Climbie Enquiry
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/5730.pdf
Victoria Climbie summary report
http://lx.iriss.org.uk/sites/default/files/resources/113A.%20The%20Victoria%20Climbie%20Inquiry%20-%20Summary-Report.pdf
Peter Connelly – first SCR report
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182527/first_serious_case_review_overview_report_relating_to_peter_connelly_dated_november_2008.pdf
Surrey Wide CCG Safeguarding Children Team
SCR – Keanu Williams
http://www.lscbbirmingham.org.uk/images/stories/downloads/executive-summaries/Case_25__Final_Overview_Report_02.10.13.pdf
SCR Daniel Pelka Overview Report
http://www.coventrylscb.org.uk/files/SCR/FINAL%20Overview%20Report%20%20DP%20130913%20Publication%20version.pdf
What to Do if You’re Worried a Child in Being Abused 2006
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/190604/DFES-04320-2006-ChildAbuse.pdf
Information Sharing Guidance for Practitioners and Managers
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/277834/information_sharing_guidance_for_practitioners_and_managers.pdf
Surrey Wide CCG Safeguarding Children Team
For advice or to make a referral:
North East Referral Hub: 0300 123 1610
South East Referral Hub: 0300 123 1620
North West Referral Hub: 0300 123 1630
South West Referral Hub: 0300 123 1640
Emergency Duty team: 01483 517898
Surrey Police: 101 (or 999 in an emergency)
Referrals should be made to Children's Service using the Multi-Agency
Referral Form (MARF). If the referral is urgent and is made verbally it
must be followed up by the MARF within 48 hours.
Children’s Services