Learning from the findings of Serious Case Reviews

1. Learning from the findings of Serious Case Reviews To enable participants to reflect on the findings of Serious Case Reviews and strengthen their practice and management • Two reviews in Bromley conducted in 2008 (summaries are on the BSCB website) • A briefing on the main findings of the detailed review of the findings of 40 SCRs 2005 – 2007

2. The purpose of Serious Case Reviews • Public enquiries into child deaths • Chapter 8 of Working Together • when to conduct a case review • how to go about it • Learning from cases • Accountability • to the LSCB • to the community (via the local authority and other agency boards) • to central government and the general public

3. The process (1) • Internal agency reviews • Appoint a reviewer • Secure the written and computer records • Prepare a chronology • Interview staff • Write the agency management review • Submit the material to the safeguarding children board SCR panel

4. The process (2) • LSCB overview report • Appoint a SCR panel • Appoint an independent chair and report author • Produce a joint chronology • Scrutinise the individual agency reports • Evaluate the practice and agree the ‘lessons learnt’ • Write the overview report • Recommendations and an action plan

5. Dissemination of the findings • Feedback for staff involved • Learning for other staff and managers • Local agency boards and the council • Reports submitted to central government • Government Office • Dept for Children Schools and Families • Strategic Health Authority • Publication of the Executive Summary

6. Main themes from the latest review of SCRs

7. M Brandon et al, Understanding Serious Case Reviews and their impact – A Biennial Analysis Of Serious Case Reviews 2005-7, (2009) Department for Children Schools and Families / University of East Anglia

8. Previous references Peter Reder and Sylvia Duncan, Lost innocents – a follow up study of fatal child abuse, 1999, Brunner-Routledge An overview of 55 cases subject to serious case review and reported to government in one year Peter Reder, Sylvia Duncan, Moria Gray, and Olive Stevenson,Beyond Blame: Child Abuse Tragedies Revisited,1993, Routledge An earlier review of a less representative sample of cases M Brandon et al, Analysing child deaths and serious injury through abuse and neglect - what can we learn? A biennial analysis of SCRs 2003 – 2005, Department for Children Schools and Families, 2008.

9. 189 SCRs in England during 2005 – 2007 • 40 cases reviewed in detail • 2/3 of children died, the remainder were seriously injured Remember • the nature of the sample • selection for SCRs is to a degree subjective

10. Some population characteristics • 47% (under one year) (6%) • 23% (1-5 years) (26%) • 72% white (slight under representation) • 13% mixed parentage (slightly over represented) • 8% black / black British (slightly under represented)

11. Legal and care status • 17% subject to a child protection plan • 11% had been previously subject to a plan • The most frequently occurring category of plan was for neglect • 13% subject to a care or supervision order • 5% were accommodated under s20

12. Most frequent causes of death and injury • 39% subject to physical assault • (24% head injury to baby under age one) • 16% died of neglect (fires, ingesting drugs, accidents) • 12% adolescent suicide

13. Children who were missing or invisible • Emotionally rejected by carers • Not spoken to or kept away from professionals • Specific vulnerability not appreciated (e.g. low birth weight, developmental delay) • Siblings of the child wrongly thought to be most at risk • Unable to speak through trauma, disability or fear So professionals need to see the child, know the child and see the world through the eyes of the child

14. Chaotic, overwhelmed and unsupported families • Physically and emotionally overwhelmed • 45% had moved very frequently • Negative relationships with extended family and others such as neighbours • Deprivation and environmental dangers • Pattern of low expectations held by families and by professionals • Half in families characterised by domestic violence and almost two thirds in a family with a mental illness (past or current)

15. Findings from the earlier 2003 – 2005 review of SCRs • Significance of mental disorder, violence and substance misuse in the earlier sample • Cumulative risk: • 34% of cases had 3 of these risk factors • 34% had two • (so 68% had 2 or more) • 19% had one • but 13% had none at all

16. A hazardous and frightening home life • Substance misuse, mental ill health, domestic violence and poor living conditions • Don’t always predict serious harm but these factors hugely increase risk to children • Points to the need for a holistic assessment

17. Reiterates from the 2003 - 2005 review of SCRs need for dynamic assessment • Stresses the importance of assessment based on ‘dynamic analysis’ as opposed to ‘description’ • Risk produced by the interaction of experience, current environment, the challenge of parenting, family and personal history and relationships • Developing and testing hypotheses about care and the child’s safety • Identifying areas where change is needed • Predicting capacity to change and care effectively

18. Findings about risks arising from organisations in the 2005-7 study • Lack of capacity / resources was not always a feature • Some individual professionals and organisations were overwhelmed by the nature and the volume of the work • Some families can drain the capacity to think and see clearly • This can contribute to lowered expectations • Refusal of some professionals to be ‘judgemental’ • Attention focused in one professional or organisational ‘silo’

19. Risks from organisations and professionals …. • Fixed views about the family (not responsive to signs of deterioration) • For example - some families were seen as ‘neglect families’ • Risks associated with certain types of parenting were underestimated (e.g. ‘rough handling’)

20. The assessment and involvement of men • Dearth of information (some organisations and professionals collude in this) • Failure to involve men in assessment • Fear of some aggressive men shaped practice • Rigid and fixed thinking – men seen as either ‘good’ or ‘bad’

21. Significance of supervision and management in this context Critical and challenging thinking about: • position and needs of the child • history and circumstances of the family • actions and attitudes of the worker • functioning of the professional network as a whole

22. Findings from the Bromley SCR in relation to baby ‘P’

23. Key facts • 3 month old Black African baby girl • 3 older half siblings were looked after by the local authority due to mother’s mental ill health • Abandoned by her mother after her mental health deteriorated seriously • Injured in the incident, but not badly

24. Concerns pointing to the need for review • No pre-birth assessment • Limited collaborative working between agencies and no pre-birth conference • Social care staff had not taken actions required by the procedures (and staff from other agencies had not challenged this) • An opportunity to review working relations between mental health and children’s staff

25. Agencies involved • Children’s Social Care Services • Bromley PCT • Bromley Hospitals • Oxleas NHS Foundation Trust • Metropolitan Police

26. Positive findings about practice • As far as the mother herself was concerned and taken in isolation from one another provision by midwife, health visitor and mental health services was good • Services were very responsive to ethnicity and cultural background

27. Key findings • Weak assessment by social care staff failed to take into account key factors • Rapid turnover of staff dealing with the case • Management input failed to identify weaknesses and prevent drift • Mother misled some professionals and facts weren’t checked

28. Key findings (2) • Inappropriate optimism based on mother’s current presentation • No challenge over referrals not responded to and actions not taken by other agencies • Mental health service worked from the assumption that mother would be able to care for the baby • CPA meetings did not consider the baby’s needs • Lack of curiosity about background and history • Level of interagency contact was far too low

29. Review of staffing and provision in social care referral service Routine joint planning between professionals and changes in the CPA approach in such cases Review and implementation of the peri-natal mental health protocol Review of joint training on mental health issues Revised procedures for use of mother and baby placements in such cases Key recommendations

30. Findings from the Bromley SCR in relation to baby ‘B’

31. Key facts • 1 month old white UK baby boy • Died of natural causes (SUDI) in August 2006 while missing with his mother from a mother and baby placement • Parents both had histories of homelessness, drug misuse, alcoholism and domestic violence • 2 older brothers looked after by Bromley for 2 years

32. Concerns pointing to the need for review • Subject to a child protection plan at the time of the death • Living in a placement provided by Bromley • Evidence of weaknesses in the way the protection plan had been implemented • Limited information provided to the foster placement • Question about whether or not a legal application should have been made

33. Agencies involved • Children’s Social Care Services • Bromley PCT • Bromley Council Legal Services • Metropolitan Police • An independent fostering agency

34. Positive findings about practice • Health staff identified concerns, offered additional targeted support and made appropriate referrals • Health staff observed and assessed health and development appropriately - but without knowledge of the wider context and history

35. Key findings • Social worker failed to complete a core assessment • Long standing and serious problems of mother were underestimated • Assessment assumed that risk came only from the (supposedly absent) father • No real testing of the mother to demonstrate that she could sustain change

36. Key findings (2) • Key aspects of the child protection plan were not implemented • Assessments • Planning and discharge meetings • Specifying the foster carer’s role • Conference chair and managers did not rectify or challenge failings of social worker • Key information was not shared with the foster carer and there was no proper plan

37. Key findings (3) • Delays in seeking legal advice • Some aspects of legal advice given were inappropriate • Social worker had a fixed view about what the legal plan should be • Disquiet about the legal advice was never raised with a more senior lawyer • Written ‘working together’ agreements were never drawn up or implemented

38. Improving information presented to CP conferences (police) Improved working with legal department Improved administrative arrangements for child protection conferences Practice in joining new born babies to existing legal proceedings Clarity in the role of the fostering agency and improved training for foster carers Development of policy and procedures in relation to mother and child placements Improved information prior to placement More developed approach to assessment of parenting Key recommendations

39. Key recommendations (2) • Briefing for managers on the implications of the case for supervision practice • Improved understanding of legal status of children in ‘mother and baby’ placements • Briefing on legal rulings on pre-birth assessment and protection of babies • Improved strategy for prevention of SUDI

40. Professional qualities, attitudes and behaviours to make a difference (1) • Do everything you can to obtain and understand the history • As well as evaluating what you do know - be extremely aware of possible gaps in your knowledge • Be alert about aspects of the children’s needs outside of your own specific brief that may not be being met

41. Professional qualities, attitudes and behaviours to make a difference (2) • Be aware of the needs of other children in the family, make referrals and seek relevant information • Don’t accept one positive sign of progress as being the equivalent of numerous negative ones (avoid undue optimism) • Be prepared to listen to and challenge others – especially when action that was agreed has not been taken

42. Professional qualities, attitudes and behaviours to make a difference (3) • Take much more pro-active responsibility for information sharing • think pro-actively about the potential value of information you have for others • think about the information that others may have that may be of use to you • Develop more effective working relationships with mental health and substance misuse services for adults • Ensure the agency insists on pursuing the right course of action with avoidant and aggressive families