Learning From Serious Case Reviews

1. Learning From Serious Case Reviews Prity Patel LLB (Hons) Independent Consultant September 2011

2. Learning Outcomes • To develop an understanding of the purpose and process of conducting a Serious Case Review (SCR) • To gain a better understanding of the Practice Guidance governing a SCR • To understand key ways of promoting action learning within the SCR process have knowledge about the purpose, process and outcomes of serious case reviews • To receive the findings of two local SCRs (Baby F and Child G) and one Case Audit (Case W) and some themes from national learning from SCRs • To have the opportunity to discuss how the learning from these cases should influence inter-, and intra-, agency working in Bournemouth and Poole  • Practice across all agencies will reflect on the learning from these cases

3. Working Principles • Each individual has a valid contribution to make which will be valued and listened to • Confidentiality should always be observed • There will be mutual respect within the group for individuals and their experiences • Naive questions will be considered the norm!

4. Serious Case ReviewThe Purpose Of A SCR • Prime purpose for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote welfare of children • Identify clearly what those lessons are both within and between agencies- What changes in practice need to be made • Lessons learned should be disseminated effectively • Recommendations should be implemented in a timely manner

5. Serious Case ReviewThe Purpose Of A SCR • Where possible lessons should be acted upon quickly without necessarily waiting for the SCR to be completed • SCRs are not inquiries into how a child died or was harmed or form part of any disciplinary process

6. Serious Case ReviewWhen To Conduct A SCR? Working Together sets out the requirement for SCRs A LSCB should always undertake a SCR: • When a child dies and abuse or neglect is known or suspected to be a factor in the death. A LSCB should consider whether to undertake a SCR: • A child sustains a potentially life threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect; or • A child has been seriously harmed as a result of sexual abuse; or • A parent has been murdered; or • A child has been seriously harmed following a violent assault perpetrated by another child or an adult and there is concern about how local services were delivered by professionals involved with the family.

7. Serious Case ReviewSCR Panel • Ensuring membership of SCR Panel is vital - should include at least representatives from relevant Partner agencies. (WT 8.14) Panel will define the scope of the Terms of Reference for the SCR • Independent Chair and Overview Author (WT 8.16) • Health - Designated Leads or Named Nurse for Safeguarding • Health Overview Author - required to prepare Health Overview Report

8. Serious Case ReviewIMR - Preparation Each agency involved in a case will write their own Individual Management Review • Review records and files • Develop initial facts/chronology and analysis • Interview staff- always keep a record. (WT 8.38) • Re-read files • Finalise Chronology and genogram • Finalise Factual Information • Finalise Analysis • Identify the Lessons Learned • Make Recommendations

9. Serious Case Review The Purpose Of an IMR • To look openly and critically at organisational practice • To identify and analyse the context within which people were working • To indicate if the case identifies that improvements could or should be made • To identify how those changes can be brought about

10. Serious Case ReviewIMR - Contents • IMR and chronology is completed using templates from the LSCB • Basic details and methodology • Contextual Background - demographics of population you are providing a service for, is there anything particular to your geographical area that may impact on how a service is provided or meeting service user’s needs ? • IMRs and SCRs are anonymised • A factual summary of the agency’s involvement is set out and analysis of this is undertaken • A genogram and family composition is supplied

11. Serious Case ReviewIMR- Analysis • Consider decisions made and the actions taken or not taken • Consider what best practice should be and how the service should have been delivered • If practice has changed since the incident that led to the SCR, this should be outlined • Were judgements made, or actions taken which indicate that practice or management could be improved? • Gain an understanding of not only what happened but also why? • Significant learning can be gained from probing beyond the surface. A good IMR should reflect this

12. Serious Case ReviewIMR - Analysis • Statements will be corroborated with effective examples to support your analysis • Analysis is related to procedures and policies in respect of your agency and LSCB • Criticism needs to be constructive • The Terms of Reference sets out the areas for focus within the IMR as identified by the SCR Panel and WT (8.39WT)

13. Serious Case ReviewIMR - Analysis • The IMR will reference Local and National Professional Standards/Guidance and learning from previous SCRs from your LSCB, and the Biennial Analysis of SCRs • It will flag up Good Practice - Over and beyond what was necessary to meet the child’s needs NOT what is expected practice

14. Serious Case ReviewIMR- Recommendations Identify Lessons Learned List Agency Recommendations- Make them SMART Be succinct! Focus on a few key areas Link to Lessons Learned Recommendations WILL NOT be about what professionals should already be doing

15. Serious Case ReviewAction Plan • Action Plan = Actual or Recognised Learning. Identify: • the action • who will have lead responsibility within the agency to ensure action is fully implemented • the timescale to achieve completion of the recommendation – Be Realistic but not foolish! • What will be the desirable outcome • How can the outcome be evidenced/measured? • Individual Agency Action Plan will form part of Composite Action Plan that LSCB will monitor until all actions completed and can be signed off • Endorsement by Chief Officers of the agency

16. Serious Case ReviewTimescales • A SCR to be completed within 6 months (WT 8.23) • SCR Chair will prepare a timetable • Important to meet deadlines- Failure to do so impacts upon the whole SCR process • OFSTED feedback from previous SCR’s- Delay in meeting timescales has been a significant factor in poor Reviews

17. Serious Case ReviewLearning-Feedback • Learning needs to be implemented and acted upon – needs to be timely • Dissemination of Learning- Consideration to be given to what type and level of information needs to be disseminated and to whom • Staff directly involved in the case need to have feedback, may require support

18. Serious Case ReviewIMR Format • Summarise the salient points of the key themes that you have identified in your analysis, including good and poor practice • Highlight any progress that has already been made regarding implementing change in practice • This will be an opportunity for SCR Panel Members to raise questions with you- make sure you read your IMR before presenting it including informing the Panel of any updating information that may be relevant to the review

19. Serious Case ReviewPresenting the IMR The SCR Panel scrutinises all the IMRs and will interview each IMR author at a SCR Panel • The Panel is an opportunity for SCR Panel members to raise questions with the author • It is very likely that the author will be asked to make amendments and additions to the IMR as the information from other agencies may indicate gaps or areas to be explored again • The IMR is re-submitted following this work

20. Serious Case ReviewOutstanding IMR’s • Comprehensive history and chronology • Good depth of detail/clear family history • Staff/Managers interviewed to support file review • Identification of strengths and good practice • Keeping the child the focus of the IMR • Focussed recommendations linked to the analysis • Clear and SMART action plan which identifies lessons already learned

21. Serious Case ReviewThe Health Overview Report • To provide a critical overview of all health services • They will not repeat information already provided in the Health IMRs – they will identify where there may be gaps in the analysis which needs to be included to tell the story from Health’s perspective • Summarise salient learning points identified in Health IMRs- Always ask “ Why and so what?” • Comment upon Health IMR recommendations- identify gaps if any, make further SMART recommendations if appropriate

22. Learning From Serious Case Reviews • Last 15 months Bournemouth & Poole Local Safeguarding Children Board (B&PLSCB) has conducted several reviews • 2 SCRs - Baby F and Child G • 1 Independent Case Review – Case W • Bournemouth & Poole Adult Safeguarding Board conducted a SCR May 2008 • Overlap of key learning from both child and adult reviews involving Professionals from all agencies

23. Baby F - Background • Baby F born in summer 2009- Unplanned first baby • Parents 18 and 17 yrs respectively • Parental relationship- known each other 8 months • Mother articulate and engaging with services initially. Father has a history of CAMHS and YOT history • Incident of abuse when baby F 5 weeks old • MARAC threshold • Father bailed - conditions no contact with mother – baby not specified • CP Inquiry, no CP Conference

24. Baby F – Background (cont.) • Mr A breached bail conditions • Further bruising on mother • CP Conference – emotional category • Father convicted of assault on mother • Bruise to face – aged 4 months – no action • Bruise discussion aged 5 months at Core Group • January 2010 admitted with serious injuries bruising to face and parts of body, torn fraenulum, 3 fractures to one leg possible broken legs

25. Themes From the Case • Assessment/Planning • Domestic Violence – impact on children • Engaging Fathers/Significant Males within the household • Record keeping

26. Assessment/Planning • Quality of assessment impacts on outcomes for the child • Drawing on historical information • Child Protection Plans- Need to be SMART (Specific, Measurable, Achievable, Realistic and Timely) and robustly monitored • Include fathers/significant males • Explore parents’ own accounts • Assessment needs to be child focussed at all times • Multi-agency – what information can be collated from other Professionals • Assessment needs to have a holistic approach.

27. Assessment of Injuries • Know your own agency procedures on seeking medical opinion • Timing of medical opinion crucial • Observation- physical and behavioural • History taking and reactions • Rooted in Child development e.g.; non mobile babies • Appropriate recording - use of Skin Maps • Referral and further investigation

28. Domestic Violence • Cycle of abuse • Impact on child • Deceit / manipulation- disguised co-operation • Reliance on bail conditions and Written Agreements • Protective measures • Contact arrangements- consider supervised or not, frequency, duration and review • Recording of injuries to both adult and child, taking a holistic approach • Direct questioning. An Investigative style of questioning needs to be developed. Probe below the surface, do not take at face value • MARAC to include planning for child

29. Engaging Fathers/Significant Males • Meet with fathers/significant males in as many assessments as possible • Don’t let them be invisible! • May have to make suitable arrangements with working males- Offer alternative appointments • Learn about their role in the family- how does it impact upon the child • Record their views • Explore their history • Understand the strengths they bring to the family and identify the risks • Talk to other Professionals • Consider them in analysis and assessment

30. Engaging Fathers/Significant Males(2) • Fatherhood Research Summary “…..If professionals systematically gather the young man’s details by, for instance, routinely asking the mothers for them in early pregnancy, develop Interagency working while making child outcomes the focus of their work and mainstream engagement through the service” ( e.g. teenage pregnancy service, “While keeping good records and comprehensively assessing the young men's needs, substantial numbers of young fathers can be reached with interventions that make a real difference…..”

31. Record Keeping Record observations of child, verbal and non-verbal Records to be child focussed- child’s perspective Record parents’ account in detail All recordings must be accurate and evidence based! Maintaining good records assists reflective Practice

32. Child G - Background SCR conducted following a case of filicide/suicide. Child G 6 years old when killed by his father in summer 2010. Father killed himself at the same time Coroner’s Inquest makes Finding - Child G unlawfully killed and Mr G, father, took his own life Child G living with both parents at time of birth. Parents separate, at time of death Child G spending considerable time with both parents Mother had little previous involvement with services. Father had significant involvement. He carried out several suicide attempts and experienced suicidal ideation over a 30 year period preceding the incident Father involved with mental health services and GP

33. Child G Background(2) Child G diagnosed with diabetes 3 years prior to incident Child G’s parents engage well with appropriate health services. There is good liaison between health and school services. Child G receives support from the local speech and language service During acrimonious separation father alleges he informed mother he wanted to commit suicide Police called to family home as mother has concerns about child’s safety, father having taken Child G from school unexpectedly Police attend family home. Police judge Child G to be safe in care of father. Mother also present at family home. Police treat as a domestic violence incident Court application made by father. Court adjourns substantial hearing, further enquiries to be made by CAFCASS. Interim Residence granted to father Child G dies before matter returns to Court

34. Themes From the Case • Suicide/Filicide • Domestic Violence/DV1 Notifications • The Court Process • Compliance/Information Sharing

35. Suicide/Filicide Suicide/Filicide very rare By it’s nature a deliberate and thought-out act with limited research available - impossible to predict Historic events regarding adult mental health, significance of these need to be retained and viewed as a continued risk Professionals to develop a style of Practice to ask questions directly of suicide and suicidal intentions expressed. Critical to any assessment of risk Parental separation - If suicide threats made, do not regard as common place, take seriously Consider implications of suicidal threats on child as part of any risk assessment Consider previous triggers Seek Management advice

36. Domestic Violence/DV1 Referrals Police oversight of DV1 notifications requires a knowledge of children’s safeguarding issues DV1 notifications – A Multi- agency assessment is likely to lead to a more comprehensive assessment leading to better outcomes for the child Role of GP pivotal to identification and management of potential risk of DV. GP a good source of information and support for the child/family following a DV incident

37. The Court Process The Private Law Programme (April 2010) at the first hearing the Court should consider risk identification and the impact of any known risk on a child’s welfare   The Court initially is dependent on being informed by the Officer’s of the Court (CAFCASS reporting officers) to make appropriate safeguarding enquiries about the family , highlighting any concerns or risks that the Court needs to be made aware of Roles and responsibilities of Court Officers need to be clear to avoid insufficient attention being given to assessing risks to a child The Judiciary need to keep abreast of Safeguarding Training

38. Compliance/Information Sharing • Failure to comply with procedures undermines effective risk assessment of children • Organisations have a responsibility to ensure staff are able to comply with procedures and able to access necessary training. Needs to be a regular part of management support and monitoring • Procedures are less likely to be followed or less stringently applied potentially leaving children at risk • Difficulties in communication and sharing of relevant information between agencies hinders effective risk assessment

39. Case Review W- Background • 3 young people, aged between 14-16 years of age from the Poole area found guilty of manslaughter. Their victim, a man sleeping rough in Westbourne in April 2009 • All of the young men were remanded to a Young Offender Institute (YOI). The trial at Winchester Crown Court concluded a year after the offence, when all three accused were found guilty of manslaughter. They are all due for release in 2011 • All 3 young people and their families known to agencies due to a number of welfare concerns • The circumstances of the case did not meet the criteria for a Serious Case Review

40. Themes From the Case • Engagement/Intervention of Agencies • Professional Judgement/Assessments • Multi-Agency Working • Peer Pressure/Anti-Social Behaviour • Family Issues • Communications/Information Sharing • Record Keeping

41. Engagement/Intervention of Agencies Opportunities for agencies to intervene at early stages not consistently taken- missed opportunities Hard to engage families Need to work with the families and be more challenging of information presented to identify risk factors Need to work together and not in isolation. Assessments may be conducted, but are not effective if information not shared with other Professionals Investigative style needs to be adopted. Do not be too accepting of responses families give i.e. do not need any support Planning required. Exit strategies for young people need to be in place

42. Engagement/Intervention of Agencies(2) • Consider the need to have specialist workers • All Professionals need to be clear about roles and responsibilities in the plan devised for the young person- could lead to better engagement from families • Need to understand a young person’s needs. Youth services play a pivotal role in ensuring there is appropriate engagement with a young person • Young person needs to feel empowered for effective engagement.

43. Professional Judgements/Assessments • Assessments- crucial to take a history from families as part of risk assessment. Likely to highlight triggers which inform services and support provided • Use of the CAF still requires clarity. Professionals need to know when to use and in what context. Confusion in use of CAF can lead to lack of appropriate intervention • The Southwark Judgement( May 2009) obliges Children's Services to provide accommodation and support to homeless 16 and 17 year olds.

44. Multi- Agency Working • Professionals need to work proactively in a multi-agency arena to gain the families’ engagement in order to help support them in their care of young people • Consider the need for a multi-agency risk assessment. Can lead to a more coherent and comprehensive assessment with better outcomes • Multi- agency meetings- Need to ensure all relevant Professionals attend to increase chances of a robust multi- agency risk assessment • Collaborative thinking by Professionals required! • Professionals need to follow through on referrals to another agency. Check referral has been actioned

45. Peer Pressure/Anti- Social Behaviour Lack of understanding by agencies including the School, Police, Anti Social Behaviour Team and Youth Offending Team involved with the young people regarding the escalation in destructive behaviour DCSF Guidance on working with young people affected by group anti social behaviour in the community will be available with relevant risk assessment tool There was a lack of reference or understanding of the misuse by young people of alcohol and drugs Substance abuse was not considered as part of any assessment of risk The use of Restorative Justice Procedures could have been used more broadly with the young people

46. Family Issues • Vital to consider all members of the family as part of risk assessment including any significant males. All three boys had difficult family upbringings and appeared to lack consistent positive male role models • Consider what support networks are in place for the family, particularly if main carer is a sole carer • All risk assessments need to consider cultural and literacy issues to inform adequate and appropriate planning. Failure to do so impacts on outcomes for young person

47. Communication • Communication needs to be clear, concise and requires the use of simple language. Professionals need to make sure what they are saying is easily understood. Use of an interpreter/ translator where English is not the first language • Communication needs to occur both inter- and intra- agency. Lack of information sharing leads to missed opportunities

48. Record Keeping • Good practice to ensure chronologies/summaries always reflect the depth of history of the families and the number of contacts. Need to make sure the information is used to inform assessments about the “here and now”. • Ensure records are accurate, evidence based and can be accessed easily. Important to be able to access historical records, crucial information may be missed if not accessed as part of a risk assessment.

49. Adult SCR Case A- Background Mrs A an elderly widowed lady aged 83 years. Mrs A murdered by her son-in law in 2008. Mrs A’s daughter and son-in-law had a history of mental health and known to have a violent relationship. They were also known to Probation and received considerable support. Both moved in and out of Mrs A’s home on several occasions. It was alleged both were violent and abusive to Mrs A. Mrs A told her GP she was frightened of her son- in –law and stressed by them both. Referrals had been made by neighbours and a family member to the Police about concerns for Mrs A’s welfare. Agencies had information on their records about concerns for Mrs A, however the information was not shared.

50. Themes From the Case Identification of Safeguarding issues. Domestic Violence. Communication/Information Sharing. Compliance.