Transcript Learning from Serious Case Reviews 2010

Learning from Serious Case Reviews
2010 - 2011
Child B
Introduction
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Statutory basis: Working Together to Safeguard
Children- A guide to inter-agency working to
safeguard and promote the welfare of children.
March 2010, Chapter 8 p233
Purpose: to examine the actions of agencies,
determine if anything could have been done
differently to avoid what occurred, to implement
change if required.
After the S.C.R: Single agency and Multi-agency
actions plans and Learning
Evaluation and Inspection: Ofsted. Proposed
changes by Munro Review of Child Protection.
Munro. May 2011
March 2010- publication Overview Report and
Executive summary.
National Learning
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Biennial Analyses England 2003-2009 (618 SCRs)
and Wales (18 SCRs)
Some patterns evident
Known to CSC ? Just under half of children not
known at the time of incident but ¾ known to CSC
in the past
Age of child? Nearly half under 1, nearly quarter 15, nearly quarter 11-17, (less than 10% aged 6-10)
Proportions of serious harm cases rising- formed
40% of all SCR in 2007-2009( although numbers
of SCRs are dropping post publication decision in
june2010)
Local Learning
There have been 2 SCRs in Newcastle over the
last 4 years
Are these SCRs unique or part of a pattern? Both
1. Known to CSC and many other professionals
2. CP Plan ? Both considered as vulnerable.
3. 17 year old females
4. Drug and alcohol misuse
5. Criminal behaviour
6. Died from drug overdose
Circumstances leading to the
Serious Case Review of Child B
 Child B was admitted to hospital from
home on 22nd March 2010 in a collapsed
state and was found to be in multi organ
failure brought on by paracetamol
ingestion. Despite intense efforts to save
her including a liver transplant she died
on the 23rd March 2010
 Initial information indicated that Child B took
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the tablets on 19th March and was ill at home
for 3 days prior to medical attention being
sought on 22nd March. Initial enquiries
indicated no other person’s culpability for
Child B’s death.
A criminal investigation followed an
allegation that Child B’s mother had been
aware of the overdose throughout the
weekend and failed to seek medical
assistance. Subsequent enquiries
suggested that her Father and sister were
also aware of her condition.
Family Themes:
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Teenage pregnancy generational
Absent fathers generational
Drug and alcohol misuse/dependency generational
Non school attendance / No educational achievement
Young carer
Poor medical health care
Economic deprivation generational
Leaving home at young age generational
Aggressive behaviour from young age
Misguided expectations from female members of the
family generational
Mistrust of professionals and lack of engagement generational
Practitioners Themes:
 Not recognising generational themes or cultural values
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and beliefs
Lack of historical perspective
Not sharing information at the right time
Incomplete paper exercise assessments
Focus on mother not seeing the children’s needs behind
the adults
Low expectations / desensitisation
Starting again
Misguided expectations
What is good enough parenting?
Totality of adolescent neglect
Learning good practice:
 Referred to appropriate services
(timing and consistency)
 Identified as vulnerable
(early intervention key)
Learning cont….
 Effective multi-agency planning and practice
 Knowledge, skills and confidence in working
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with families where neglect is a feature
(adolescent neglect)
Recognise the potential risks to children of
alcohol misuse and the need for early
identification
Strategies and skills for working with ‘hard to
change’ or ‘highly resistant’ families
Learning cont….
 Importance of alternative education provision
 Strengthening of formal admission and transition
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arrangements involving schools
Importance of support for the child and family
whilst excluded from school
Reinforces the message about the potential
dangers of drugs that contain paracetamol
Greater focus on issues of equality and diversity
within case work and delivery of services
Next steps:
 Take learning back to your workplace for
discussion and suggestions to improve
practice and front line delivery
 Implement monitor and review
Practice improvement is a
Continuous activity
Learning from what works
 Always focus on the child
 Serious Case Review
Learning (National)
 NSCB Appreciative Enquiry
Model
 Signs of Safety
 Family Group Conferences
 Involvement of Families
Any questions