Learnings from Serious Case Reviews

Sharing learning from SCR’s in order to improve safeguarding practice is vital. We use the recommendations from case reviews to improve safeguarding of children and young people.

If you would like to discuss a SCR or any of its contents then please speak to your line manager or contact the CSCP Team.

Cumberland Safeguarding Children Partnership (CSCP)
Cumbria House
2nd Floor
117 Botchergate
Carlisle
Cumbria
CA1 1RD

Email: CSCP@cumbria.gov.uk

Learning for the future: final analysis of serious case reviews, 2017 to 2019

‘Learning for the future’ is an overview and analysis of 235 cases which led to serious case reviews (SCRs) between April 2017 and September 2019.The report gives an overview of the key characteristics of the cases, and addresses:

• the problem of neglect
• the challenges of practice
• the task of listening to the child’s voice

Serious case reviews: analysis, lessons and challenges (GOV.UK)

Triennial Analysis of Serious Case Reviews 2022

Learning for Future: Final analysis of Serious Case Reviews, 2017 to 2019.

This report is an overview and analysis of 235 cases which led to serious case reviews (SCRs) between April 2017 and September 2019, because children or young people had died or suffered serious harm, and abuse or neglect was known or suspected (and, in the non-fatal cases, there was cause for concern as to the way in which agencies had worked together to safeguard the child).

Serious Case Reviews | Serious Case Reviews (researchinpractice.org.uk)

Serious Case Reviews 1998 to 2019 – Continuities, changes and challenges 2022

‘Serious case reviews 1998 to 2019’ considers government-commissioned periodic overviews of SCRs, from 1998 until the dissolution of SCRs in 2019. This report aims to give a final overview of practice during that period and the major continuities, changes and challenges for SCRs.

Serious case reviews: analysis, lessons and challenges (GOV.UK)

Child CH (published 24 July 2020)

A Serious Case Review takes place "where abuse of a child is known or suspected; and 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".

Child CH's Story

Child CH died in 2018 from hanging. At the time of her death, Child CH was a looked after child and an inpatient at a mental health hospital in Lancashire.

Child CH had social worker involvement for most of their life. There had been long-term concerns that Child CH may have experienced abuse and neglect while living at home. Child CH became looked after in 2016, with significant harm being found due to long-term neglect and emotional abuse. After coming into care Child CH disclosed extensive alleged sexual abuse from multiple perpetrators from the age of 7 years. It is possible that she had not finished her disclosures before she died.

Lessons to be learned from Child CH

1. When a child moves placement or has to stay in hospital, particularly outside of area, this will have an impact on the child themselves but also on the awareness of the child by those providing services in the new area. There need to be systems in place, and timely robust practice, for information sharing and communication. This should include an updated health plan being shared by the CLA nurse. 
2. When a child in care is particularly vulnerable, there should be a plan for service delivery which takes this vulnerability into consideration. This should be communicated to partner agencies in the area where they are living by agencies in Cumbria.
3. Different agencies and professionals have different thresholds regarding the perceived risk from self-harm, including using ligatures. This needs to be acknowledged. Risk assessments and plans need to be holistic, shared across disciplines, agencies and areas, and reviewed regularly.
4. The perceived risk can increase professional anxiety and be a barrier for access to services and placements.
5. Tier 4 mental health provision for young people brings additional risks. There should be open discussion and challenge within the setting and across agencies around this and regarding the risk of staff and young people being desensitised to behaviours and risks in these settings.
6. When a child has to move placement there needs to be a commitment to finding a solution and ownership of the problem from all of the agencies involved, in a way that is as timely and uncomplicated as possible.
7. When a child who is looked after needs to attend a hospital it is good practice that they attend the same hospital on every occasion when there is more than one hospital in a geographic area. The Residential Unit should request this when they contact 111/999.
8. When a child needs a period of in-patient care in a mental health hospital, every effort should be made to ensure that the hospital is as close to the placement as possible.
9. Those responsible for children who are exposed to or at risk of exploitation must ensure that in all cases:
   • assessments and safety plans are multi-agency, outcome focused, and appropriately shared when a child moves, including consulting with the new area on the appropriateness of a placement   
   • practice is ‘trauma informed’
   • processes across and within agencies should be streamlined to avoid repetition and increased bureaucracy 
10. Child CH had the opportunity to speak to professionals on a daily basis and appeared to be able to voice her fears, frustrations and pain. However when a child has placement moves and changes of professionals involved with them, when they can’t be reassured about where they will be living next, and when they can’t have intensive therapeutic input due to moves and instability, they are likely to feel that their voice is not heard, or be unable to trust those caring for them.
11. Information sharing and local involvement in a child’s plan is essential both before and when a child who is looked after moves areas, and/or when there are frequent crises. If it is known that information has not been shared with an agency, it should be requested by them.   
12. Unmet needs and lack of progress with the most vulnerable children need to be escalated to senior managers within and across agencies. Agencies should aim for an organisational culture where a professional can say to a senior manager ’can I speak to you about this child?’
13. Robust planning for vulnerable children who are looked after is crucial. When there are numerous crises that impact on the ability to step back and consider the bigger picture, a more senior manager from CSC or a relevant partner agency should become involved and chair planning meetings.  

Child BF (published 15 May 2020)

Cumbria LSCB commissioned a Serious Case Review (SCR) regarding Child BE in 2017.  Due to ongoing parallel criminal proceedings, which have now concluded it has not been possible to publish the SCR report until now.

A Serious Case Review takes place "where abuse of a child is known or suspected; and 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".

Child BF's Story

Child BF was placed on a child protection plan prior to her birth due to professionals concerns about her parents’ ability to care for her. BF lived with her parents and another male who was not a family member. When BF was three months old she received non accidental injuries comprising of two hemorrhages. Child BF’s father has since been convicted of grievous bodily harm and received a custodial sentence.

Lessons to be learned from Child BF

1. In cases where there are concerns about the capacity of parents to meet their children’s needs and where the parents are showing increasing vulnerabilities such as depression or relationship problems, continued non-engagement with assessments and support should be recognised as significantly increasing the risk to the child.
2. When lack of engagement is recognised in cases where the parents have vulnerabilities, an approach that provides additional support is good practice.
3. In cases where an unborn baby of first time parents is thought to be at risk of neglect due to the predisposing vulnerabilities and risks, the possibility that the baby may be at risk of physical harm should also be considered.
4. Professionals should ensure that they apply robust professional curiosity in relation to fathers; particularly when they disengage from services and from their parenting role with their child. This curiosity should be supplemented by robust challenge to fathers regarding their parenting role.
5. Without a prompt and decisive response to a pre-birth referral there will be babies going home from hospital without the required assessment and parenting work being completed. The time available prior to the child’s birth needs to be utilised to ensure there is an understanding of the risks and protective factors and a plan that enables those involved to work towards providing preventive and protective interventions as required.
6. Where an assessment indicates a significant change in a parent that increases the risk factors they present, this assessment should be shared expeditiously with appropriate professionals who are involved in the Child Protection Plan and PLO.
7. Professionals transferring cases involving vulnerable parents to colleagues in other areas must satisfy themselves that all relevant information is shared and accurately recorded, and that there is a shared understanding of the vulnerabilities and risks, particularly if there is a view that a referral to the Safeguarding Hub is required.
8. It is important for all professionals and agencies that hold relevant information on a child or their family to be invited to contribute to strategy meetings, child protection conferences and core groups. Conference chairs should make particular efforts to ensure that the relevant GP is invited and receives the record of meetings.
9. Where a child presents at Accident and Emergency and Non-Accidental Injury is one potential cause of the presentation and a referral to Children’s Services has been made, early consideration should be made to notifying the police.

George (published 15 May 2020)

Cumbria LSCB commissioned a Serious Case Review (SCR) regarding George in 2018.  Due to ongoing parallel criminal proceedings, which have now concluded it has not been possible to publish the SCR report until now.

A Serious Case Review takes place "where abuse of a child is known or suspected; and 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".

George's Story

George suffered extensive injuries while in the care of his mother and her partner, at the time of the injuries occurring George was two years old.  George was the subject of a child in need plan that was about to be closed. He had twice previously been the subject of a child protection plan with the category of neglect. Mother’s partner had lived with George and his mother for around six-months, initially part time.  The response to his injuries resulted in George being appropriately safeguarded and he is currently doing well in care. 

Lessons to be learned from George

1. Information held about parents and those living with or having extensive contact with a child, including historic information, needs to be analysed by all agencies and considered in respect of the risks and on-going impact on the child at all relevant points of the case.
2. Any new information emerging requires thorough consideration, which may lead to a change in the plan for the child. 
3. Families like this one should be made aware that they are likely to require on-going involvement with support services due to the challenges they will face because of their own history.
4. Professionals working in safeguarding need to exercise respectful uncertainty, healthy scepticism and be supported to always consider if they have the whole picture.
5. Good information sharing is key, as is professional curiosity. However there are a number of barriers such as time, staffing, data systems, protocols and concern about consent. 
6. Not all practitioners are aware of, or use, the CSCP escalation policy.
7. Professionals need encouragement, support and confidence to reconsider their position when new information is shared during a meeting.

Child BE (published 11 July 2019)

Cumbria LSCB commissioned a Serious Case Review (SCR) regarding Child BE in 2017.  Due to ongoing parallel criminal proceedings, which have now concluded it has not been possible to publish the SCR report until now.

A Serious Case Review takes place "where abuse of a child is known or suspected; and 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".

Child BE's Story

When Child BE was 6 months old he presented with an injury to his eye, said to be self-inflicted. Child BE is permanently blind, in one eye; it was as a result of the injury sustained that led to this serious case review.

Child BE was first referred to Children’s Social Care as an unborn. BE’s half-sister had been on a child in need plan due to domestic violence within the family. A linked child was alleged to have sustained injuries at the hands of BE’s father at the age of 5 weeks. BE’s father has a long history of mental health problems, drug misuse and anger management issues. A number of the adults in the family had been known to services and risk issues were not effectively shared among agencies.

Lessons to be learned from Child BE

1. Risk was assessed using a variety of tools within different agencies; a more in depth risk assessment should have taken place. The agencies across the LSCB should use a common approach and an agreed tool to assess where Domestic Abuse is a factor.
2. Multi-agency meetings were taking place but the purpose of the plan and the follow up of key actions were missed. This case highlighted inconsistencies in the way meetings are recorded and inadequate assessment of risk.
3. On completion of a Child in Need Plan professionals must consider who else needs to know this information. The analysis that is used to inform assessments should also be shared with other professionals that are involved with the family.
4. To be effective, assessments must incorporate both information gathering and analysis of that information to understand risk and to formulate effective plans.
5. Without professional curiosity professionals fail to recognise risks and the focus shifts away from the child and onto the parent.
6. Effective safeguarding supervision needs to balance support and challenge and is facilitated by systems for clearly recording and reviewing concerns relating to individual children.
7. There is cumulative risk of harm to a child when different parental and environmental risk factors are present over periods of time. These include: domestic abuse; parental mental health problems; drug and alcohol misuse; adverse childhood experiences; a history of criminality, particularly violent crime