Child Maltreatment – Lessons from
Serious Case Reviews
Dr Peter Sidebotham and Dr Carol Hawley, Warwick Medical School
c.a.hawley@warwick.ac.uk
Serious Case Reviews (SCRs)
Every year over 4,000 infants and
children die in England and Wales.
Although the UK has one of the lowest
rates internationally, there is still room for
improvement with wide variations in
mortality rates and patterns across
different regions, socio-economic status
and ethnic groups. Many of these deaths
are preventable and amenable to
interventions from health and other
agencies. Understanding the factors
influencing infant and child deaths can
help to target appropriate interventions.
In 2008, the government introduced a
national programme of inter-agency child
death review. Whenever a child dies
unexpectedly or is the subject of serious
maltreatment a Serious Case Review is
carried out. The total number of Serious
Case Reviews during the calendar year
2008 was 141, of which 80 were related
to fatal cases
Deaths related to but not directly caused
by maltreatment
138 cases (50%)
Sudden Unexplained Death in Infants
(48) <1yrs
Suicide / self-harm (41) >8 yrs
Mean age 16.1 (boys), 14.5 (girls)
Other (49) 0-17 yrs (median age 64.0
months)
55% male
69% related to neglect:
Fires; accidents; accidental
asphyxiation; methadone; natural causes
Previous child protection concerns/
evidence of previous abuse or neglect
Deliberate / overt homicides
31 cases (11%)
• Covers entire age range
• Median age 70.0 months
• 67% <5
• 67% male
• 22% known to child protection services
• Profile changes with age
• Multiple killings/extended suicide (61%)
The prime purpose of a Serious Case
Review (SCR) is for agencies and
individuals to learn lessons to improve
the way in which they work both
individually and collectively to
safeguard and promote the welfare of
children. Working Together, 2010
Research Questions
• How many children suffer serious and
fatal maltreatment?
• Are the numbers/rates changing?
• What can we learn from serious and
fatal cases of maltreatment?
• Can we do anything to prevent it?
Violent Child Deaths
Looked After Children
Factors Contributing to Childhood Deaths
In England there were 64,400 looked
after children as at 31 March 2010, an
increase of 6 per cent from 2009 and an
increase of 7 per cent since 2006.
27,800 children started to be looked after
during the year ending 31 March 2010,
an increase of 8 per cent from the year
ending 31 March 2009 and 13 percent
from the year ending 31 March 2006. Of
these children 9,500 are classed as
being taken into care.
Overall, the main reason why social care
services first engaged with children who
started to be looked after during the year
was because of abuse or neglect. The
number of children looked after for this
reason was 14,500 (52 per cent of the
total). This percentage has increased
since 2009.
Severe Physical Assaults
60 cases (21%)
• Highest risks in infancy
 Median age 4.0 months
 78% < 1 year; 60% male
• 12% known to child protection services
• Violent assaults
 NAHI (shaking/shaking-impact injury)
(60%)
 Multiple injuries (33%)
 Abdominal injuries
Factors intrinsic to the child
• Acute or Chronic illness
• Disability
• Prematurity/low birth weight
• Age, gender, ethnicity
Family & environmental factors
• Social Class
• Geographic spread
• Social isolation
• Unsafe environments
Sudden
Unexpected
Childhood
Death
Parental care
• Age
• Marital status
• Substance misuse
• Health, Mental health
• Learning difficulties
• Abuse or neglect
Service provision & need
• Service needs
• Services provided
• Gaps in provision
• Information sharing
Serious Long-term Abuse
Fatal SCRs, 2005-9
Violent deaths in infants
Who is at Risk of Abuse or Neglect?
60
50
Assault
40
30
20
Assault +
undetermined
10
Homicides
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
0
2005
Violent deaths in children
Peter Connelly, ‘Baby P’, 2007
Assault
80
60
40
Assault +
undetermined
20
Homicides
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
0
Violent deaths in adolescents
160
140
120
100
80
60
40
20
0
Assault
Holly Wells & Jessica Chapman, 2002
Assault +
undetermined
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
• High Profile Cases
• Media Attention
• Claims that the Child Protection
Systems are not working
Violent Deaths in Adolescents
• For young women (15-19 years) rates
of death from assault fell from 1.3 to 0.5
per 100,000
• For young men, rates declined from 1.6
to 0.8 per 100,000 in the late eighties,
then increased again to 1.3 per 100,000
in the 2000s
• Numbers of adolescent deaths from
assault were 41-47 in 1974-6 and 23-35
in 2006-8
• Rates and numbers for all deaths from
assault and undetermined are much
higher with no evidence of decline.
Categories of Fatal Maltreatment
• Infanticide and “covert” homicide
• Severe physical assaults
• Extreme neglect / deprivational abuse
• Deliberate / overt homicides
• Deaths related to but not directly
caused by maltreatment
50
Infanticide / covert
homicide
40
Severe physical assault
30
Extreme neglect
20
Deliberate / overt
homicide
10
Death related to
maltreatment
0
<1yr
1-5yrs
6-10yrs 11-15yrs >16yrs
2008
2009
• Serious Case Reviews – 2009-11
• Department for Education Child Death
Overview Panel data
• Department for Education Child in Need
databases
• Office for National Statistics: Registrar
General’s national mortality statistics
• Home Office: Crime Statistics,
• Department of Health Hospital Episode
Statistics
• Problems matching the data:
• Data collected for different reasons
• Different time periods (calendar year or
financial year)
• Different age bandings, especially
problematic when looking at adolescents
(DfE uses ages 0 – 18, ONS uses ages
0-14 )
ONS Data
Home
Office
Data
SCR Data
Assault
Assault +
Undeter
mined
Homicide
Direct
maltreatment
All deaths
Infant
6
16
22
15
32
Child
15
46
39
11
28
0-14 / 0-15
21
62
61
26
60
Adolescent
26
92
-
1
10
Patterns of fatal maltreatment 2005-9
60
2007
Comparing SCR data with National
Datasets to Measure Prevalence
120
100
2006
Data averaged over 2005-9
Victoria Climbié, 2000
Conclusions
• Deaths from maltreatment represent a
spectrum with different class
characteristics
• 50% are related to but not directly
caused by maltreatment
• Neglect is rarely the primary cause of
death, but is a contributory factor in at
least 40%
• Risks are highest in infancy, but there
are continuing risks in older children and
adolescents
Current Research for Department for
Education
2009-11 SCR Study with University of
East Anglia
• Observatory function including Child Death
Overview Panel data
• In-depth qualitative analysis
• Analysis of recommendations and action
plans
• Evaluating different methods of
dissemination