LEARNING FROM SERIOUS CASE
REVIEWS AND AUDITS
FOR BOURNEMOUTH AND POOLE LSCB
JUNE 2013
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Training MatterS
AIMS AND OBJECTIVES
AIM
 All participants will understand serious case review learning
and be able to relate this to their work
 By the end of the session participants will be able to
 State the key messages from recent local serious case reviews
and audits
 Apply this learning to their team’s own work to improve
practice
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Training MatterS
BLAME
 Person centred approach to explaining errors creates blame
culture driven by society’s desire to avoid risk
 World seems less dangerous – someone to blame
 Once we know the outcome, over-estimate what could have
been anticipated
 Procedures are about visible tasks but judgement and
expertise required
(Munro 2010)
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Training MatterS
PRACTICE LEARNING EVENTS
 Future SCR’s and audits
 Will be looking systematically at what went wrong and well
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– moving to understanding, not blame
Meaningful involvement of practitioners and family members
Seeking to understand practice from the viewpoint of
individuals and organisations at the time, not hindsight
Looks not just at what professionals did but why they acted as
they did
Develops key themes for analysis and look at lived experience
of the child
Training MatterS
WHICH CHILDREN MOST AT RISK?
 Vulnerability factors
 Co-morbidity of parental problems
 Cumulation of negative childhood experiences
 Genetic transmission of parental disorders
 Involvement in parental delusions
 Drug use
 Protective factors
 Quick resolution of parental problems
 Day to day presence of a safe caring adult
 Child’s own temperament, coping strategies
(Cleaver et al 2011)
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Training MatterS
FAMILY C6 CASE AUDIT
 10 week baby bruising and multiple fractures
 Mother history of depression and mental health problems
 Variable engagement with services
 Domestic violence history
 Use of historical information to inform assessments
 Questioning ongoing issues
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Training MatterS
FAMILY C8
 Tragic suicide of mother of 4 children
 Significant long term mental health needs
 August 11 CP plans for younger 2 – mother’s
unpredictable behaviour
 December 11, mother told application for care orders,
killed herself
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Training MatterS
FAMILY C8 Cont.
 Good practice
 Regular communication between professionals
 Child-centred approach
 Responsiveness to mother despite volatility
 Robust recording
 Challenges
 Working with parents behaving inconsistently and at
times mental health needs dominated parenting
 Geographical relocation affected mental health support
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Training MatterS
FAMILY C8 Cont.
 Delay in full mental health assessment of mother’s
parenting capacity
 Psychiatric reports from 2006 not included in current
assessments
 Value of shared chronologies
 Importance of maintaining focus on child in need once
CP plan ceased
 Importance of using historic information when further
pregnancies
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Training MatterS
LINKS WITH MENTAL HEALTH
PROBLEMS 1
 Parents with mental health problems
 high risk of living in poverty
 very low employment rates
 isolation
 fear and experiences of stigma, discrimination.
 ⅓ young carers have a parent with mental health problems
 Most parents not physical risk to children
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Training MatterS
LINKS WITH MENTAL HEALTH
PROBLEMS 2
 More risk to safety when parents psychotic and multiple
mental health difficulties and socially deprived
 Parents with mental health problems may be less
available emotionally to children
 Compensation by other relatives and friends
(J Tunnard 2006)
 Toxic trio – risks to welfare of children is 14 times
where DV, mental ill health and abused in past
themselves
(Cleaver et al 2011)
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Training MatterS
LINKS WITH MENTAL HEALTH
PROBLEMS 3
 Impacts more further into system
 43% of conferenced families
(Brophy 2003)
 33% of fatal child abuse
(Falkov 96 )
 60% national SCR 09-11 parents mental health issues
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Training MatterS
GROUP WORK 1
 How can we more effectively manage the welfare of
children where parents have mental health problems or
substance misuse?
 How can we keep more useful chronologies and use
historical information more effectively to protect
children?
“live tool for improving practice” and “vital tool to assist
reflection, analysis, decision-making, planning, and
intervention in the lives of children and their families”
(Hollows 2012)
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Training MatterS
CASE AUDIT M/C
 December 2011 concerns children not sufficient care and
supervision, home conditions poor and mother misusing
alcohol.
 Discussion with children – unannounced visit at end of
school day – removal of youngest children of 4.
 Identifying and responding to concerns
 Long history with school, HV and EWS
 Common response of poor engagement by mother
 17 referrals to Social Care since 1999 as concern peaked
 Unusually high range of referring agencies
 Sect 47 not met and no Family Support Service
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Training MatterS
CASE AUDIT M/C Cont.
 2004 attempts by Social Care to engage - closed
 Chronology not updated – cumulative and repetitive concerns
 When closed, not usually multi-agency plan for follow up.
 Services over optimistic re sustaining improvements
 Referral agencies could have challenged Social Care decisions
 Father was not in family home and not involved in assessment
or planning
 Little involvement with children by Social Care
 Older children caring for younger two – one 2004 referral to
young carer’s service.
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Training MatterS
CASE AUDIT M/C Cont.
 Children protective of their mother
 Hard to engage/ responses
 Health managed proactively – home visits
 School proactive – compensatory care
 multi-agency planning meeting would have helped
 Bruising of 8 month old – insufficient corroboration of
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mother’s account – no medical or further assessment.
Poor school attendance
Indicators of neglect/poverty over sustained period
Overcrowded accommodation
Alcohol misuse and mental health problems in mother
disclosed but not diagnosed or treated or effect on
children considered
Training MatterS
GROUP WORK 2
 How can we ensure the voice of the child is not lost?
 In what ways can we communicate better between agencies
when there are different views about the level of response
needed?
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Training MatterS
INTER-AGENCY WORKING
 Challenges about listening to agency concerns and
accepting views of others
 Difficult for schools to maintain their support role
 Insufficient acknowledgement of their role
 Insufficient weight to school’s concerns
 Unreasonably high thresholds for neglect and emotional
abuse
 Inadequate feedback and advice
 Insufficient timely information about individual families
 Often therefore supported single agency as school
and not part of multi-agency plan
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Training MatterS
(Ward et al 2012)
ESCALATION AND CHALLENGE
 Need to be able to challenge other agencies
 Pan Dorset multi-agency escalation protocol
 Address concerns at lowest level possible within 5 days or
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less – practitioners
Unresolved concerns about safety and welfare of child
escalated first to team manager level within 5 days or less
Passed up to Service manager, head teacher level
Up to heads of service if remains unresolved and on to LSCB
Record and date at every stage
Training MatterS
NATIONAL RESEARCH - THE VOICE OF
THE CHILD : LEARNING LESSONS FROM
SCR 2010 1
 67 SCR
 Importance of listening to the child
 Child not seen frequently by professionals or not asked
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their views or feelings
Safe trusting environment needed for child to share views
What is the child trying to tell us?
Recognise behaviour as a means of communication
Agencies didn’t listen to adults who spoke up for child –
neighbours, grandparents
Training MatterS
NATIONAL RESEARCH - THE VOICE OF
THE CHILD : LEARNING LESSONS FROM
SCR 2010 2
 Parents and carers prevented access to child
 Practitioners focused on parents, especially vulnerable ones,
and overlooked implications for child
 Over reliance on parents’ report
 Tendency to overlook fathers and male partners
 Agencies didn’t interpret findings well enough to protect
child
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Training MatterS
NATIONAL RESEARCH - THE VOICE OF
THE CHILD : LEARNING LESSONS FROM
SCR 2010 3
 Direct observation of babies and young children and linking
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this to risk factors
Assess disabled children and protection needed
Consider risks to children if professionals concerned for
own safety
Protection for home educated children
Implications of DV for unborn child
Vulnerabilities of young carers
Training MatterS
PROTOCOL FOR NON MOBILE CHILDREN
 All non mobile children with bruise or burn referred to Social
Care and paediatrician
 All non mobile with bleeding nose or mouth, swelling of head,
reduced movement in a limb discussed with paediatrician
 Where referral, Social Care will
 Take and record details
 Check if known
 Discuss with paediatrician
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Training MatterS
CASE REVIEW SD
 Family moved between areas
 6 children, 3 fathers
 Concern about oldest – ADHD and violent
 July 2010 Referral to Social Care – concerns about mother and
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father (of youngest 4) ability to parent, safety and hygiene
 March 2011 – father left, greater concerns
 Mother
 Mental ill health
 Home Conditions poor
 Basic care chaotic
 Older child (11) main carer
Training MatterS
SD Cont.
 November 2011 Children’s services requested dad take
care of 4 youngest
 CP plan for neglect
 December 2011 SD hospital
 Critically unwell
 Diabetes
 Frozen watchfulness
 Low weight
 Developmental delay due to environment
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Training MatterS
SD Cont.
 Lack of chronologies
 No multi-agency meeting
 Health professionals were unaware of the state of the
home
 Reviewing of CIN needs to be robust and have clear
actions planned
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Training MatterS
RULE OF OPTIMISM
 Tendency of workers to over estimate ability of parents
to understand professional concern and make the
necessary changes
(Selwyn 2006)
 Reasoning processes of social workers
 Valued family maintenance and sought to bolster this
 Viewed service users as capable of change and honest
(Keddell 2011)
 Assessment of facts and interpretation challenging for all
workers
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Training MatterS
GROUP WORK 3
 How can universal and specialist services work more
effectively and assertively intervene in neglect cases?
 What can help to challenge the drift towards optimism by
professionals?
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Training MatterS
HARD TO REACH FAMILIES
 Lack of parental engagement leads to less intervention
due to non-cooperation. Obstruction reduces access to
evidence
(Farmer and Lutman 2009)
 Quick turn around of assessments makes it harder to identify
families accurately
(Broadhurst 2010)
 Hostile parents can trigger defensive, impersonal workers –
low levels of listening and empathy
(Howe 2010)
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Training MatterS
WORKING HARDER TO ENGAGE WITH
CHILDREN,YOUNG PEOPLE AND FAMILIES
MORE EFFECTIVELY
 W case audit
 Where agency refers to another and failure to engage – may
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not realise
Make effective clear referral
Communicating clearly with family
Raising confidence of family in specialist service
Communicating to specialist service any potential difficulties
and any strategies that may work
Making appropriate and personal invitation
Training MatterS
WORKING HARDER TO ENGAGE WITH
CHILDREN,YOUNG PEOPLE AND FAMILIES
MORE EFFECTIVELY
 Use of language
 Appropriate responses if family fail to attend and to
repeated failure to attend
 Identifying families who are disguising lack of cooperation
and compliance or are hostile or violent
 Appropriate responses to complaints about service
providers as an avoidance technique
 Ongoing communication with the referring agency
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Training MatterS
NEGLECT GUIDANCE 1
 Easy to focus on adult needs and lose sight of the child
(Burgess et al 2011)
 To prevent drift and “start again”
 Helps with uncertainty about thresholds
 Compensatory care
 Disguised compliance or false engagement
 Rule of optimism
 Clarify fact and opinion
 Younger child more risk
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Training MatterS
NEGLECT GUIDANCE 2
 What is it like for this child in this family?
 Focus on family but not to exclusion of child
 Share information
 Get help – environmental health, fire service
 Framework for recording conditions in home
 Graded Care Profile
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Training MatterS
BABY J SERIOUS CASE REVIEW
 Died aged 5 months 2012
 Co-sleeping on sofa with mother who had consumed large
amount of alcohol
 Parents not living together, 2nd child
 DV concerns in relationship – not taken seriously enough
 History of mother would have led to concerns – troubled
adolescent and risky behaviour. Maternal risk factors:
 Alcohol and drug misuse
 Criminal activity including assaults
 Childhood history of watching DV
 Family history of SA
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Training MatterS
BABY J Cont.
 Coped well with first child
 Referral to Children’s Social Care 6 wks before death after
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complaints to Housing by neighbour – did not meet
threshold for action, no feedback
Little attention to father of two children – lack of curiosity
How effective were early help arrangements?
Response to safeguarding concerns timely?
Further promotion of safe sleeping learning
Family using children’s centre- 3 assessment models in use
Dangers of start again and rule of optimism
Training MatterS
ENGAGING FATHERS
 Men much less engaged in CP process than women
 60% men not talked to prior to initial CP meeting
 DV underplayed and sanitised
 Little attention to men’s practical caring skills
 Violent men more likely to be engaged than non-violent
– categorized as irrelevant unless a threat
(Baynes and Holland 2012)
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Training MatterS
LINKS WITH SUBSTANCE MISUSE
 Parents misusing substances
 52% of case on CP plan
 62% proceedings parental substance misuse
 ‘the more serious type of case being studied, the higher the
proportion in which substance misuse was an issue’
(Forrester and Harwin 2006)
alcohol central substance of concern
 high incidence of crack cocaine use
 both strongly correlated with violence
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(Manning 2009)
 Parental abuse of alcohol or drugs in 50% of neglect cases
(Dunn 2002)
 42% national SCR 09-11 parents misusing substances
 33% fathers and 66% mothers with problem drug use still
living with their children
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(Advisory council on misuse of drugs 2003)
Training MatterS
LINKS WITH DOMESTIC VIOLENCE
 Two thirds of conference cases
(Sloan 2003)
 Physical risks , 30-66% of children living with DV direct
abuse
(Edleson J 1999)
 Emotional abuse of witnessing violence
 65% of national SCR 09-11 DV
 86% one of three toxic factors
 Twice as likely as non-DV houses to have confirmed
neglect by age 5 years
(Davies and ward 2012)
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Training MatterS
EFFECT OF CHILDHOODS ON PARENTS
 Parents who were physically abused or neglected in
childhood were more likely to treat their own children the
same way –
 Distorted beliefs
 Unrealistic expectations
 Not age-appropriate
 Over-reacting or coercive parenting
 Harsh punishment
(Hindley et al 2006)
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Training MatterS
INTERVENTION WITH FAMILIES
 Parents who succeeded in making changes
 Less likely to have experienced abuse
 To have come to terms with removal of older child
 Gained insight from that
 Used support
 Many parents go through the motions – appointments, never really
active partners, some active saboteurs
 Some defining moment – change to meet baby’s needs
 SW assessments failed to focus on core issue
 LT support or intervention not there
(Ward et al 2012)
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Training MatterS
GROUP WORK 4
 How are we doing engaging hard to reach families? How can
we improve this?
 Why do we keep hearing the same messages in SCR’s and
audits? What blocks are there that stop change happening?
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Training MatterS
CO-SLEEPING RESEARCH
 Link between bed sharing and sudden infant death
syndrome
 UNICEF study 1472 cot deaths called for definite stand
against all bed sharing especially up to 3 months
 Increased risk with recent consumption of drugs or
alcohol
(Blair 2009)
 Different opinions on co-sleeping for non risk groups
 Co-sleeping guidance and e-training for all front line
staff and for parents– Dorset Healthcare 2011 –
pathways.
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Training MatterS
CO-SLEEPING GUIDANCE
 Safest place for baby to sleep is in cot by bed
 Sleeping with baby on sofa puts baby at greatest risk
 Baby shouldn’t share a bed with
 Smoker
 Consumed alcohol
 Taken legal or illegal drugs making them sleepy
 Increased risk of SIDS
 Parents in low SOE groups
 Parents who currently abuse alcohol or drugs
 Young mothers with more than one child
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 Premature infants and low birth weight
Training MatterS
SEXUAL EXPLOITATION OF CHILDREN
AND YOUNG PEOPLE
 Up to 18
 Danger of seeing risk as informed consenting choice
 5 years age difference, exchange of goods
 Lists indicators
 Child sexual exploitation risk assessment tool and matrix
 Low risk – single agency response
 Medium risk- TAC and CAF
 Medium/high risk – Refer to Social Care, strategy meeting,
possible S 47 and interim safeguarding plan
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©Training MatterS