Serious Case Reviews
Local Lessons & Actions
www.hertsdirect.org/safeguardingchildren
Why do we undertake SCRs?
Regulation 5 of the LSCB Regulations 2006
states:
“(1)The functions of a LSCB in relation to its
objective ....are as follows(e) Undertaking reviews of serious cases
and advising the authority and their Board
partners on lessons to be learned.”
When do we undertake SCRs?
When a child dies and abuse or neglect is
known or suspected to be a factor in the death,
the LSCB should always conduct a SCR into
the involvement of the organisations and
professionals in the lives of the child and family.
(Working Together, 2010)
When do we consider undertaking
SCRs?
• When a child sustains a potentially life-threatening injury or
serious and permanent impairment of physical and/or mental
health and development through abuse; or
• A child has been seriously harmed as a result of being
subjected to sexual abuse; or
• A parent has been murdered and a domestic homicide review
is being initiated under the Domestic Violence Act 2004; or
• A child has been seriously harmed following a violent assault
perpetrated by another child or an adult;
AND
The case gives rise to concerns about the way local
professionals and services worked together to safeguard the
children.
What is the purpose of a SCR?
• To establish what lessons there are about the
way professionals and organisations worked
individually and together.
• To identify how theses lessons will be acted
on; in what timescale; and what is expected to
change
• To improve intra- and inter-agency working &
therefore better safeguard children.
What would the role of the school
be?
• An Individual Management Review would be
completed by Standards & School
Effectiveness
• This would look at he role & involvement of all
educational staff, including school employees
• The report author would review school records
& interview relevant staff
• The aim would be to establish if there are
lessons to be learnt in respect of how the
school contributed to safeguarding the child
The national picture
Understanding Serious Case Reviews and
their Impact
A Biennial Analysis of Serious Case
Reviews 2005-07
M Brandon, et al, 2009
The Children
•
•
•
•
•
•
30 % were aged 0-3 months
45% were under 1 year old
67% were 5 years old or younger
25% were over 11
17% were subject to a child protection plan
About half were known to children’s social
care
www.hertsdirect.org/safeguardingchildren
The Families
•
•
•
•
•
•
•
45% Families had had frequent house moves
53% Domestic Violence (current or past)
33% Substance Misuse (current or past)
63% Mental Health problems (current or past)
15% Parental learning disability
45% Parent with criminal conviction
75% of children had lived with domestic violence,
parental mental ill health or substance misuse
www.hertsdirect.org/safeguardingchildren
The issues
• Chaotic behaviour in families can be mirrored
in chaotic professional thinking and actions
• Failure to see the child - practice is not ‘child
focused’
• Efforts not to be judgemental becoming failure
to exercise professional judgement
• Silo practice – professionals not looking at the
needs of the child outside their own specific
brief.
www.hertsdirect.org/safeguardingchildren
Issues (cont’d)
• ¾ of the families did not co-operate with
services – a lack of authoritative child
protection practice
• Multiple risk factors – parental substance
misuse; mental health problems; domestic
abuse; poor living conditions
• Little or limited information about men
• Fixed views of a family
• Perceived, or real, difficulty in engaging older
children
SCR in Hertfordshire
•
•
•
•
•
•
•
•
•
5 SCR completed in past year
3 deaths and 2 serious injuries
3 under 5 years old
1 teenager
Parental mental health problem
Domestic Violence
Parent with learning disability
Substance misuse
Neglect
www.hertsdirect.org/safeguardingchildren
3 cases
4 cases
1 case
1 case
5 cases
What were the lessons in
Hertfordshire
• Keeping a focus on the child
– Can/are the parents meeting the child’s needs
• Working across adult and children's services
– Making best use of expertise
• Accessing and taking account of past history
– Start again syndrome & the rule of optimism
• The need for professionals to escalate
concerns where they feel these are not being
addressed appropriately
www.hertsdirect.org/safeguardingchildren
What were the lessons in
Hertfordshire
• Assessing the impact of cumulative risk
factors on parenting ability
– Working with complexity
• All significant adults should be included in
assessments
– The absence of fathers, male partners, relatives
• Critical and authoritative child protection
practice
– Family & professional accountability