DSCB Learning from Serious Case Reviews on babies

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Pre mobile infants
Compilation of themes arising from
recent SCR and Management
Reviews
2 Serious Case Reviews
• Four weeks old
• Seven weeks old
Management Review
Five months old
Vulnerability Indicators- Parents
• Young parents
• Formerly in care
• Substance abuse
• Mental Health
• Limited support network
• Learning difficulty
Vulnerability Indicators- Parents
• Previous child removed
for adoption
• Violence and petty
criminality
• Wider family violence
• Non-co-operation with
services
Agency involvement
•
•
•
•
•
Universal services
2 previous MASH referrals
Previous social care involvement
Child protection plan pre birth
Public Law Outline
Agency Involvement
• Police
• Multi Agency Risk Assessment Conference
(MARAC)
• Mother refusal to engage with Perinatal Mental
Health Team and Children’s Centre
• Devon Docs, GP, Health Visitor, Minor Injuries
Unit, Emergency Department
Common to all three
• Pre mobile babies
• Physical injuries
• Living at home
BUT
• All had vulnerability indicators
Themes
• Voice and experience of the unborn baby or
baby
• Analysis and planning
• Information sharing
Themes
• Parental needs superseding the needs of the
unborn or baby
• Parental lack of engagement or disguised
compliance
• Professional curiosity and avoid overly
optimistic planning
Actions
• What can you change in your practice TODAY?
• What can your organisation do differently?
• How can you make this happen?
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