A serious case review of Zara, a four year old girl of dual heritage (White/Black Caribbean), who was admitted to hospital with stomach pains. Following surgery it transpired that she suffered life threatening injuries following a severe blow to her stomach. Zara's mother's boyfriend was found guilty of GBH for inflicting the injuries to Zara. Her mother and the other defendants were cleared
(Edited publisher abstract)
A serious case review of Zara, a four year old girl of dual heritage (White/Black Caribbean), who was admitted to hospital with stomach pains. Following surgery it transpired that she suffered life threatening injuries following a severe blow to her stomach. Zara's mother's boyfriend was found guilty of GBH for inflicting the injuries to Zara. Her mother and the other defendants were cleared of causing or allowing the little girl to suffer physical harm. The serious case review concluded that the assault on Zara could not have been predicted by any health, social care, police or other professionals who had contact with mother and daughter, nor is it clear that any action that might reasonably have been predicted by a local professional could have served to prevent what appears to be a spontaneous event. The approach of the review panel incorporated elements of the 'Learning Together' methodology developed by the Social Care Institute for Excellence.
(Edited publisher abstract)
On 12 October 2012, Baby Z was taken to the local hospital’s Emergency Department by her parents who reported that “she had not been herself” and had not been feeding. The conclusion from medical experts was that some of the fractures were caused up to 3 weeks before the head injuries, i.e. “multiple episodes of non-accidental injury”. There followed a criminal investigation by the police
(Edited publisher abstract)
On 12 October 2012, Baby Z was taken to the local hospital’s Emergency Department by her parents who reported that “she had not been herself” and had not been feeding. The conclusion from medical experts was that some of the fractures were caused up to 3 weeks before the head injuries, i.e. “multiple episodes of non-accidental injury”. There followed a criminal investigation by the police and a Section 47 investigation on Care Proceedings initiated by Children’s Social Care, leading to the child be placed in foster care. On 6 November 2012, it was recommended that a Serious Case Review be invoked. This report summarises agency involvement – mainly by the local hospital trust, a Children’s Centre run by Leicester City Young People’s Service, the Health Visiting team and GP service. It comments on 11 key practice episodes, which indicate some evidence of good practice, but also missed opportunities in not considering or acting on the possibility that non-accidental injury had occurred. Although there is evidence that GPs were up to date with child protection training, there was a lack of professional curiosity and of triangulating information on the part of the health visitors, GPs and practice teacher. This report lists what learning has taken place as a result of this case, which has had a great impact on the local health community as a whole. It makes recommendations: on managing attendance and follow-up appointments at child health clinics; auditing the use of body maps; developing guidance for the role of Lead GP for child protection (safeguarding) in each GP practice; and the recording of meetings with health visiting students to ensure consistency in practice. The appendices also include a list of questions for a review to consider by each of the relevant agencies regarding episodes identified, particularly in relation to the care of the child and “hearing the voice of the child”.
(Edited publisher abstract)
Subject terms:
serious case reviews, babies, injuries, interagency cooperation, child protection;
This serious case review (SCR) was commissioned due to the circumstances of the youngest child of a family who received life threatening injuries in early 2010. This child, who will be referred to as Rachel in this report, and who has since recovered, was under 2 years old at the time of her injuries. Following a criminal investigation into how the injuries were caused, Rachel’s mother injuries. Also at this time, the family were living with another family who were also recent new arrivals to the UK. This review aimed to: establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between
This serious case review (SCR) was commissioned due to the circumstances of the youngest child of a family who received life threatening injuries in early 2010. This child, who will be referred to as Rachel in this report, and who has since recovered, was under 2 years old at the time of her injuries. Following a criminal investigation into how the injuries were caused, Rachel’s mother was prosecuted and found guilty of one count of cruelty, for which she received a two year custodial sentence. Rachel and her older siblings were all from outside of the UK and moved to this country a few months before the serious injury to Rachel occurred. At that time, none of the family could speak English and the mother was a single parent. The older children were all of school age at the time of Rachel’s injuries. Also at this time, the family were living with another family who were also recent new arrivals to the UK. This review aimed to: establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and Improve intra and inter-agency working to better safeguard and promote the welfare of children.
Subject terms:
injuries, serious case reviews, child abuse, child protection, collaboration;
This serious case review (SCR) was commissioned due to the circumstances of the youngest child of a family who received life threatening injuries in early 2010. This child, who will be referred to as Rachel in this report, and who has since recovered, was under 2 years old at the time of her injuries. Following a criminal investigation into how the injuries were caused, Rachel’s mother injuries. Also at this time, the family were living with another family who were also recent new arrivals to the UK. This review aimed to: establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between
This serious case review (SCR) was commissioned due to the circumstances of the youngest child of a family who received life threatening injuries in early 2010. This child, who will be referred to as Rachel in this report, and who has since recovered, was under 2 years old at the time of her injuries. Following a criminal investigation into how the injuries were caused, Rachel’s mother was prosecuted and found guilty of one count of cruelty, for which she received a two year custodial sentence. Rachel and her older siblings were all from outside of the UK and moved to this country a few months before the serious injury to Rachel occurred. At that time, none of the family could speak English and the mother was a single parent. The older children were all of school age at the time of Rachel’s injuries. Also at this time, the family were living with another family who were also recent new arrivals to the UK. This review aimed to: establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and Improve intra and inter-agency working to better safeguard and promote the welfare of children.
Subject terms:
injuries, serious case reviews, child abuse, child protection, collaboration;
NATIONAL SOCIETY FOR THE PREVENTION OF CRUELTY TO CHILDREN, SOCIAL CARE INSTITUTE FOR EXCELLENCE
Publishers:
Social Care Institute for Excellence, NSPCC
Publication year:
2016
Place of publication:
London
This briefing looks at examples of child protection cases where agencies incorrectly interpret medication information from health professionals about possible causes of injuries as definitive, rather than one of a range of possibilities. It is one of a series 14 briefings looking at difficult issues in inter-professional communication and decision-making in children’s safeguarding identified
(Edited publisher abstract)
This briefing looks at examples of child protection cases where agencies incorrectly interpret medication information from health professionals about possible causes of injuries as definitive, rather than one of a range of possibilities. It is one of a series 14 briefings looking at difficult issues in inter-professional communication and decision-making in children’s safeguarding identified from 38 Serious Case Reviews, with added information gathered from three multi-agency ‘summits’. The briefing draws on a number examples for serious case review reports to highlight the reasons for the wrong interpretation of advice from health professionals, which include a general over-reliance on medical opinion to determine risk, rather than the weighing up of a range of types of evidence. It provides solutions suggested by summit participants and contains a set of self-assessment questions to support managers and practitioners to tackle similar issues in their own local area.
(Edited publisher abstract)
Subject terms:
child protection, interagency cooperation, serious case reviews, health professionals, injuries, decision making, interprofessional relations;
A nine year old boy of Bangladeshi ethnic origin was brought to the Accident & Emergency (A&E) Department of a local hospital with a cut to the back of his neck inflicted by his father. The mother had previous made ten allegations of domestic abuse against her husband. Agencies’ understandings of how the family functioned being dominated by the mother and allegations of domestic abuse. The review notes areas of good practice, systemic weaknesses across agencies and individual weaknesses of practice. Findings highlight the many and varied needs of the family, made more challenging due to the special/additional needs of two of the children; the number of agencies providing support; poor relations between mother and father. It also identifies the need for professionals to have been more effective in developing a holistic understanding of the inability of the family to provide good enough parenting of its growing number of children. Lessons learned included: evidence-based multi-agency assessments of need and risk are essential; the provision of regular reflective supervision for all professionals involved in safeguarding; and that views of children and their fathers must be taken into account in any investigations.
(Original abstract)
A nine year old boy of Bangladeshi ethnic origin was brought to the Accident & Emergency (A&E) Department of a local hospital with a cut to the back of his neck inflicted by his father. The mother had previous made ten allegations of domestic abuse against her husband. Agencies’ understandings of how the family functioned being dominated by the mother and allegations of domestic abuse. The review notes areas of good practice, systemic weaknesses across agencies and individual weaknesses of practice. Findings highlight the many and varied needs of the family, made more challenging due to the special/additional needs of two of the children; the number of agencies providing support; poor relations between mother and father. It also identifies the need for professionals to have been more effective in developing a holistic understanding of the inability of the family to provide good enough parenting of its growing number of children. Lessons learned included: evidence-based multi-agency assessments of need and risk are essential; the provision of regular reflective supervision for all professionals involved in safeguarding; and that views of children and their fathers must be taken into account in any investigations.
(Original abstract)
Subject terms:
domestic violence, injuries, child abuse, South Asian people, serious case reviews, child protection;
National Society for the Prevention of Cruelty to Children
Publication year:
2014
Pagination:
69
A serious case review of Child D, who was just under three weeks old when admitted to hospital with multiple serious injuries in October 2012. Medical advice was that these injuries had been inflicted. Child D’s mother, a woman in her early twenties, was arrested. She was known to adults’ and children’s social care services and to a range of health services, before and during her pregnancy
(Edited publisher abstract)
A serious case review of Child D, who was just under three weeks old when admitted to hospital with multiple serious injuries in October 2012. Medical advice was that these injuries had been inflicted. Child D’s mother, a woman in her early twenties, was arrested. She was known to adults’ and children’s social care services and to a range of health services, before and during her pregnancy and following the birth of Child D. The review found that the agencies had a great deal of information about Ms E. There were numerous indications that she would find it difficult to cope with the responsibilities of being a new parent. Those signs can be found in her childhood, when she had been abused and exploited, her mental health, her learning disability and her continuing isolation and lack of reliable support. The review highlights that the fundamental failing was that agencies did not work together and despite the number of services involved there was never any inter-agency meeting. Maternity services had the greatest amount of direct contact with Ms E but made little positive use of that contact. Given that the assessment of her learning disabilities was inconclusive, no agency gave adequate weight to the implications of her pregnancy. The report concludes that while the consequences of this in this case were extreme it will not be unusual that vulnerable young people fall between various sets of eligibility criteria and are denied critical support and services.
(Edited publisher abstract)
A serious case review of Child H, a 3-year old Somalian boy who died of injuries received whilst in the care of his father. A week earlier, his youngest brother had suffered a serious injury, and had been admitted to hospital in a neighbouring borough. The children were subject of Child Protection Plans, due to the history and pattern of domestic violence and abuse that had emerged
(Edited publisher abstract)
A serious case review of Child H, a 3-year old Somalian boy who died of injuries received whilst in the care of his father. A week earlier, his youngest brother had suffered a serious injury, and had been admitted to hospital in a neighbouring borough. The children were subject of Child Protection Plans, due to the history and pattern of domestic violence and abuse that had emerged in the relationship between their parents. Key findings include: a tendency among professionals to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed; inadequate check and balance mechanisms, including poor professional supervision and lack of multi-agency discussions; poor range, availability and quality of interpreters; miscommunication between social care and medical professionals and misunderstanding about past and future risks in child protection investigations; and inadequate information-sharing practice.
(Edited publisher abstract)
Child T, born in 2007, was the subject of two child protection investigations after suffering extensive injuries, first in the summer of 2010 and then in February 2011. On both occasions, he returned from hospital to the care of his family and was subsequently subjected to further physical abuse. He and his siblings were then brought into the care of the local authority, where they remain. This report describes the chronology of the case regarding injuries sustained by the child, and the role of agencies involved: the local hospital, children’s services in Haringey and Enfield, the Metropolitan Police, health visiting services, GPs and Barnet, Enfield and Haringey Mental Health Trust. Among issues identified for consideration in the terms of reference were: problems in communication about the family circumstances; few attempts to communicate with the children; lack of awareness of “what it was like to be that child”; failure to identify that abuse had been taken place; and what agencies could or should have done to gather information about the family from Poland. Key findings include: that this was not a “borderline case, as Child T had multiple injuries; there were failures to collect
(Original abstract)
Child T, born in 2007, was the subject of two child protection investigations after suffering extensive injuries, first in the summer of 2010 and then in February 2011. On both occasions, he returned from hospital to the care of his family and was subsequently subjected to further physical abuse. He and his siblings were then brought into the care of the local authority, where they remain. This report describes the chronology of the case regarding injuries sustained by the child, and the role of agencies involved: the local hospital, children’s services in Haringey and Enfield, the Metropolitan Police, health visiting services, GPs and Barnet, Enfield and Haringey Mental Health Trust. Among issues identified for consideration in the terms of reference were: problems in communication about the family circumstances; few attempts to communicate with the children; lack of awareness of “what it was like to be that child”; failure to identify that abuse had been taken place; and what agencies could or should have done to gather information about the family from Poland. Key findings include: that this was not a “borderline case, as Child T had multiple injuries; there were failures to collect information or to think the unthinkable; substance misuse and children’s services did not communicate with each other; and there were failures to listen to “the voice of the child”. The report notes that there have been many changes to the way in which services are organised and delivered by all agencies involved since the events it reviews. An appendix lists recommendations made in the individual management reviews of the contributing agencies.
(Original abstract)
Serious case reviews are local enquiries into the death or serious injury of a child where abuse or neglect are known or suspected. The overall aim of this national analysis of such reviews, covering the 184 reviews undertaken over the period 1 April 2009 to 31 March 2011, was to identify common themes and trends and to draw out implications for policy and practice. The research was the 6th two yearly analysis and drew on serious case review notifications and comparative data from other sources. The report describes the background and methodology and sets out key findings and learning points. It looks at serious case review data in context with other data on violent and maltreatment-related deaths of children, background characteristics of the children and families and agency involvement, thematic analysis of serious case reviews involving children aged 5-10 years, child and family practitioners' understanding of child development, and recommendations and new themes arising from serious case reviews. It includes statistical tables.
Serious case reviews are local enquiries into the death or serious injury of a child where abuse or neglect are known or suspected. The overall aim of this national analysis of such reviews, covering the 184 reviews undertaken over the period 1 April 2009 to 31 March 2011, was to identify common themes and trends and to draw out implications for policy and practice. The research was the 6th two yearly analysis and drew on serious case review notifications and comparative data from other sources. The report describes the background and methodology and sets out key findings and learning points. It looks at serious case review data in context with other data on violent and maltreatment-related deaths of children, background characteristics of the children and families and agency involvement, thematic analysis of serious case reviews involving children aged 5-10 years, child and family practitioners' understanding of child development, and recommendations and new themes arising from serious case reviews. It includes statistical tables.
Subject terms:
injuries, serious case reviews, social care professionals, child abuse, child protection, children, death;