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)
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;
Serious case reviews are local enquiries into the death or serious injury of a child where abuse or neglect are known or suspected. This briefing summarises the findings from the 6th two yearly national analysis of such reviews, covering the 184 reviews undertaken over the period 1 April 2009 to 31 March 2011. The overall aim was to identify common themes and trends and to draw out implications for policy and practice. The summary describes the background and methodology and sets out key findings and learning points. It covers the number of violent and maltreatment-related deaths of children in England per year, patterns of serious case reviews, new learning about patterns and behaviour in families, changes in agency responses, children aged between 5 and 10 years, practitioner knowledge of child development and its importance in child protection, recommendations from reviews, insights for practitioners and implications for policy.
Serious case reviews are local enquiries into the death or serious injury of a child where abuse or neglect are known or suspected. This briefing summarises the findings from the 6th two yearly national analysis of such reviews, covering the 184 reviews undertaken over the period 1 April 2009 to 31 March 2011. The overall aim was to identify common themes and trends and to draw out implications for policy and practice. The summary describes the background and methodology and sets out key findings and learning points. It covers the number of violent and maltreatment-related deaths of children in England per year, patterns of serious case reviews, new learning about patterns and behaviour in families, changes in agency responses, children aged between 5 and 10 years, practitioner knowledge of child development and its importance in child protection, recommendations from reviews, insights for practitioners and implications for policy.
Subject terms:
injuries, serious case reviews, social care professionals, child abuse, child protection, children, death;
A review of the circumstances involved in cases where babies under-one-year-old have been harmed or killed by their fathers or other males in a caring role. Findings include: a range of risk factors were common in many of the cases, a lack of information sharing was a key factor that prevented practitioners from responding to risk to babies, and many services aimed at new parents are predominantly focused on the mother. Recommendations include: the government should fund pilots to develop holistic work with fathers and the engagement of fathers must be embedded in prospective and current family-focused programmes. Additional reports published with the main report include: fieldwork report and Psychologist report: national review of non-accidental injury in under 1s.
(Edited publisher abstract)
A review of the circumstances involved in cases where babies under-one-year-old have been harmed or killed by their fathers or other males in a caring role. Findings include: a range of risk factors were common in many of the cases, a lack of information sharing was a key factor that prevented practitioners from responding to risk to babies, and many services aimed at new parents are predominantly focused on the mother. Recommendations include: the government should fund pilots to develop holistic work with fathers and the engagement of fathers must be embedded in prospective and current family-focused programmes. Additional reports published with the main report include: fieldwork report and Psychologist report: national review of non-accidental injury in under 1s.
(Edited publisher abstract)
Serious case review in relation to Child J who died due to non-accidential injuries. Child J was the second child of Adult P, a young white British woman in her early 20s Child J and family had contact with a range of services. Four referrals to Children’s Social Work were made during Child J's life but none led to child protection or other legal procedures being instigated. These included
(Edited publisher abstract)
Serious case review in relation to Child J who died due to non-accidential injuries. Child J was the second child of Adult P, a young white British woman in her early 20s Child J and family had contact with a range of services. Four referrals to Children’s Social Work were made during Child J's life but none led to child protection or other legal procedures being instigated. These included a referral made by the police due to an incident of domestic abuse, which led to an initial assessment by Children's Social Work. On the day of Child J’s death, a 999 call was made by Adult P who said that Child J had fallen an hour previously. Child J died a day later. The review looks at risks, assessment and decision making, using and sharing information; and practice support and supervision.
(Edited publisher abstract)
Subject terms:
injuries, domestic violence, death, serious case reviews, child abuse, information sharing, assessment, staff supervision;
Windsor and Maidenhead Local Safeguarding Children Board
Publication year:
2014
Pagination:
185
Place of publication:
Maidenhead
... are very likely to have led to the detection of serious injuries and would probably have prevented his death. The report makes a number of recommendations, including: the LSCB should oversee the production of a ‘pathway’ for the management by health professionals of bruising so as to ensure that it is consistent with sound multi-agency child protection practice; all health visiting teams should
(Edited publisher abstract)
The review concerns two children: EY was aged 11 months when he died on 20 March 2011 and his older brother OY was aged 23 months. On the morning of 18 March 2011 EY was taken to hospital by ambulance. He had suffered a very serious head injury, which caused his death two days later. The post-mortem examination revealed that EY had suffered bruises and fractures at different ages and determined that it was virtually impossible to explain the head injury other than as the result of non-accidental injury. There was evidence that the mother’s denied or concealed her two pregnancies and that she showed little positive interest in EY; professionals missed opportunities to protect EY on several occasions when they identified suspicious bruises but failed to take action. The conclusions of the SCR were that 1) over the long term the risks to EY were underestimated 2) when he moved to live with his mother he should have been closely monitored because of the concerns about the circumstances of his birth and his mother’s failure to visit him for long periods when he had been looked after 3) in the two weeks before his death professionals missed opportunities to intervene which, if they had been taken, are very likely to have led to the detection of serious injuries and would probably have prevented his death. The report makes a number of recommendations, including: the LSCB should oversee the production of a ‘pathway’ for the management by health professionals of bruising so as to ensure that it is consistent with sound multi-agency child protection practice; all health visiting teams should be briefed about action take in the event of observed bruising on an infant; and children’s social care services should develop local good practice guidance for the staff, including the provision of training on concealed pregnancy and birth.
(Edited publisher abstract)
Baby V died at four months old, after being admitted to hospital following a respiratory arrest at home. She was found to have multiple injuries at the time of death, including a healed rib fracture. The family was not known to social services, and all dealings by the GPs (which were frequent), health visitors and midwives with the parents or the older child were not deemed to be out of the ordinary. Baby V had visited the GP with facial bruising shortly before her death. Father was found responsible for causing the injuries and convicted. The review highlights opportunities to identify risk at nursery school, through the health visitor, relatives and their GP and out of hours GP service. Key themes from the review include: a review of protocol and policy for dealing with bruising
(Original abstract)
Baby V died at four months old, after being admitted to hospital following a respiratory arrest at home. She was found to have multiple injuries at the time of death, including a healed rib fracture. The family was not known to social services, and all dealings by the GPs (which were frequent), health visitors and midwives with the parents or the older child were not deemed to be out of the ordinary. Baby V had visited the GP with facial bruising shortly before her death. Father was found responsible for causing the injuries and convicted. The review highlights opportunities to identify risk at nursery school, through the health visitor, relatives and their GP and out of hours GP service. Key themes from the review include: a review of protocol and policy for dealing with bruising in children who are not independently mobile; a review child protection training in organisations; the need respectful scepticism to ensure staff that the confidence to challenge what they are told in the interests of child safety; and to improve communication between GPs, health visitors and midwives.
(Original abstract)
Subject terms:
babies, serious case reviews, death, injuries, child abuse, health professionals, interprofessional relations, general practitioners, health visitors;
South Gloucestershire Local Safeguarding Children Board
Publication year:
2014
Pagination:
63, 17
Place of publication:
Bristol
... to unascertained causes, in the months preceding her death, Child C sustained a number of injuries, which were either noticed by social workers or reported to hospital staff. The review outlines key learning points and recommendations, including: children who become mothers and fathers should be considered by all agencies as children first and their particular vulnerabilities and service requirements addressed from that perspective; a multi-agency protocol should be developed in relation to the management of injuries (incidents) concerning non-mobile babies and the phrase 'Children Who Don't Cruise Rarely Bruise' should be adopted as a multi-agency guide when professionals are considering injuries or unusual presentations in non-mobile babies; fathers and partners should be fully considered and involved
(Edited publisher abstract)
A serious case review of Child C, who died at the age of 17 weeks. At the time of her death she was living in a household with her brother, her mother and her mother's boyfriend. Child C's mother became pregnant for the first time aged fifteen and was further vulnerable as a result of her family experiences of family violence and inconsistent parenting. While the death is recorded as due to unascertained causes, in the months preceding her death, Child C sustained a number of injuries, which were either noticed by social workers or reported to hospital staff. The review outlines key learning points and recommendations, including: children who become mothers and fathers should be considered by all agencies as children first and their particular vulnerabilities and service requirements addressed from that perspective; a multi-agency protocol should be developed in relation to the management of injuries (incidents) concerning non-mobile babies and the phrase 'Children Who Don't Cruise Rarely Bruise' should be adopted as a multi-agency guide when professionals are considering injuries or unusual presentations in non-mobile babies; fathers and partners should be fully considered and involved in assessments of need. The review concludes that there were a number of connected themes which included fragmented practice, a lack of holistic assessment, multi-agency review and professional challenge. These factors undermined the potential to provide a more robust safeguarding response to Child C and her family.
(Edited publisher abstract)
This report examines case where children have died or been injured from ingesting methodone or buprenorphine (opioid substitution treatment medicines), prescribed to help people overcome drug addiction. It draws on evidence from a literature review, serious case reviews conducted between 2003 - 2013, a review of media coverage and interviews, focus groups and a round-table discussion with frontline practitioners and policy experts. Areas discussed include safety and storage; prescribing and dispensing; intentional administration, professional practice, assessing risk, information sharing, and learning and development. The report found an inconsistent picture of practice regarding safeguarding and OST and the need to build professional confidence and competence in addressing issues of risk assessment in substance using families. It also found that in rare cases methadone was used by parents as a pacifier for small children.
(Original abstract)
This report examines case where children have died or been injured from ingesting methodone or buprenorphine (opioid substitution treatment medicines), prescribed to help people overcome drug addiction. It draws on evidence from a literature review, serious case reviews conducted between 2003 - 2013, a review of media coverage and interviews, focus groups and a round-table discussion with frontline practitioners and policy experts. Areas discussed include safety and storage; prescribing and dispensing; intentional administration, professional practice, assessing risk, information sharing, and learning and development. The report found an inconsistent picture of practice regarding safeguarding and OST and the need to build professional confidence and competence in addressing issues of risk assessment in substance using families. It also found that in rare cases methadone was used by parents as a pacifier for small children.
(Original abstract)
Subject terms:
families, drug misuse, serious case reviews, risk, death, vulnerable children, children, injuries, child abuse;
... respectively at the time of their brother’s death. Daniel was murdered by his mother and stepfather in March 2012. For at least six months prior to this, he had been starved, assaulted, neglected and abused. His older sister was expected to explain away his injuries as accidental. His mother and stepfather acted together to inflict pain and suffering on him and were convicted of murder in August 2013, both were sentenced to 30 years' imprisonment. This report documents analysis of professional practice in responding to domestic abuse in the household, concerns about neglect and health, and to the child's injuries. The report documents the events leading up to Daniel's death, including school concerns and injuries noticed by school staff. The findings note opportunities missed to protect Daniel
(Edited publisher abstract)
This Serious Case Review (SCR) was commissioned following the death of Daniel Pelka, the middle child of a family who had migrated to this country in 2005 from Poland and who lived in Coventry for most of the time that they resided in the UK. Daniel was 4 years 8 months old when he died on 3rd March 2012,. He had an older sister and a younger brother, aged approximately 7 years and 1 year respectively at the time of their brother’s death. Daniel was murdered by his mother and stepfather in March 2012. For at least six months prior to this, he had been starved, assaulted, neglected and abused. His older sister was expected to explain away his injuries as accidental. His mother and stepfather acted together to inflict pain and suffering on him and were convicted of murder in August 2013, both were sentenced to 30 years' imprisonment. This report documents analysis of professional practice in responding to domestic abuse in the household, concerns about neglect and health, and to the child's injuries. The report documents the events leading up to Daniel's death, including school concerns and injuries noticed by school staff. The findings note opportunities missed to protect Daniel and to potentially uncover the abuse he was suffering: he appeared to have been "invisible" as a needy child. The professionals needed to “think the unthinkable”, and to believe and act upon what they saw in front of them, rather than accept without robust challenge, parental versions of what was happening at home. The report highlights a “Start Again Syndrome” (involving changes of address and the children starting a new school), which led this SCR to question professional communication, information sharing and liaison over service delivery (including that between those working out of hours and across borders). It questions the extent to which practitioners were knowledgeable both about potential indicators of abuse or neglect, and about what to do if they had concerns about a child’s welfare. It asks whether the work in this case was consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards (including the involvement of senior managers). Overall, this case raises particular questions about the ability of the different agencies to address domestic abuse, and whether they could have prevented the abuse to and death of Daniel, had they had more enquiring minds. However, the SCR concludes that "it would be too simplistic to identify failings by individual practitioners as the reasons why Daniel was not protected". The report recommends that there must be a review of the systems which currently exist for the notification and sharing of information in respect of domestic abuse incidents within families to ensure that they generate effective outcomes in relation to the safeguarding of children. The review must focus on: the timeliness of notifications; the agency to which they should be distributed, including schools, the importance of a focus on the needs and safety of the children, the efficiency and effectiveness of the joint screening processes and the responsibility for agreed outcomes, and how repeat domestic abuse incidents need to be responded to more holistically. The LSCB needs to demonstrate a clear cohesive understanding of the scope of early help and prevention work to support children living with domestic abuse. Appendix 2 lists the main domestic abuse incidents reported to the police, whether they made any referrals, and what, if anything, they noticed about the children.
(Edited publisher abstract)