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;
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;
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)
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)
This review involves a Pembrokeshire baby, referred to as Child H, who died as a result of an unexplained infant death at seven weeks old. The child’s parents were both under the age of 20 years at the time of the birth. The purpose of the Serious Case Review was to examine the involvement of the agencies that had significant involvement with Child H and family, including those with child protection, child welfare, health and criminal investigation responsibilities. The review recommended the Minutes of multi-agency meetings held under Child Protection Strategy procedures should record any discussion that takes place and provide an analysis as to how any decisions are reached. Further training should be provided for all Agencies in Child Protection, and particularly the relevance of risk factors for infants. A clear written contract should be in place when a baby, who is thought to have been abused, is placed within the family before a formal Child Protection plan is agreed by a Child Protection Conference. Finally, written medical reports should be available at Strategy meetings, particularly when the relevant medical staff are unable to attend.
This review involves a Pembrokeshire baby, referred to as Child H, who died as a result of an unexplained infant death at seven weeks old. The child’s parents were both under the age of 20 years at the time of the birth. The purpose of the Serious Case Review was to examine the involvement of the agencies that had significant involvement with Child H and family, including those with child protection, child welfare, health and criminal investigation responsibilities. The review recommended the Minutes of multi-agency meetings held under Child Protection Strategy procedures should record any discussion that takes place and provide an analysis as to how any decisions are reached. Further training should be provided for all Agencies in Child Protection, and particularly the relevance of risk factors for infants. A clear written contract should be in place when a baby, who is thought to have been abused, is placed within the family before a formal Child Protection plan is agreed by a Child Protection Conference. Finally, written medical reports should be available at Strategy meetings, particularly when the relevant medical staff are unable to attend.
This serious case review concerns a three year old child, who was subject to serious neglect at the hands of his mother and her partner. The child was found by Police Officer’s at the family home locked in a room, and was described as being cold, dark and without any lighting or furniture, with the walls covered in human excrement. The child was naked, covered in bruises, and suffering the effects of cold and dehydration. Police Officer’s initiated Police Protection Orders in relation to the child and his two half siblings. The child was transported immediately to hospital for treatment. Agencies were periodically involved with the mother dating back to her own childhood. They again became involved when she became pregnant, as a teenager, with her first child. The mother found it increasing difficult to manage the child, whose behaviour she perceived to be challenging. It would appear that agencies did not fully appreciate the impact that the mother's lifestyle and parenting capacity had on the child. The child displayed emotional distress as a result of the parenting he was receiving although the full extent did not became apparent until the mother and child resided with her new partner and his mother. This review however has highlighted a number of factors of specific relevance to the mother. It is recognised that neglect can be inter-generational and the mother's own history of being parented will have impacted on her capacity to care for her own children.
This serious case review concerns a three year old child, who was subject to serious neglect at the hands of his mother and her partner. The child was found by Police Officer’s at the family home locked in a room, and was described as being cold, dark and without any lighting or furniture, with the walls covered in human excrement. The child was naked, covered in bruises, and suffering the effects of cold and dehydration. Police Officer’s initiated Police Protection Orders in relation to the child and his two half siblings. The child was transported immediately to hospital for treatment. Agencies were periodically involved with the mother dating back to her own childhood. They again became involved when she became pregnant, as a teenager, with her first child. The mother found it increasing difficult to manage the child, whose behaviour she perceived to be challenging. It would appear that agencies did not fully appreciate the impact that the mother's lifestyle and parenting capacity had on the child. The child displayed emotional distress as a result of the parenting he was receiving although the full extent did not became apparent until the mother and child resided with her new partner and his mother. This review however has highlighted a number of factors of specific relevance to the mother. It is recognised that neglect can be inter-generational and the mother's own history of being parented will have impacted on her capacity to care for her own children.
This report provides the findings of a Serious Case Review that was undertaken during 2011 following significant injuries to Child K who was at the time subject to a Child Protection Plan. Child K was born in Tameside in April 2010. Both his parents are believed to have some form of learning difficulty. When he was 2 weeks old, bruises were identified on his leg and he was placed with foster parents. In August 2010, a police investigation concluded that there was no basis for a criminal prosecution and he was returned to his parent’s care subject to a Child Protection Plan. In January 2011 further unexplained injuries were identified during a home visit. Medical examinations subsequently confirmed that Child K had a number of bruises as well as having sustained 5 limb fractures.
This report provides the findings of a Serious Case Review that was undertaken during 2011 following significant injuries to Child K who was at the time subject to a Child Protection Plan. Child K was born in Tameside in April 2010. Both his parents are believed to have some form of learning difficulty. When he was 2 weeks old, bruises were identified on his leg and he was placed with foster parents. In August 2010, a police investigation concluded that there was no basis for a criminal prosecution and he was returned to his parent’s care subject to a Child Protection Plan. In January 2011 further unexplained injuries were identified during a home visit. Medical examinations subsequently confirmed that Child K had a number of bruises as well as having sustained 5 limb fractures. It was further noted that Child K appeared to have developmental delay. Following a police investigation, both parents have been charged with wounding and neglect. This Serious Case Review establishes the facts and analyses the actions and practice of the agencies which provided services to Child K and his family. It identifies 5 key themes in the management of the case: assessment; effectiveness of planning and intervention; engagement with Child K’s parents; effective multi-agency working; and supervision and reflective practice. These themes form the basis of a number of recommendations intended to improve future practice.
Subject terms:
injuries, interagency cooperation, parents with learning disabilities, serious case reviews, assessment, child abuse, child protection;
The summary findings of a Serious Case Review (SCR) undertaken following Child C being admitted to hospital with multiple life threatening injuries in September 2009. Child C’s mother’s partner was later convicted of causing the injuries and Child C’s mother has pleaded guilty to child neglect and is awaiting sentence. The summary presents the key facts of the case and the sequence of events;
The summary findings of a Serious Case Review (SCR) undertaken following Child C being admitted to hospital with multiple life threatening injuries in September 2009. Child C’s mother’s partner was later convicted of causing the injuries and Child C’s mother has pleaded guilty to child neglect and is awaiting sentence. The summary presents the key facts of the case and the sequence of events; summaries the key issues, key decisions and whether with hindsight different decisions or actions could have been taken; and identifies examples of good practice and notes where systems need to improve. The conclusions and lessons learned from the review and recommendations are also detailed.
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
Briefing paper which looks at the issue of professionals not making a child protection referral to children’s social care after observing bruising in non-mobile babies. 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’. Drawing on the analysis of the serious case review reports, it identifies some reasons why this might occur, including: a lack of understanding of child protection procedures, a lack of professional curiosity and ‘respectful scepticism’ about explanations for bruising, and second opinions not being sought from more experienced clinicians. 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)
Briefing paper which looks at the issue of professionals not making a child protection referral to children’s social care after observing bruising in non-mobile babies. 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’. Drawing on the analysis of the serious case review reports, it identifies some reasons why this might occur, including: a lack of understanding of child protection procedures, a lack of professional curiosity and ‘respectful scepticism’ about explanations for bruising, and second opinions not being sought from more experienced clinicians. 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:
referral, childrens social care, injuries, general practitioners, interagency cooperation, serious case reviews, decision making, child protection;
Croydon Safeguarding Children Board, Lewisham Safeguarding Children Board
Publication year:
2017
Pagination:
44
Place of publication:
London
... of suspected non-accidental injuries. Key themes identified by the review process included: thresholds for intervention when assessing neglect over time; the challenges faced by young parents (20 and 21 at the time) caring for very young children; the role of early intervention in cases of neglect and the interface with statutory intervention when families reject early help; the impact of childhood trauma
(Edited publisher abstract)
Overview report of a Serious Case Review jointly commissioned by Croydon Safeguarding Children Board (CSCB) and Lewisham Safeguarding Children Board (LSCB) following the serious injury of Child W, a 6 month old baby girl whilst in the care of her mother and her mother’s partner. When presented to hospital Child W had 26 bruises, very bad nappy rash, appeared malnourished, and a number of suspected non-accidental injuries. Key themes identified by the review process included: thresholds for intervention when assessing neglect over time; the challenges faced by young parents (20 and 21 at the time) caring for very young children; the role of early intervention in cases of neglect and the interface with statutory intervention when families reject early help; the impact of childhood trauma on parenting capacity; and different interpretation of procedures when families move across Local Authority boundaries (the family moved between at least 3 London boroughs during the period of the review).
(Edited publisher abstract)
Subject terms:
child neglect, teenage parents, early intervention, interagency cooperation, parenting, serious case reviews, procedures, local authorities, safeguarding children, injuries;