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)
This serious case review (SCR) concerns a baby, Child H. Child H was admitted to hospital with multiple injuries. The injuries were felt to be indicative of non-accidental injury. The family were known to the agencies, there having been previous involvement with the police and children’s services in respect of domestic violence and long standing involvement with health services due
This serious case review (SCR) concerns a baby, Child H. Child H was admitted to hospital with multiple injuries. The injuries were felt to be indicative of non-accidental injury. The family were known to the agencies, there having been previous involvement with the police and children’s services in respect of domestic violence and long standing involvement with health services due to the father’s mental health problems following a traumatic brain injury. The learning points for this SCR are considered within the following themes: information sharing and communication; thresholds for intervention; assessment of risk of harm; missed health appointments; the need to follow safeguarding children procedures; and sensitivity to children’s needs. The SCR concludes that Child H and sibling were at risk of suffering from significant harm, this was not recognised by the agencies. Robust assessment based on intra-agency and inter-agency information sharing should have concluded that risks were present due to parental mental health, parental substance and alcohol misuse, and domestic violence. With each reported incident or concern, assessment should have concluded increasing risk.
Subject terms:
injuries, interagency cooperation, risk, serious case reviews, assessment, babies, child protection, childrens social care, domestic violence;
... by social care failed to identify the risks to children before he was murdered by his mother and stepfather. It expands on the delays in recording information within and between agencies; problems with information sharing; and failures of four separate assessments, and assessments within the school in identifying risk, weight loss and recurring injuries to Daniel. The knowledge and skill required
(Edited publisher abstract)
This deeper analysis into the circumstances of the death of Daniel Pelka in March 2012 was completed at the request of Edward Timpson, Parliamentary Under-Secretary at the Department for Education (DfE). It answers these issues which he raised following the Serious Case Review: why information was not effectively recorded; why information was not shared; and why four separate assessments by social care failed to identify the risks to children before he was murdered by his mother and stepfather. It expands on the delays in recording information within and between agencies; problems with information sharing; and failures of four separate assessments, and assessments within the school in identifying risk, weight loss and recurring injuries to Daniel. The knowledge and skill required to undertake social work assessments where there is a presence of substance misuse, parental mental ill health and domestic violence is significant in this case. The social worker who completed the initial assessment was experienced in working with domestic violence, but lacked access to the relevant information because of delays in updating records; and also lacked training on parental substance misuse and mental health. The second initial assessment and the core assessment were of very poor quality. Part 2 of this document summarises progress made by partners on implementing the recommendations of the Serious Case Review up to the end of December 2013. Work has started on all 15 recommendations; 7 have been completed in full and 8 others require further action and monitoring by partners and the Safeguarding Children Board.
(Edited publisher abstract)
Subject terms:
serious case reviews, child abuse, child neglect, injuries, domestic violence, death, homicide, risk, outcomes, interagency cooperation, assessment, record keeping;