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)