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;
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;
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)
Overview report of a Serious Case Review (SCR) commissioned following serious injuries sustained by a Child N when she was aged five weeks old. When rushed to hospital she had sustained bilateral subdural haemorrhages, two rib fractures, a leg fracture and a wrist fracture; the medical evidence is that these injuries had been sustained over a period of several weeks. The parents were charged not effectively challenge the parent’s insufficient explanation of the injuries; there needed to be better sharing of information in terms of both parent’s mental health difficulties; the x-ray was not reviewed by a paediatric specialist; and there were indications of possible neurological trauma and even a potential brief seizure soon after admittance, but these do not appear to have been taken in to account
(Edited publisher abstract)
Overview report of a Serious Case Review (SCR) commissioned following serious injuries sustained by a Child N when she was aged five weeks old. When rushed to hospital she had sustained bilateral subdural haemorrhages, two rib fractures, a leg fracture and a wrist fracture; the medical evidence is that these injuries had been sustained over a period of several weeks. The parents were charged with allowing and causing significant harm to a child. The review finds that: there should have been greater consideration of safeguarding as an alternative explanation for the symptoms the baby had during her 6 hospital admissions; practitioners need to consider a differential diagnosis of non-accidental injury and take into account the history of admissions – and not view singularly; practitioners did not effectively challenge the parent’s insufficient explanation of the injuries; there needed to be better sharing of information in terms of both parent’s mental health difficulties; the x-ray was not reviewed by a paediatric specialist; and there were indications of possible neurological trauma and even a potential brief seizure soon after admittance, but these do not appear to have been taken in to account when causes for Child N’s illness were considered. The review makes a number of recommendations, including: ensure specific clinician case accountability, clinical overview and follow up for individual children when non-accidental injury is a possible diagnosis; review how joint working can be improved between health (the acute hospitals) the multi-professional MASH and children’s social care; and ensure all practitioners seek, collect and share all available information about family and parental history.
(Edited publisher abstract)
Subject terms:
serious case reviews, child protection, child abuse, parents, safeguarding children, injuries, joint working, information sharing;
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;