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Case reviews published in 2012

A chronological list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews reviews published in 2012.


[2012] – Ceredigion – Child J
Serious injury of a baby (age unspecified) in 2007.  History of suspicions of abuse from medical professionals and numerous visits were made to GP, paediatrician and Accident and Emergency Department by Child J and his two older siblings over a four-year period.  Child J and siblings were made subject to care proceedings following the incident. 
Makes recommendations that photographs are taken as part of initial clinical assessments in cases where injuries are potentially non-accidental.
Non-accidental injuries, physical abuse, medical assessment.

[2012] – Ceredigion – Child K
Death of a 17-year-old boy in June 2009, by hanging.  K was not known to agencies and there was no involvement with social services or the criminal justice system and no known problems with drugs. 
Makes recommendations for guidance for children’s services staff to assist them in responding to children who are self-harming or have suicidal thoughts.
Suicide, self-harm.

[2012] – Ceredigion – Child V
Death of a 15-year-old boy in 2009, as a result of a methadone overdose.  History of behavioural problems in school, offending, drug and alcohol problems and difficult mother-son relationship and Child V was known to local services at the time of his death. 
Makes recommendations for multi-agency training and guidance for managing cases where a child is at risk but where professionals have no control over the management of risk factors.
Drugs and alcohol, young offenders, risk assessment.

[2012] – Ceredigion - Child Z.
Death of a 17-year-old girl in April 2009, found to have choked on her own vomit following abuse of Heroin and other drugs.  Child Z was known to agencies from the age of 11, following her parents’ separation.  History of school exclusion, self-harm, offending, homelessness, drug and alcohol use and sexual exploitation. 
Makes recommendations for effective working with uncooperative adolescents who engage in risky behaviour.
Drug misuse, alcohol misuse, self-harm, homelessness, youth offending.

2012 – Grampian – Alexis Matheson
Death of a 6-week-old baby girl on the 10th December 2007 as a result of non-accidental injury.  Mother’s partner was found guilty of murder and sentenced to life imprisonment.  Alexis and her Mother were not known to children’s services and no concerns had been expressed by anyone over Mother’s Partner’s involvement with Alexis, Mother’s parenting abilities or Alexis’ health prior to her death. 
Makes recommendations for the GP appointments system; training of GPs and health visitors to detect signs of physical abuse; the practice of GPs prescribing drugs by telephone for new-born babies; and GP and Health Visitor liaison.
Physical abuse, GPs.
Executive summary

[2012]  – Haringey – Family Z (overview report)
Chronic neglect of children, aged 8 months to 16 years from 2002-2009 after which children were removed by police and placed in local authority care. Family were known to a number of agencies and had been involved with children's social care since 2002 after an anonymous referral raising concerns about neglect.  Further referrals over the years from schools and the public relating to personal hygiene, persistent head lice and poor school attendance. Attempts by social workers to visit were blocked through openly hostile and aggressive behaviour.
Makes recommendations for equipping staff with the professional authority required to work with hostile families, encouraging effective challenge to practitioners and adopting an organisational approach to child protection.
Child neglect, family violence, hostile behaviour.

[2012] – Leeds – Child Q
Death of a 32-month-old baby in December 2008, as a result of ingesting a lethal amount of mother’s prescription drugs.  Family were known to various agencies, including asylum seeker services and health and police services; Child Q and an older sibling were known to children’s services and had presented with unexplained injuries at nursery and school on a number of occasions.  Mother was difficult to work with, manipulated agencies and in some cases intimidated staff. 
Makes recommendations for safeguarding training for UK Border Agency staff (UKBA) and for professionals in recognising disguised compliance.
Alcohol misuse, parents with a mental health problem, domestic abuse, physical abuse, asylum seekers.
Executive summary 

[2012]- Leicester – Child U
Death of a child in 2007 following admission to hospital with significant injuries. 
Makes recommendations covering issues including: the importance of fathers in assessments and in providing services; pre-birth assessments; risks to children from adults where there may be domestic abuse combined with illegal drug taking; and, overly optimistic thinking from professionals. 
Physical abuse, drug misuse, domestic abuse.
Executive summary

[2012] - North Tyneside - Child E
Serious injury of a 2-year-old boy admitted to hospital with non-accidental unexplained injuries.  Mother and father charged with causing the injuries.  Child E was diagnosed with a serious medical condition at 12 months and hospitalised for 9 months, after which he received continued intervention from community and hospital health professionals.  Child E and 2 older half siblings were all subject to child protection plans. History of domestic violence in mothers' previous relationships.  Mother became pregnant during Child E's time in hospital and subsequently agreed to place the baby for adoption. 
Makes recommendations for multi-disciplinary training in working with complexity and uncertainty, use of effective challenge and maintaining professional scepticism.
Chronic illness, supervision, assessment.

2012 - Warwickshire - G.A
Death of a 6-year-old girl in the summer of 2011.
It is believed G.A was killed by her mother who then took her own life. Father lived with mother and G.A for most of her life, interrupted by periods of parental separation; the most recent period of separation began several weeks before the incident. Mother’s recreational drug use resulted in an episode of drug induced psychosis and compulsory detention when she was 17-years-old.
Issues identified include: GPs positive view of mother resulting in uncritical decision-making following several incidents of minor injury; children’s services failing to act following concerns raised by father over mother’s parenting capacity; and the impact of mother’s cannabis withdrawal in months prior to the incident.
Identifies lessons including: where pregnant women have a history of mental health problems midwives should have access to mental health professionals; GP safeguarding training should be reviewed and attendance records kept; and professionals working with families and children should understand the role of fathers.
Makes various single agency recommendations.
GPs, suicide, parents with a mental health problem

November 2012 -  Bexley - Child B
Death of a 3-year-old boy in January 2011.  Child B, who had a severely disabling medical condition, was taken to hospital with multiple injuries and pronounced dead on arrival.  Mother's partner was subsequently convicted of manslaughter. 
Issues identified include: child B's severely disabling medical condition; and mother's social isolation, separation from child's father and new relationship with a man unknown to professionals. 
Makes recommendations for health visitors developing a working knowledge of services available to families with disabled children, schools following up on unexplained absences, and raising awareness of the vulnerability to abuse of children with disabilities.
Unknown men, social exclusion, children with disabilities.

November 2012 – Havering – Child F
Death of a 17-year-old boy from injuries sustained after he threw himself in front of a vehicle, in 2011.  Child F’s mother had died after a suicide attempt in 2006.  History of parental mental illness, domestic abuse, anti-social behaviour and periods of school exclusion.  Family were known to various agencies including: police, probation, health, mental health, education and children’s services. 
Makes recommendations covering: working with families that are hard to engage; and, improving agencies’ understanding of and practice in working with families where domestic violence, mental health and substance misuse issues are present.
Suicide, anti-social behaviour, parents with a mental health problem
Executive summary

November 2012 – Newport – Child X
Death of a 16 year old boy by hanging in September 2011 six weeks after the attempted murder of his mother by his father and the subsequent death of his father by hanging.
Parental separation; domestic abuse, paternal depression and anxiety; father's suicide.
Recommendations include the use of a multi-agency risk assessment and screening tool in cases where children and young people are living with domestic abuse and sharing findings with the adult safeguarding board, particularly in relation to the mental health on risk assessments
Executive summary

October 2012 – Leeds – Child U
Assault of Child U1, a 17-year-old boy in Autumn 2009, perpetrated by Child U2 and Child U3, also 17-year-old boys, all of whom are subject to this serious case review.  All three children were living in supported accommodation for young people with learning difficulties at the time of the incident.  History of peer violence, bullying and aggression, anti-social behaviour, and youth offending with all boys. 
Recommendations include: raising the profile of bullying as a child protection issue; and, developing guidance for social work teams where it becomes apparent that the behaviour of one or more looked after children is having a negative impact on another looked after child.
Peer violence, residential child care, adolescents with learning difficulties
Executive summary

September 2012 - Rochdale - Multi-agency responses to the sexual exploitation of children
Review how agencies including the council, police, and NHS worked to safeguard children at risk of exploitation between 2007 and 2012.
Makes recommendations for the development of a local strategy for responding to child sexual exploitation; training for professionals; better inter-agency working; and effective use of referrals to ensure children are provided with good services, specific to their needs.
Child sexual abuse, organised abuse

September 2012  - Kent - Amy (Singleton)
Death of a 10 year old girl in October 2011 by hanging.  History of allegations of sexual abuse and concerns of neglect and physical abuse reported by neighbours and child's school, leading to contact with Specialist Children's Services at various times.  Makes recommendations for safeguarding systems in schools and guidance for commissioners of health services in responding to requests for Health Overview Reports to support future Serious Case Reviews.
Physical abuse, sexual abuse, health services, child neglect
Executive summary

July 2012Kent – Ashley (overview report)
Death of a 4-month-old baby boy in January 2011 from a brain haemorrhage as a result of violent shaking. Father has been charged with his manslaughter. Repeated contact with children’s services following anonymous referrals with concerns of emotional abuse and neglect of Ashley’s half-sister, Jo and allegations from Jo concerning Ashley’s father’s behaviour. History of parental drug misuse; maternal depression and anger management problems; paternal behavioural problems and aggression dating back to childhood; father given 21 month custodial sentence for serious assault committed in 2009.
Makes recommendations for interagency information sharing and central involvement of children during social work assessments .
Neglect, emotional abuse, cannabis

July 2012 - North East Lincolnshire - Child A
Death of a 6-month-old boy on 22nd December 2011 following complications from a head injury. Mother's partner was charged with Section 18 Assault (Causing Grievous Bodily Harm) and subsequently charged with Child A's murder.  There was no previous contact with specialist services and no safeguarding concerns for child. 
Makes recommendations for developing the educational aspect of the Safeguarding Children's Board's e-safety policy and developing a greater exchange of ideas and improvements between adult and children's safeguarding systems.
Head injuries

June 2012Leicester – Baby L (overview report)
Death of a 7-month-old baby in 2011, after being smothered by her mother, who then attempted suicide. Mother pleaded guilty to infanticide and was ordered to undergo secure psychiatric treatment for sever post-natal depression.  Family known to agencies following several incidents of domestic violence, which led to police involvement when Baby L was approximately 3-months-old. Maternal history of contact with GP for anxiety and panic attacks.
Makes recommendations for the sharing of information with universal services, i.e. health visiting services, in relation to young children and for all agencies in assessing the impact of adults’ behaviour on young children.
parents with a mental health problem, post-natal depression, domestic violence
Executive summary

May 2012– Bridgend – Child Q a baby boy
Serious injury of a 2 month old boy in autumn 2010.  History of parental mental health problems and substance misuse issues but no previous child protection concerns. 
Makes recommendations for issues of information sharing between agencies and potential risk posed to children by parents with mental ill health.
Substance misuse, parents with a mental health problem
Executive summary

May 2012 – Coventry – Child W
Death of a baby, a few months old, in July 2011. Child W was found dead by his/her mother, after the child had been brought to bed by the mother’s partner and placed between the couple as they slept.  History of domestic abuse and family were known to various agencies in Coventry and previous place of residence, Birmingham, where Child W’s older siblings had been subject to child protection plans.
Makes recommendations covering: the provision of residential accommodation to those fleeing domestic violence; patterns of multi-agency working; and, risk assessment processes and tools used by professionals.
Domestic abuse, substance misuse
Executive summary 

April 2012 – Bridgend – Child R
Death of a 13-year-old boy in September 2010 by hanging.  History of behavioural problems leading to school exclusions and contact with police and various children’s services.  Makes recommendations for issues of safeguarding training for health and community services; information sharing between agencies and non-attendance at necessary health service appointments.
Behaviour disorders, anger management, suicide
Executive summary

April 2012 – Haringey – Family Z
Review into agency involvement in the chronic neglect of children in Family Z, over a 7 year period, up until the children (aged between 8 months and 16 years) were placed in local authority care in April 2009. Both parents were convicted and served custodial sentences.  Family were known to a range of agencies, including children’s social care since 2002, and children had been placed on the Child Protection Register for neglect in 2006.
Makes recommendations for effective working with non-engaging families.
Neglect, hostile families, domestic violence

April 2012 - Lancashire – Baby J
Death of a 24-week-old baby boy in 2011, at the hands of his father. Family was known to agencies including probation, drug and alcohol services and Children’s Social Care.  Baby J had older siblings who had been subject to care proceedings on the grounds of neglect; one sibling had been removed and adopted prior to Baby J’s birth.  Mother had a history of drug and alcohol misuse, poor mental health and an extensive criminal history.  Father was a relatively recent partner and professionals had little knowledge of his background.  Reports 10 findings covering issues including:  focus on the child; assessment of men in the family; over-reliance on self-reporting from parents; and, assessments as a dynamic process that take into account new information and re-assess the risk to the child. The report includes a response from the LSCB on the findings from the review and details of action being undertaken and planned.
Alcohol misuse, offenders, parents with a mental health problem

April 2012 – Westminster – Child EG
Infant boy aged almost 1 year found dead in his cot by ambulance services who had been called by his mother Mrs G. Mother was arrested but died 2 days later. EG had died as his mother had been too ill to look after him.
Child neglect, asylum seekers, refugees, parental illness, domestic abuse, poverty, homelessness
Executive summary

March 2012 – Bridgend – Child O a Baby Girl
Serious injury of Child O, a 7-week-old baby girl in February 2010.  History of health agency, education, police and social services involvement with Child O, her 8-year-old half-sister and their families, prior to her admittance to hospital. 
Makes recommendations for interagency child protection procedures and child protection procedures within schools. 
Assessment of children, physical abuse, family conflict
Executive summary

March 2012 - Doncaster - J Children (overview report)
2 brothers (aged 10 and 11) committed serious assaults against 2 children in April 2009. Pleaded guilty to grievous bodily harm with intent. Finds that no-one could have reasonably predicted the "severity and extent" of the assaults but the attacks might have been preventable had officials taken "assertive and effective" action to address the brothers' escalating pattern of violence.
Young offenders, violent behaviour, children in violent families, school exclusion, behaviour problems, abusive fathers, physical abuse.
Note: Full overview report published by Department for Education in 2012. Executive summary (originally published in 2010).

March 2012 – Islington – Child B and Child C
Death of two primary school aged siblings in 2011, as a result of knife wounds inflicted by their father during a contact visit. Father was found guilty of murder and received a lengthy custodial sentence. Children had no contact with father until September 2010, when supported contact began. In the week preceding the incident father sent a number of abusive text messages to mother and attended several meetings with his solicitor in relation to the possible repossession of his flat. After admitting killing his children to the police, father referred to the court hearing for repossession of his flat as evidence of why he had committed the murders.
Identifies lessons learnt, including: insufficient assessment of risk the children during court proceedings; impact of cultural factors on women’s capacity to understand their rights and protect themselves and their children; and missed opportunities by the police to speak to children as potential witnesses to domestic abuse.
Abusive fathers, domestic abuse, CAFCASS

March 2012 - Leeds - Child K (executive summary)
Murder of a 15 year old girl by a neighbour, a registered sex offender who befriended the family. Child K (from Poland) had only been in the country for 5 weeks. Murder was not foreseeable but more should have been done to effectively manage the risk posed by the perpetrator.
Sex offenders, immigrants, probation service, risk management, police.

March 2012 – Oxfordshire – Child V
Death of a 4-month-old child in June 2009, from injuries resulting in irreversible brain damage. The partner of Child V’s maternal aunt was found guilty of manslaughter and sentenced to six years imprisonment. A child protection investigation in respect of Child V’s cousin was instigated following Child V’s admission to hospital. Child V was known only to universal services with the exception of professional involvement following a minor head injury, sustained whilst in mother’s care. Partner of V’s aunt was misusing steroids and was known to have previously sought medical care for injuries suggestive of aggressive behaviour.
Issues identified include: all injuries to non-mobile children should be regarded as highly suggestive of non-accidental injury; awareness of parental misuse of steroids as a potential risk factor for children should be improved; and referral following suspected abuse should include details of any other children who are in contact with the suspected perpetrator.
Makes recommendations for: Oxfordshire Local Safeguarding Children Board, health and police services. Non-accidental head injuries, abusive men
Executive summary

March 2012 - Pembrokeshire - Child H (executive summary)
7 week old baby died as a result of an unexplained infant death. Abuse and neglect were not a contributory factor but a review was undertaken because Child H was subject to a child protection investigation at the time of death.
Adolescent parents, non-accidental bruising and fractures, aggressive father, kinship care, no investigation of Safe Adults

March 2012 – Worcestershire – AW
Death of a 6-month-old baby in 2009, from a traumatic head injury associated with shaking. Father was convicted of manslaughter.  History of domestic violence, convictions for violent assault and threats by father against unborn child.  Agencies mistakenly believed that parents had permanently separated but father returned from work (in the Armed Forces) at weekends. 
Makes recommendations for assessing risks to children (including unborn children) and particularly vulnerable young women in cases of domestic abuse.
Domestic abuse, physical abuse.
Executive summary 

February 2012 - Islington - Child B and Child C (overview report)
2 primary school aged children murdered by their father in 2011 while on a weekend contact visit. History of domestic violence but no previous child protection concerns. Finds that the potential risk of harm to the children arising from the history of domestic violence was given insufficient weight during contact court proceedings.
Murder, contact, parental separation, domestic abuse, CAFCASS, police, culture, ethnicity, disabled children.
Executive summary

February 2012 - Newham - Michael
Death of a 12 year old boy in May 2011 as a result of organ failure brought on by bronchial pneumonia. Death was judged to be from natural causes. A number of concerns prompted the serious case review. History of investigations into allegations of neglect, frequent school absence and concerns that Michael's health and developmental needs were not met.
Makes recommendations for: reviewing inter-agency arrangements for children in need who do not meet the threshold for child protection intervention; strengthening arrangements for working with hard to engage parents; and considering the links between safeguarding and childhood obesity.
Neglect, obesity, absenteeism.

February 2012Renfrewshire – Declan Hainey (overview report)
Death of a 23 month old baby boy on 30 March 2010, cause of death unknown.  Declan’s death had been concealed by his mother for up to six months.  Mother was found guilty of his murder and sentenced to a mandatory life sentence with a minimum term of 15 years.  History of maternal heroin and alcohol use, known issues of homelessness and non-attendance at antenatal appointments and drug rehabilitation support meetings. 
Makes recommendations for an initial child protection conference to be held in all cases where children are born to drug abusing parents.
Drug misuse, non-attendance

January 2012 – Bedfordshire – Child B
Serious injuries sustained by 8 month old girl, including head injuries and a fractured arm in December 2009. Mother admitted causing the injuries. Signs of previous injuries were seen. The child was in care for first 5.5 months of her life. Highlights role of risk assessment before and after birth and context of family violence, including in parent’s family of origin.
Adolescent parents, physical abuse, family reunification
Executive summary

January 2012 – Bridgend – [Child S]
Alleged serious sexual abuse of a young girl by a member of her extended family, with sole caring responsibility for her, over a number of years. History of instability in the maternal home and known child protection concerns for young person’s siblings who remained in maternal home. Sole male carer of young person had past convictions of sexual offences against children.
Makes recommendations for interagency information sharing and assessing and reviewing risks to children’s welfare and safety when parents/carers are not cooperating.
Child sexual abuse, resistance, sex offenders
Executive summary

January 2012 - East Riding - Child F (executive summary)
Child F sustained serious non accidental injuries in 2009 caused by mother's partner. Also found to have healing fractures. Perpetrator was a known risk as there had been a previous allegation of physical abuse against a child. Highlights that evidence of risk was not acted upon. Disciplinary action taken by Police and Children's Social Care against various members of staff involved in the assessment and decision making.
Physical abuse, police, children’s social care, abusive men, risk assessment, decision-making.

January 2012 - Flintshire - Sion D (executive summary)
Death of 7 year old boy with disabilities and developmental delay (cause found to be an infection). Concerns about neglect, unexplained injuries and faecal smearing before his death. Finds that professionals were not sufficiently challenging to the parents during their contact with the family.
Disabled children, neglect, physical abuse, home education, parental engagement, resistance to professional support.

January 2012 – Luton – Child B
Serious injury of 9-month-old baby girl, who sustained a bleed into the brain and fractured arm in December 2009.  Older injuries were identified when Child B was taken to hospital.  Child’s mother admitted causing the injuries and received a custodial sentence for assault and causing grievous bodily harm.  History of maternal depression and domestic abuse and child’s father was in prison. 
Makes recommendations for assessment regarding the reunification of looked after children with their parents.
Parents with a mental health problem, domestic abuse
Executive summary

January 2012 - North Somerset - Abuse of pupils in a first school (overview report)
Sexual abuse of primary school children by their teacher. Teacher sentenced to minimum of 8.5 years. Failure by colleagues to formally report concerns and recognise grooming behaviour.
Executive summary

January 2012 - Child Q - Surrey
Death of a 1 year-old baby boy on 16th September 2011, following drowning in bath water four days earlier. Mother was arrested and convicted of manslaughter and neglect. Maternal history of: mental health and behavioural problems from age 8, involvement with children's services as a child and aggressive and anti-social behaviour including drug and alcohol misuse. Paternal history of significant drug and alcohol misuse.
Issues identified include: lack of integrated working by agencies; lack of professional curiosity; agency interaction with father; and lack of focus on the child.
Makes interagency and single agency recommendations covering midwife services, health visiting, GPs, social housing providers, children's services.
Anti-social behaviour, parenting capacity, substance misuse

January 2012 - Waltham Forest - Child B (overview report)
8 week old girl found dead in her cot in May 2011. Cause found to be dehydration due to gastroenteritis.
Maternal mental health, signs of neglect, non-attendance of appointments, mother was child in need, domestic abuse, disguised compliance, parental substance misuse.
Executive summary

This list was last updated: 20 February 2014

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