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Case reviews published in 2013

A chronological list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2013.


December 2013 - Derbyshire - BDS12
Death of a 2-year-old boy in March 2013 from cardiac arrest.
BDS swallowed his mother's methadone, which was in a child's beaker. Posthumous toxicology reports found traces of Class A drugs and alcohol in BDS' system, thought to have been directly ingested. Mother and father were convicted of manslaughter and received custodial sentences. Mother was also convicted of cruelty against a child under 16. Mother was a long-term substance misuser; she was on a methadone programme at the time of the incident and also using Class A drugs.
Issues identified include: overreliance by universal health services on specialist health professionals to inform them of child protection concerns; and lack of recognition of thresholds for referral to children's services.
Recommendations include: exploring the feasibility of drug-testing children who are the subject of child protection plans and whose parents are known substance users; and prescribing services consider the parenting capacity of non-drug abusing partners and ensure that they are seen alone and referred to support services if necessary.
Substance misuse, pre-birth risk assessments, unknown men

December 2013 - East Sussex - Child G
Abduction of a 15-year-old girl in 2012, by her teacher, Mr K. Child G was involved in a sexual relationship with Mr K, which began around her 15th birthday. Mr K was found guilty of abduction and admitted a number of charges of sexual activity with a child under 16-years; he received a custodial sentence of 5-and-a-half-years.
Identifies serious concerns relating to school's actions, including: failure to identify the abuse and exploitation of Child G; fixed thinking; failure to hear concerns raised by students; failure to involve Child G's mother; insufficient recognition of Mr K's inappropriate use of Twitter to communicate with Child G; and serious concerns with the ways in which information was recorded, stored, retrieved and provided for the review.
Identifies procedural failings in police handling of allegations relating to inappropriate images of Mr K on Child G's phone.
Makes various interagency and single agency recommendations covering: East Sussex Local Safeguarding Children Board, children's services, school and police services.
Grooming, social media, fixed thinking

December 2013 - Oxfordshire - Child Y
Death of a 22-month-old baby boy from a serious head injury in November 2010. Mother and father were arrested; father later pleaded guilty to child neglect and received a 15-month custodial sentence. Maternal history of: troubled upbringing; behavioural issues at school; alcohol and drug misuse; depression; housing and debt problems; and one known suicide attempt.
Issues identified include: missed opportunities for assessment; impact of emotional and mental ill health on parenting capacity; impact of persistent housing concerns and debt on mother's wellbeing; lack of professional curiosity and challenge; and allegations from mother deflecting agencies' attention away from children.
Makes various interagency and single agency recommendations covering health services, children's services and police.
Non-accidental head injuries, maternal depression, debt
Executive summary

December 2013 - Rochdale - Young People 1,2,3,4,5 and 6
Serious and prolonged sexual exploitation of 6 adolescent girls at the hands of a number of men, who subsequently received criminal convictions.
Issues identified include: frequent incidences of young people missing from home; recurrent attendances at A&E; optimistic thinking; unqualified staff; and inadequate supervision.
Contains multi-agency and single agency recommendations covering: placing young people at risk of sexual exploitation with specialist foster carers rather than semi-independent living accommodation; and having a twin safeguarding focus when working with teenage parents and their children.
Sexual exploitation, teenage parents, abusive men

December 2013 - Rochdale - Young Person 7
Serious and prolonged sexual exploitation of a young person who was looked after under section 20 of the Children Act 1989. The young person had severe learning difficulties.
Issues identified include: recurrent attendances at A&E; frequent periods of going missing from care; unqualified staff; and a lack of understanding about the complex relationships that sometimes exist between perpetrators of child sexual exploitation and their victims.
Contains multi-agency and single agency recommendations covering: decision-making in regard to specialist placements for young people with complex needs; reviewing escalation policies; and reviewing procedures to reinforce agencies' responsibilities around 16 and 17 year olds.
Sexual exploitation, looked after children, children with learning difficulties

December 2013Wakefield – Emma
Death of a 7-week-old baby girl in April 2012 from a serious head injury.
Father was sentenced to 8 years imprisonment for causing or allowing the death of a child. Emma was subject to a Child in Need plan following a pre-birth assessment. Father had significant learning difficulties and a considerable history of domestic abuse including convictions. Mother was understood to possibly have learning difficulties and was in contact with services regarding anger management.
Issues identified include: implications of learning difficulties on parenting capacity; and lack of professional curiosity in regards to father’s history. Frames key findings using the systems model developed by the Social Care Institute for Excellence (SCIE).
Makes recommendations covering: health services, Barnardo’s Young Families and the commissioning of adult services.
Domestic abuse, parents with a learning difficulty
Executive summary

December 2013Wolverhampton – Daniel Jones
Death of a 23-month-old boy in May 2012, as a result of ingesting heroin. Post mortem revealed evidence of regular exposure to heroin. Father was convicted of manslaughter and mother was convicted of causing or allowing the death of a child. Maternal history of drug and alcohol misuse and offending; she had one older child who did not live with the family. Paternal history of prolific offending and drug misuse. Both parents were known to addiction services, had separate key workers, were involved in a methadone programme and were known to have used heroin during Daniel’s life. Family was well known to children’s services.
Issues identified include: lack of focus on the child; professional optimism; insufficient management and supervision; insufficient information sharing; and working with resistance and avoidance.
Makes various inter-agency and single agency recommendations, covering: Wolverhampton Safeguarding Children Board, health services, children’s centres, GPs, police and drug and alcohol services.
Drug misuse, parents with a physical disability, professional optimism

November 2013 - Bradford - Hamzah Khan
Death of a 4-year-old boy in December 2009, as a result of chronic neglect; Hamzah's body was discovered by police during a search of the family home in September 2011. Mother was convicted of manslaughter and child cruelty in October 2013.
Maternal history of: chronic alcohol dependency; depression; social isolation; domestic abuse; and reluctance to engage with services, including registering children for health and education services. Father was made the subject of a non- molestation order in 2008 following an arrest for assault against mother.
Issues identified include: invisibility of children to education and health services; failure to take into account the impact on children of living with domestic abuse; absence of enquiry into the cultural and religious complexity of the family; insufficient significance given to disclosure by adolescents; lack of professional curiosity; insufficient interagency cooperation and lack of an overall picture of family life.
Sets out key findings using a systems model based typology developed by Social Care Institute for Excellence (SCIE) and raises issues for consideration in regards to identified themes for learning.
Neglect, alcohol misuse, social isolation
Executive summary

November 2013Isle of Wight – anonymised
Findings from an anonymised review into an incident found to have met the statutory requirements for a serious case review.
Generalised findings reflect those from an Ofsted inspection in November/December 2012, which found overall local child protection services to be inadequate. These include: focus on the parents’ needs over the child’s; insufficient supervision; inconsistent application of policies and procedures; professional optimism; poor quality assessments; and insufficient professional challenge.
Makes various recommendations, covering: Isle of Wight Safeguarding Children Board, children’s services, schools, The Children’s Society, GPs and Isle of Wight NHS Trust.
Reflective supervision, professional optimism

November 2013Rochdale – Adults A, B, C
Review into the serious, systematic sexual abuse of three adults, in the 1980s, Adults A, B and C by FABC. FABC was convicted of 23 offences and sentenced to 22 years imprisonment. FABC was well known to agencies and a number of child protection concerns had been raised during the time the abuse was occurring. All adults subsequently experienced significant difficulties, including substance misuse, mental health issues and offending.
Issues identified include: response to allegations, disclosures and indicators of abuse fell significantly short of good practice in contemporary terms; absence of professional concern when Child B became pregnant at 14-years-old; and failure of agencies who became aware of allegations against FABC to take action to protect other children within his family and the community.
Makes various single agency recommendations and multiagency challenges.
Adults sexually abused as children, abusive fathers

November 2013Rochdale – Child R and Q
Learning lessons review examining the circumstances in which serious indicators of child abuse were overlooked for siblings R and Q, born almost one year apart. Both children had the same undiagnosed neurological condition resulting in multiple physical and learning difficulties. Child R and Q received a high level of multiagency services in their early years. Child Q died of natural causes and Child R continued to receive multiple services over the following six years. Mother reported shaking Child R from the age of 3-months, which was initially understood to be the cause of his disability. This information was widely known to agencies but mother was permitted to continue caring for Child R and later Child Q without any assessment of the risk to the children. Professionals reported mother’s lack of understanding of and intolerance to the children’s disability.
Issues identified include: focus on the needs of the adult carers at the expense of the children; and need for greater understanding of indicators and conditions for harm of disabled children.
Makes various interagency and single agency recommendations.
Children with disabilities, physical abuse, teenage parents

November 2013 - Surrey - Child J and Child K
Death of Child J, aged 3-years and sibling, Child K, aged 2-years. Mother was convicted of murder. Child J and K were known only to universal services until 4 months before their deaths. Mother left father and moved to Surrey from East Sussex at which point Father reported concerns for the welfare of the children to police.
Issues identified include: allegations of domestic violence made by mother and accepted "at face value"; and concerns from Partner 1 and teacher of emotional abuse by Mother towards older children.
Identifies lessons emerging from the review, including: the potential impact of gender and class bias; the need to verify allegations of domestic violence in order to inform action; and challenges of identifying where parental separation is adversely affecting children. Makes various interagency and single agency recommendations.
Abusive mothers, parental separation

November 2013 – Wolverhampton – Child FJ
Death of an adolescent girl by hanging, in the early summer of 2011. FJ became known to agencies four months before her death when she disclosed a history of self-harming to mother and GP.
Issues identified include: inadequate exploration of FJ’s ‘inner world’; lack of professional challenge; and insufficient importance attached to FJ’s indications that she would self-harm if returned home and mother’s indications that she could not guarantee FJ’s safety.
Makes various interagency and single agency recommendations, covering: police, educational psychology services, leisure services, child and adolescent mental health services (CAMHS), children’s services, GP, community health and NHS services.
Suicide, self-harm
Executive summary

October 2013 - Birmingham - Keanu Williams
Death of a 2-year-old boy in January 2011 from multiple injuries, later determined to be the result of separate incidents with several major injuries being sustained over a period of days. Mother was convicted of Keanu's murder and of 'cruelty to a child' in respect of one his older half siblings; she was sentenced to 18 years imprisonment. Mother's partner was convicted of 'cruelty to a child' and received a 9 month suspended sentence.
Mother spent periods of time in foster care subject to care orders throughout her own childhood. Keanu's older siblings were subjects of residence orders to maternal grandfather. History of: frequent house moves and periods of homelessness and frequent changes in maternal relationships, including partners met over social networking sites.
Issues identified include: focus on the child; commitment to interagency child protection processes; and professional curiosity in relation to injuries.
Recommendations include: multi-agency audits to track records across agencies; critical review of the interagency protocol for child protection medical assessments; and procedures for managing internal and external professional disagreement and escalation, to ensure it does not delay service provision.
Transient families, physical abuse, unknown men

October 2013 - Hampshire - Child R and Child S
Death of two siblings in 2012 at their family home in Wiltshire. Cause of death is still to be determined but it is believed that father drugged then suffocated Child R and Child S before hanging himself. Family were well known to services and the children had spent time looked after by the local authority.
History of: parental substance misuse; domestic abuse; paternal convictions for violent offences and possession of illegal substances; and concerns regarding emotional abuse.
Issues identified include: destructive nature of the parents' relationship; insufficient multi-agency assessment and planning; failure to revise professional judgments and evidence of 'rigid' thinking; and lack of clarity and confidence among professionals in the use of legal processes to protect the children.
Recommendations include: review of management and supervision processes across agencies, to ensure that fixed thinking by professionals is identified and challenged; and evaluation of frontline professionals' communication with children to ensure a balance between responding to children's wishes and ensuring that their needs are met.
Substance misuse, offenders, domestic abuse

October 2013 - Isle of Wight - Baby T
Serious injury of a 3-month-old baby boy in July 2012, thought to be caused by shaking. At the time of the incident, baby T was living with his mother, his sister, S, and S's father. Baby T had been looked after by 4 people shortly before he was injured. Mother and S's father were arrested but criminal charges were not pursued to trial as it could not be identified when T's injuries occurred.
Maternal history of: mental illness; substance misuse; domestic abuse; child abuse; homelessness; and reported miscarriages and a stillbirth following being kicked in the stomach when 13-years-old.
Issues identified include: lack of professional curiosity and insufficient examination of parents' histories; inappropriate use of thresholds; and overreliance on less qualified staff playing the role of lead professional in Common Assessment Framework (CAF) cases.
Recommendations are organised into four headings covering: practice, process, management oversight and organisational culture.
Non-accidental head injuries, domestic abuse, unknown men

October 2013 - Kingston - Tom and Vic
Serious, life-threatening injuries to two young men in 2012. The incident involved a third person; all three individuals were considered suspects and arrested. Tom and Vic pleaded guilty in 2012. Both were well known to agencies, had histories of periods of going missing and substance misuse, convictions for criminal behaviour and experienced placements in secure accommodation. Tom was looked after by the local authority at the time of the incident and had been absent from formal education for over a year.
Issues identified include: agency focus on procedures not outcomes; insufficient direct work with young people; slow pace of service delivery; insufficient consideration of adolescents who offend in groups.
Recommendations include: a holistic package of intervention and support to ensure young people involved in criminal activity access education; children’s social care to prioritise improved understanding of related issues including racial harassment, gangs, possessing weapons, and anti-social behaviour.
Young offenders, gangs, education
Executive summary

October 2013 - Southampton - Child G
Death of a 3-month-old baby boy (Child G) and injury of his twin brother (Child H), in September 2011. History of maternal depression and incidents of maternal and paternal self-harm. Father had been convicted of child cruelty against one of his children from a previous relationship and served a 12 month prison sentence when living in a different local authority and before meeting mother. Following the death of Child G, Child H was placed in the care of the local authority and mother and father were arrested.
Issues identified include: lack of robust enquiry into the background of father or his role with the children; inaccurate record keeping/information sharing in regards to fathers convictions; need for exploring potential risk factors associated with maternal mental health during the ante natal and post natal period.
Recommendations include: review of national systems for monitoring individuals who have offended against children; and review of local outcomes from the implementation of action plans from previous local serious case reviews in respect to engagement with fathers and the transfer of GP records.
Physical abuse, offenders, abusive fathers
Executive summary

October 2013 - Wiltshire - Child H
Serious injury of a 5-month-old baby boy in December 2011. Injuries are likely to impact on Child H's long term development. Medical report concluded that Child H was subjected to an escalating pattern of physical abuse thought to have occurred within 10 days of the incident. Mother and father were both arrested on suspicion of causing grievous bodily harm; neither were ultimately prosecuted due to insufficient evidence.
History of: paternal and maternal excessive drinking; conflict in the parental relationship; father's previous prison sentence for violent assault; and regular admittance of Child H to hospital.
Issues identified include: irregularity in Child H's care; insufficient attention paid to the impact of parents' backgrounds on their parenting capacity; and lack of attention paid to issues of racial and cultural identity.
Makes various interagency and single agency recommendations.
Physical abuse, teenage pregnancy, culture

October 2013 - York - Baby A
Death of a 20-week-old baby from a brain injury thought to be non-accidental. Mother and her then partner were arrested on suspicion of murder and causing or allowing the death of a child. Baby A was known to children's services and a pre- birth core assessment was commenced when Mother was 12 weeks pregnant.
Issues identified include: insufficient significance given to request from Mother not to pass information regarding Baby A's weight loss to children's services; lack of attention paid to mother-baby attachment in hospital's medical model of care following Baby A's premature birth; and reluctance among nursing staff to record observations about a parent, which may be considered judgemental rather than a record of professional judgment.
Makes various interagency and single agency recommendations.
Non-accidental head injuries, shaking, unknown men
Executive summary

October 2013 - York - Child B
Sexual exploitation of an adolescent girl. Child B was known to a range of agencies and she was being managed as a child in need of support.
Issues identified include: insufficient exploration of Child B's expressed fears leading to missed opportunities for assessment; failure to escalate case to a child protection level despite a number of referrals from different sources; insufficient knowledge of local child sexual exploitation procedures within relevant organisations; lack of significance given to high risk sexual behaviours; and ineffective use of safeguarding leads as a source of advice and support.
Identifies learning that has been implemented in response to Child B's case.
Makes various interagency and single agency recommendations covering: children's services, police, education, child and adolescent mental health services, hospitals and GP services.
Child sexual exploitation, risk
Executive summary

September 2013 - Bath and North East Somerset – David A
Suicide of an adolescent boy in October 2012.
David A had a history of suicide ideation and self-harm, thought by professionals to be largely related to parental conflict. In 2009 David A became the subject of a child protection plan under the category of neglect and his sister became categorised as a child in need. Family received a wide range of services, including: child and adolescent mental health services (CAMHS), school counselling, family therapy, couple counselling, alcohol support services and parenting education.
Issues identified include: focus of work on parents’ relationship at the exclusion of work with David A; provision of services on a basis of availability; failure to understand the impact of mother’s alcohol misuse; and child protection meetings held in office hours inhibiting father’s ability to participate.
Makes recommendations, including: need for flexibility in arranging child protection meetings to support the involvement of working parents and other relevant professionals.
Suicide, family conflict, alcohol misuse

September 2013 - Bolton - Child 1
Death of a baby as a result of a traumatic head injury. Mother had limited leave to remain in the UK following her marriage to father. Father had some learning difficulties, which was not known to mother before the marriage. Prior to Child 1s birth mother, father and Child 2 lived with father's extended family. After moving to their own accommodation mother and father reported that paternal grandfather was physically abusive and controlling. Mother had previously disclosed domestic abuse and unhappiness with father to her GP.
Identifies lessons learned, including: significance of mother's vulnerabilities in relation to her arranged marriage, father's learning difficulties, her social isolation and her immigration status.
Makes recommendations covering children's services, GPs, housing, hospital and ambulance services.
Non-accidental head injuries, adults with learning difficulties
Executive summary

September 2013 - Coventry - Daniel Pelka
Death of 4 year old boy on 3 March 2012 as the result of an acute subdural haematoma. Daniel's mother and step father were convicted of murder in August 2013 and sentenced to 30 years' imprisonment. For a period of at least six months prior to his death, Daniel had been starved, assaulted, neglected and abused.
History of incidents of serious domestic abuse and violence, chaotic lifestyle with multiple house moves and alcohol misuse by mother and various partners.
Issues identified include: deception of agencies and services by mother; impact of witnessing violence on children; impact of culture, race and language; and Daniel's isolation and 'invisibility'.
Recommendations include: review of information sharing and notification systems in respect of domestic abuse; ensuring a robust system for recording injuries or welfare concerns by school staff; and guaranteeing health professionals consider child abuse as a differential diagnosis, when assessing the welfare of children who present with unclear concerns.
Child abuse, domestic abuse, alcohol misuse

September 2013 - Glasgow - D
Review into the services received by a 13 year-old boy, who was detained by police in June 2011, after stabbing his foster carer. Mrs L died the following day and D was charged with murder. He was sentenced to 7-years detention in August 2012 after accepting a plea of culpable homicide. No previous history of violent or aggressive behaviour.
Issues identified include: under-estimation of the impacts of early trauma and over-estimation of resilience.
Recommendations include: embedding inter- and single-agency chronologies and case histories in policy and practice; review of interagency guidance for working with hostile and uncooperative families; multi-agency review of practices so that staff are alert to potential risks when a child’s behaviour is not in keeping with their experiences; and review of the management of contact in the context of children’s access to social networking sites.
Homicide, trauma, children in care

September 2013 - Haringey - Child T
Review into agency contact with Child T and his family between 2010 and 2011. Child T was admitted to hospital with injuries thought to be non-accidental twice during this period and the family had contact with a number of agencies including children’s services, health services, drug and alcohol services and police. Mr C was sentenced to 4 years in prison for “wilfully assaulting a young person under the age of 16”, Ms B and MGM are believed to have returned to Poland. Full care orders were made in respect of Child T and his siblings in 2012.
Issues identified include: organisational confusion; language and communication problems with Ms B and children; a hurried and non-analytical approach to assessment; and a failure to listen to the voice of the child.
Summarises changes to the management and delivery of services of individual agencies made since the incidents described in the review occurred.
Physical abuse, substance misuse, language barrier

September 2013Rochdale – Baby F
Death of a 3-month-old baby boy, presented to hospital unconscious and not breathing, in January 2013. Baby F’s father was arrested on suspicion of murder and bailed without charge. Baby F’s parents were both Polish and had been living in the United Kingdom for 6 years.
Issues/lessons identified include: access to interpreter services and the impact on communication between parents and services; difference in cultural approaches to possible non-accidental injuries between hospital and police staff; the inability of professionals to identify when a strategy meeting is required; and where opinion of cause of injury is unknown or conflicting, professionals should proceed as if injuries are inflicted.
Makes various interagency and single agency recommendations, covering children’s services and health services.
Physical abuse, interpreters, language

August 2013 - Brent - Child H
Death of a 13-year-old boy by hanging in April 2011. Child H was in residential care at the time of his death and had been known to various agencies, including police and children's services since 2008. Child H came to the UK from Africa in 2006 and was granted asylum with his mother and other family members.
History of childhood trauma, truancy and school expulsion, violent and aggressive behaviour, youth offending and gang involvement.
Recommendations include: strengthening 'culturally competent' practice; developing a strategy for working with children affected by gangs; and improving agency collaboration to meet the educational needs of vulnerable and looked after children.
Gangs, looked after children, suicide, out of area placements
Executive summary

August 2013 - Birmingham - Case No.2010-11/3
Serious sexual assault of a toddler, Subject Child, by an early years student and staff member, the Perpetrator, at a nursery in Birmingham in 2010. Knowledge of the incident came to light following an accusation by a 13-year-old girl of online grooming in January 2011. Examination of the Perpetrator's computer revealed a number of child abuse images, including videos of the assault against Subject Child.
Issues identified include: recruitment and screening procedures; staff supervision; organisational safeguarding practices and policies; management and team culture; inspection and complaints procedures; and early identification on online sex offenders by police.
Recommendations include: effective recruitment processes that explore motivation and value base; balancing physical environments in nursery settings between a respect for privacy and reducing opportunities to abuse; rigorous inspections of early years settings that examine the implementation of safeguarding policies and procedures; and effective communication across the three relevant arms of the Local Authority: Early Years, Local Authority Designated Officer and Children's Social Care.
Nurseries, child sexual abuse, staff supervision, organisational safeguarding procedures

August 2013 - Essex - Olivia
Death of a 2-year-old girl in June 2011, as the result of a gunshot wound. Olivia's father shot Olivia and her mother, who also died, before shooting and injuring himself. Father was found guilty of both murders in May 2012 and received a whole life sentence.
Significant history of domestic abuse involving considerable contact with police. Parents were undergoing an acrimonious separation and custody dispute at the time of the incident and mother was awarded a non-molestation order two months prior to the incident.
Issues identified include: lack of focus on the needs of the children; failure of systems and professionals to find a way to assist mother and children in communicating the full extent of abuse that they were suffering; and lack of agency engagement with father.
Makes various interagency and single agency recommendations covering: children's services, police, family courts and Cafcass.
Domestic abuse, information sharing

August 2013 - Tower Hamlets - Child F
Death of an adolescent boy by hanging in January 2012, whilst in a Young Offenders Institution. Child F suffered significant childhood neglect and abuse and was placed in foster care from 2002 until October 2011 when he was sentenced to a 10 month Detention and Training Order.
Issues identified include: the impact of early childhood abuse and neglect; therapeutic support offered following sexual abuse; foster parent support services; and local authority provisions made in relation to racial identity and ethnicity.
Makes various local- and national-level recommendations aimed at: children's services, education services, health services, child and adolescent mental health services, prison and probation services and police.
Child sexual abuse, children in care, young offenders, suicide
Executive summary

July 2013 - Knowsley - Child A
Death of an 11-year-old boy in 2009; coroner recorded a verdict of death by misadventure. Child A exhibited challenging behaviour and risk of injury to himself at a young age and was permanently excluded from school at 8-years-old. Child A had been living at the same out-of-area residential school for over two years.
Information received by the Review Panel resulted in the Panel considering additional terms of reference in the review. This included historical information form investigations into Child A's school (School 1) and another school (School 12).
Issues identified include: insufficient efforts to find suitable foster carers and local education based on assessment needs; and insufficient focus on the application of restraint as a behaviour management technique.
Includes individual agency action plans based on recommendations from individual management reviews, covering: children's and adult's social care, education and health services, youth offending services, police, Ofsted, residential School 1 and Cafcass.
Challenging behaviour, children in care
Executive summary

July 2013 - Lancashire - Baby E
Death of a 4-month-old baby boy from a serious head injury in December 2011. Both parents had been looked after as children, had experienced childhood abuse and were chronic substance users.
History of prolific paternal offending including convictions for actual bodily harm, harassment and threatening behaviour.
Identifies themes for learning including: establishing a professional lead in multi-agency processes; acquiring comprehensive social histories from parents; recognising unemployment and poverty as risk factors; recognising disguised compliance and maintaining a sufficient level of professional scepticism; impact of coercive relationships on vulnerable women; and engaging with men and fathers. Sets out key findings using a systems based typology developed by SCIE and raises issues for consideration in regards to the identified themes for learning. Includes Lancashire Safeguarding Children Board's response to findings.
Substance misuse, parental mental health problems, domestic abuse

July 2013 - Lancashire - Baby H
Death of a 4-month-old baby boy from a serious head injury in November 2010. Baby H died three days after presenting to hospital in cardiac arrest. Issues include: significance of mother's young age on parenting capacity not recognised by agencies; lack of agency engagement with and knowledge of mother's partner; and lack of professional scepticism.
Identifies themes for learning including: training for medical professionals to recognise indicators of unusual or abusive injuries; and importance of acquiring comprehensive social and family histories.
Makes various interagency and single agency recommendations covering children's services, health services and open access organisations including Children's Centres.
Physical abuse, teenage parents, professional scepticism

July 2013 - Lancashire - Child K
Death of a 3-year-old girl in August 2012, from internal bruising to the abdomen as a result of blunt force trauma. Post mortem revealed evidence of older injuries. Father pleaded guilty to manslaughter and mother was convicted on a charge of child cruelty. Paternal history of: time spent looked after by the local authority; frequent use of cannabis; and having his first child placed for adoption. Father was known to criminal justice agencies and had spent time in prison for burglary and an offence of having sex with a girl under the age of legal consent.
Key themes include: importance of enquiring into parents' history and how this might impact on parenting capacity; addressing professional optimism and lack of professional curiosity; addressing the needs of children who have a parent in prison; and increased and more consistent use of risk assessment tools and frameworks.
Physical abuse, children of prisoners, professional optimism

July 2013 - Northamptonshire - Maisie Harrison
Death of a 4-week-old baby girl on 4th May 2012, found in her parents' bed with blood around her nose and mouth. Cause of death is unknown but co-sleeping is thought to be a contributory factor. Maisie was subject to a child protection plan under the category of neglect.
Maternal history of: alcohol abuse; learning difficulties; sexual relationships with older men; homelessness; and domestic abuse. Father had a previous conviction for grievous bodily harm to a child, after causing serious internal injuries to his 6- year-old step son.
Lessons identified include: unannounced visits should be carried out where there is a long history of parental difficulties; and universal services should appropriately identify safeguarding concerns which may have implications on a young person's future parenting capacity.
Recommendations include: child protection cases involving adults who pose a known risk to children need a specific procedure; and SMART child protection plans should be defined and training provided to Child Protection Chairs.
Neglect, co-sleeping, substance misuse
Executive summary

July 2013Stockport – Olivia
Review undertaken using a systems methodology, examining the experiences of Olivia, for whom children’s services received 10 referrals between 2003 and 2010. Olivia was identified as part of Operation Windermere, a specialist joint investigation into child sexual exploitation (CSE) in 2011.
There was no obligation to conduct a serious case review; Stockport Safeguarding Children Board chose to review Olivia’s case to identify learning for the agencies involved.
History of: periods of time missing from home, homelessness, disengagement with people and services and chaotic and risky behaviour.
Key themes identified include: the non-availability of child and adolescent mental health services (CAMHS); insufficient assessment of family functioning; inadequate response to indicators of CSE; and focus of interventions on stabilising Olivia’s behaviour rather than CSE concerns.
Identifies learning achieved as a result of the review, the most pressing issues in working with children at risk of CSE and future developments in Stockport’s response to CSE.
Child sexual exploitation, systems methodology

July 2013 - Sutton - Child B
Death of an adolescent boy in December 2012, by hanging. Child B was well known to a number of agencies and was in contact with child and adolescent mental health services (CAMHS) from the age of 9. History of self-harm, domestic abuse and maternal physical ill health. Child B's girlfriend was pregnant with his child at the time of his death.
Issues identified include: lack of focus on the voice of the child; ineffective supervision and management oversight; and insufficient recognition of the impact of witnessing domestic abuse.
Recommendations include: a risk assessment tool for CAMHS to establish when self-harm should be consider grounds for an S47 investigation; and improving the cross referencing of risk factors for safeguarding across family members' notes in GP services.
Self-harm, suicide, domestic abuse
Executive summary

June 2013 - Family W (LSCB is not identified to protect the anonymity of the children)
Review into the circumstances of mother M and the "adoption" of four children, A, B, C and D, over the course of 16 years. A, B, C and D were brought into the care of the local authority following the birth of child D. Child D was conceived, following repeated attempts at artificial insemination of child A, at M's direction, over a period of two years. The family was known to a wide range of agencies.
Issues identified include: an illegal adoption; the neglect, emotional abuse and social isolation of the adopted children; the physical abuse of the youngest child; the children's home schooling to avoid scrutiny of their care.
Recommendations include: ensuring that multi-agency guidance on the safeguarding of children who are electively home educated is informed by the findings of the review; LSCBs should remind General Practitioners of the potential safeguarding implications of miscarriages in girls under the age of 16.
Emotional abuse, physical abuse, inter-country adoption
Executive summary

June 2013 - Lincolnshire – Family T/S
Serious injuries of C6, a 7-week-old baby girl, admitted to hospital with a serious head injury on 8th May 2011 and C5, her twin brother, who was subsequently found to have a healing fracture to the left clavicle. Both children were subjects of Child Protection Plans at the time of the incident.
History of maternal mental ill health, domestic abuse and previous conviction of the Mother for wilful neglect and Grievous Bodily Harm. Mother had 4 other children, all of whom had been removed from her care.
Lessons to be learnt include: the need for prompt collation and assessment of evidence so that decisive action to protect children can be taken as early as possible; and child protection plan visits should focus as much on practical parenting assistance as on monitoring.
Physical abuse, serious head injuries, abusive mothers
Executive summary

May 2013Gateshead – Baby A
Death of a 10-week-old baby boy in March 2011, as the result of a severe blow to the head.
Further examination revealed older injuries to Baby A. Mother’s partner, Mr C, was found guilty of murder and mother was found guilty of causing or allowing the death of a child. Maternal grandmother was 16-years-old when mother was born and mother was 18-years-old when Baby A was born. Mother separated from Baby A’s father before Baby A’s birth and reported that the relationship had been abusive.
Issues identified include: mother’s vulnerability; mother, father and Mr C’s involvement with children’s services as children; Mr C’s abuse of a family pet as a child and “thoughts of doing bad things to his sister”; and Baby A’s presentation at GP service with bruising for which mother gave inconsistent explanations.
Identifies a lack of professionals’ knowledge around services and guidance available to them. Shaking, adults neglected as children
Additional Overview report
Executive summary

May 2013Kent – Daniel
Death of a 14-year-old boy in November 2009. Family was well-known to agencies and Daniel and his parents had made several requests to children’s services that he be accommodated by the local authority.
Includes a collated, chronological list of risk factors to demonstrate how much information was known to agencies about the risks Daniel was exposed to, including: underage sexual relationships; periods of going missing; difficulties in parent- child relationships; drug and alcohol misuse; self-harm; poor school attendance; overdose and suicidal thoughts; offending; significant sexual experimentation; and possible sexual exploitation.
Issues identified include: shared view among professionals that a child could not be suffering significant harm unless that harm was attributable to their parents; shared view among children’s services workers that it was the parent’s responsibility to manage the risk; and insufficient professional challenge of children’s services.
Makes various interagency and single agency recommendations.
Adolescents, sexual behaviour, drug use

May 2013 - Medway - Callum
Death of a 17-year-old boy, last seen alive in January 2012. Callum's body was found in a river in March 2012. It is not known for certain when or how Callum died however evidence points toward suicide.
History of school exclusions, substance misuse, running away, unstable living arrangements, mental health problems, self-harm and suicidal threats and gestures.
Recommendations include: review of local arrangements for administering Severe Hardship Payments; review of arrangements for Joint Housing Assessments of vulnerable young people; improved responses to self-harm; increased use of the Common Assessment Framework and other joint assessment arrangements in work with adolescents.
Substance misuse, running away, suicide
Executive summary

May 2013 -Bournemouth and Poole - Baby J
Death of a 5-month-old baby boy on 19 September 2012, of natural causes. Baby J's mother was found to have consumed significant amounts of alcohol and to be co-sleeping on the sofa with Baby J at the time of his death. The family were known to children's services and there was a history of domestic abuse, maternal risk-taking and criminal behaviour in adolescence.
Makes recommendations including: multi-agency assessment and planning is essential for working effectively with adolescents with complex needs; assessments of parenting capacity should take parental history into account; and the role of fathers should be taken into account during assessments.
Sudden infant death, co-sleeping

May 2013 - Buckinghamshire - Baby C
Death of a baby boy in October 2011, from a head injury thought to have been caused by shaking. Post mortem revealed additional fractures, which occurred approximately two weeks before Baby C's death. Parents were questioned by police at the time of Baby C's death and a criminal investigation and care proceedings in relation to Baby C's siblings were underway at the time review was published.
History of: maternal depression and panic attacks; maternal cardiac condition; family homelessness and house moves; and claims of racial harassment from neighbours.
Issues identified include: Baby C's slow weight gain; withdrawal of family contact with professionals, now known to have been around the time at which Baby C suffered injuries; and mother's tendency to exaggerate accounts of her circumstances and difficulties faced by the family.
Recommendations include: arrangements for identification and review of vulnerable families in GP surgeries; promotion of better liaison and information sharing between health visitors, GPs and antenatal services; and development of a consistent national approach to the recording of responses to confidential questioning during pregnancy about domestic abuse.
Non-accidental head injuries, shaking
Executive summary

May 2013 - Knowsley - Child J
Death of a baby boy in 2010. Child J was found dead after falling asleep on his parent's chest in a warm room where both parents had been drinking and had smoked cannabis.
Maternal history of domestic abuse and extensive history of parental substance misuse. Child J's older half siblings were in the care of mother's family members and Child J's younger half siblings were subject to child protection plans.
Lessons identified include: unborn children should be treated as born children for the purpose of safeguarding; agencies should establish factual information rather than relying on self-reporting; and GP practices should understand the importance of GP records as a source where patients' history accumulates.
Makes various interagency and single agency recommendations.
Substance misuse, unknown men, co-sleeping
Executive summary

May 2013 - Surrey - Children U and V
Death of a 7-year-old boy (Child U) and his 6-year-old (Child V) sister on 30 September 2012. Children were found on a bridleway with their Father who was also deceased. Police evidence later revealed that Father stabbed both children before taking his own life. Mother had disclosed domestic abuse (verbal/emotional) to GP in October 2011 and had reported deterioration in the marriage in the months preceding the incident. Mother left father following what she claimed was a first instance of physical abuse several weeks prior to the incident. A contact agreement had been reached and it was during a contact visit that the incident took place.
Lessons learned, include: domestic abuse is a child protection issue; children should be actively spoken to, engaged with and observed by professionals; and violent acts that lead to the death of children can occur without any prior indication.
Makes various single agency and multiagency recommendations for: children's services, health services, police and education services.
Suicide, filicide

April 2013 - Barnsely - Child L
Death of a 5-week-old baby girl in February 2011, from a non-accidental head injury. Child L and her family were only known to universal services. Father was arrested and charged with murder and Section 18 Wounding Offences Against the Person Act 1861 in connection with fractured ribs, which occurred 7-10 days prior to Child L's death. Mother was charged with attempting to pervert the course of justice.
Review concludes that Child L's death could not have been prevented however it recognises a failure of professionals to take a full history from father or to record whether or not he was present at appointments.
Makes various interagency and single agency recommendations covering Barnsley Safeguarding Children Board, midwifery and other health services.
Fathers, non-accidental head injuries, physical abuse
Executive summary

April 2013 – Bridgend – Family T
Review into multiple sexual offences committed by an adult male against female children in his family between 1984 and 2009. In 2001, following the perpetrator's approval as a foster carer, his adult daughter reported his abuse to agencies in Hereford at which point he was de-registered. Perpetrator continued to abuse children in his family until 2009 and, in 2011 was convicted of gross indecency, indecent assaults, and sexual assaults and sentenced to 10 years imprisonment and a Sexual Offences Prevention Order with Unlimited Conditions.
Makes recommendations for Fostering Panel's functions in considering applications for registration and de-registration of foster carers and greater training and awareness raising of the legal and professional responsibilities for staff appointed to Multi-agency Panels.
Child sexual abuse, interagency cooperation, foster care
Executive summary

March 2013Wakefield – Christine
Death of Christine, a 17-year-old girl on 12th March 2012, at the hand of her sister's ex-boyfriend, Michael. A friend of Christine was also murdered and her sister kidnapped, Michael tried to flee the country but was caught and arrested; he has been sentenced to serve a minimum of 34 years. Christine had been known to children's services since 2007 and was living in supported independent living at the time of her death.
History of: challenging and risk-taking behaviour; drug and alcohol use; going missing from home; suspected child sexual exploitation (CSE) by older men; and disclosures of domestic abuse made against an ex-boyfriend.
Recommendations include: activities to raise awareness of CSE risks to young people, particularly those over the age of consent; and an action plan for addressing domestic abuse between young people.
Children in care, substance misuse, domestic abuse, child sexual exploitation
Executive summary

February 2013 – Isle of Wight – Child D
Serious injury of a 12-week-old baby girl in December 2008. Child D was presented to hospital by her mother, following the identification of unexplained bruising by her GP. Child D was found to have 16 separate fractures thought to have been up to 4 weeks old. No individual has been convicted of causing the injuries, though medical evidence has shown them to be non-accidental.
Identifies lessons for learning, including: assessment of pregnant teenagers must take account of their family background; the requirements of parenting support for both mothers and fathers must be considered; and incidents of domestic abuse where a young child is resident at the address should be investigated even if the child is not present.
Makes various recommendations covering: children’s social care, Isle of Wight Safeguarding Children Board, education services, police, GP, paediatricians, maternity services and health visitors.
Teenage parents, physical abuse, fractures
Executive summary

February 2013Manchester – Child U
Death of a 4 year old girl in September 2011 who was subject to a child protection plan. Mother pleaded guilty to manslaughter on the grounds of diminished responsibility and was detained in a secure mental health facility.
History of inappropriate sexual behaviour by mother towards her daughter and parental mental health issues.
Makes interagency and various single agency recommendations covering children’s social care, police, GP and NHS Trusts (including mental health) and housing.
Mentally ill parents, Substance misuse, Child sexual abuse, Hostile behaviour
Executive summary

February 2013 - Oxford – Infant W
Serious injury of a baby girl in February 2010, consistent with her having been shaken. Father was convicted of grievous bodily harm with intent and both parents were convicted of child cruelty. At the time of the incident Infant W was the subject of a Child Protection Plan. Mother had been a looked after child from her early teenage years. Father was well known to a number of agencies in connection with abuse and neglect within his family, a problematic education, youth offending and homelessness.
Identifies lessons for learning, including: blurring of professional boundaries in respect to working simultaneously in the best interests of the mother as a looked after child and Infant W; support provision for teenage parents; the role of fathers; and professional knowledge of legislation and powers.
Makes various recommendations covering: children’s social care, Oxfordshire Safeguarding Children Board and Oxfordshire Health and Wellbeing Board.
Shaking, teenage parents, fathers
Executive summary

February 2013 - Stoke-on-Trent - Case No.SOT12(1)
Death of a pre-school aged child in January 2012. Mother's partner was arrested and charged with murder; he initially indicated a plea of not guilty but later changed this to guilty and received a life sentence. When first born, Child lived with mother, father and three elder half siblings. Father was physically abusive and controlling towards mother, misused alcohol, was described as a strict parent and verbally abusive toward one of the subject child's siblings. Children witnessed significant domestic violence and experienced multiple moves before father was convicted of assault against mother and mother and children moved permanently.
Maternal history of: previous abusive relationships, conviction for benefit fraud, debt and concerns over hygiene levels in relation to the children.
Issues identified include: lack of professional curiosity; lack of focus on the children during domestic abuse risk assessments; lack of assessment of mother's ability to protect and care for her children; and insufficient information sharing between agencies across local authority boundaries.
Makes various interagency and single agency recommendations.
Domestic abuse, unknown men, abusive men

February 2013 – Torbay – Case 26
Review into the sexual abuse/exploitation of a number of girls by a small number of young men between 2006 and 2011. Abuse was facilitated by the supply of drugs and alcohol and there is no clear evidence that the abuse was highly organised or that the girls were being introduced to prostitution.
Makes recommendations for identifying whether Fraser guidelines and Gillick competences are being used appropriately to protect vulnerable girls from sexual exploitation.
Sexual exploitation, substance misuse, children in care
Executive summary

January 2013 – Cardiff – Yaseen Ali
Death of a 7 year old Asian Muslim boy in July 2010 as a result of complications from blunt force trauma as inflicted by his mother.
History of domestic violence but no recent reports of violence or contact with specialist services.
Makes recommendations for designated safeguarding staff in schools, children's social care and domestic abuse services.
Physical abuse, domestic abuse
Executive summary

January 2013 - Conwy and Denbighshire - 1/2013
Death of a young person from an overdose of prescription medication, thought to be suicide. History of truancy and bullying, parental mental health problems and suicidal ideation. The young person was on a Child in Need plan and a professionals’ meeting was due to take place at the time of their death. Review undertaken using the pilot Child Practice Review methodology.
Identifies a number of learning points including: need for access to comprehensive family histories; and emphasis on the assessment of parenting capacity.
Recommendations include: considering the possibility of a single electronic health record for children; and strengthening arrangements for interagency cooperation and information sharing.
Suicide, parental mental health problems, bullying
Concise review

January 2013 - Rhondda Cynon Taf - 1 / 2011
Death of an infant under 3-months-old from a serious head injury. Family was known only to universal services until the time of the incident. Review undertaken using the pilot Child Practice Review methodology.
Identifies a number of learning points including: the importance of not stereotyping families and remaining mindful of the potential for abuse; and ensuring that a full and comprehensive history is gathered about a child on admission to hospital.
Recommendations include: information collected in the national midwifery record should capture the nature of the relationship between mother and partner, including how long they have been together; and the value of inviting paramedics to strategy and child protection meetings should be reviewed.
Non-accidental head injuries, professional scepticism
Concise review

January 2013West Sussex – Child G
Death of a 10 month old baby from a non-accidental head injury. The mother’s boyfriend was convicted of manslaughter. Mother was 16 and living in a hostel and Child G was the subject of a child in need plan. Considers issues around supporting young mothers and assessing the needs of the mother and the baby; disguised compliance; neglect; parenting capacity; assessing unknown men in the family; optimistic thinking; failure to take up support services offered; adolescent behaviour; substance misuse; capacity to challenge families and professional colleagues.
Teenage parents, homeless teenagers, disguised compliance
Executive summary

January 2013Wirral – Child G
Death of a 17-year-old girl in May 2012, by strangulation. Her boyfriend at the time of her death was charged with her murder. Child G had learning difficulties, ADHD and behavioural problems and had been the subject of a child protection plan for neglect when she was younger. She was living independently in specialist accommodation at the time of her death.
Makes recommendations for developing professional understanding of the effects on child development and social presentation of moderate learning difficulties; working with young people who are sexually active from a young age; and, safeguarding young people who are 16 and 17 years old.
Children with learning difficulties, ADHD, runaway adolescents

January 2013 – Worcestershire – FW
Death of a baby from cardiac arrest. FW was found not breathing by the parents who called an ambulance. FW had been co sleeping with the parents, who had both consumed alcohol and cannabis, prior to the ambulance being called. A criminal investigation was conducted but a cause of death could not be ascertained. Family was known to a wide range of agencies and there was a history of maternal mental ill health and suicidal thoughts and parental alcohol and drug misuse.
Makes multi-agency recommendations for training on drug and alcohol risk assessment, information sharing practices and interagency procedures to ensure the role of fathers and male partners is systematically assessed.
Substance misuse, parental mental health, co-sleeping
Executive summary

2013 – Bridgend – Child P
Death of a 16-year-old girl in Spring 2010, as a result of an overdose of drugs.
History of domestic abuse, family drug and alcohol misuse and evidence of sexual exploitation. Child P was living with a man in his late twenties at the time of her death, who was known to misuse substances.
Makes recommendations for training in safeguarding practice and skills required when working with adolescent children; the importance of listening to the wishes and feelings of the child in reaching judgments; and, understanding sexual activity by adults involving children as abusive and not the responsibility of the child.
Drugs and alcohol, domestic abuse, sexual exploitation
Executive summary

2013Somerset – Baby A and Baby B
Serious injury of six-and-a-half-week-old twin babies, who were admitted to Somerset hospital and found to have serious head injuries and body bruising. Babies’ father was convicted of unlawfully and maliciously inflicting grievous bodily harm and received a sentence of 45 months’ imprisonment.
History of paternal mental illness and violent offences, domestic violence and unsettled living arrangements.
Makes recommendations for reviewing pre-birth assessment guidance to ensure the specific risks of multiple births are considered; multi-agency training focusing on the importance of cumulative histories in analysing risk when working with mobile families; and raising with central government the issue of rights of the unborn child.
Domestic abuse, transient families, pre-birth assessments
Executive summary

This list was last updated: 27 June 2014

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