Case reviews Case reviews published in 2014

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 2014. To find other case reviews search the national repository.

December 2014 – Blackpool - Child BR
Death of a 15-year-old in early 2014, as a result of complications caused by a chronic health condition.
Background: Child BR was receiving care from a tertiary health centre, geographically remote from their home town. Child BR was made subject to a Child Protection plan on the grounds that Child BR was resisting medical intervention, concerns of parental neglect and parental inability to endorse attendance at medical appointments. Parents had agreed to a bespoke residential plan to improve Child BR’s access to health care; Child BR died before the plan could be implemented.
Learning: scope for exploring joint working practices between tertiary and primary health services, including the role of the GP as the repository of all health information; when brief interventions are successful ways to maintain them should be explored; and commissioners of specialist health services should consider prompt access to psychological services for children and young people with chronic conditions.
Model: review was undertaken using the Welsh Child Practice Review model.
Keywords: children with chronic illnesses, health services
Read the overview report

December 2014NSPCC on behalf of unnamed LSCB - Child C
Serious sexual abuse of a 5-year-old girl.
Background: Child C’s second cousin, OF, pleaded guilty to charges including rape of a female child under 13-years-old and was sentenced to 13 years imprisonment in January 2014. Child C had previously been subject to a Child Protection plan under the category of sexual abuse in relation to an identified risk posed by her paternal step-grandfather and paternal great-uncle, both convicted sex offenders.
Key issues: extensive and complicated family networks of Child C’s parents; frequent moves between local authorities; use of private landlords for accommodation removing the involvement of housing professionals, making usual organisational contact more difficult; plans focusing on risk of sexual abuse despite significant evidence of neglect; and lack of apparent safeguarding oversight in out of hours service.
Learning: need for agencies to be sure that parents are able to fully understand what is being asked of them; and a need for healthy professional curiosity and challenge.
Model: review was undertaken using the Significant Incident Learning Process (SILP).
Keywords: sexual abuse, professional challenge
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December 2014 - Tameside – Child H
Non-accidental head injury of a 2-year-old, Asian Muslim child in June 2013. Mother was convicted of Child Cruelty and sentenced to 20-months imprisonment.
Background: Family moved to the UK from Asia in 2011. Due to issues with visa applications Child H did not join the family until 2013, aged approximately 2-years-7-months. Family were known to agencies, following a number of incidents including allegations of shaking involving Child H's siblings and domestic abuse.
Key issues: gaps in agency knowledge of family history; focus on evidence-based assessment and outcomes and a lack of confidence in professional assessment of family functioning; and dismissal of child protection concerns on the grounds of misunderstandings due to language barriers.
Recommendations: need for a professional culture of respectful uncertainty; need for more robust systems of management oversight in Child in Need cases; and need for further embedding safeguarding processes in the role of the GP.
Model: hybrid approach.
Keywords: non-accidental head injury, language, culture
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December 2014 - Thurrock - Julia
Disclosure of sexual abuse by a 14-year-old girl, following attendance at a Sexual Assault Referral Centre (SARC) in December 2012. Julia was made the subject of a child protection plan following this disclosure.
Background: Julia had made a number of disclosures of sexual assault and rape between 2010 and 2012. Following the December 2012 disclosure she gave a history of sexual abuse at ages 6 and 11.
Key issues: family were well known to agencies and there were extensive and longstanding concerns about Julia and her siblings, regarding: neglect, intra-familial sexual abuse, physical abuse, domestic abuse and social exclusion.
Learning: a pattern of national and local policy focusing on sexual health and teenage pregnancy rather than sexual abuse in cases of underage sexual activity; lack of clear analysis and challenge of the language used by parents and young people regarding early sexual experiences leading to inadequate response or protection; and lack of developed understanding of adolescent neglect.
Model: uses the Social Care Institute for Excellence (SCIE) systems model.
Keywords: sexual abuse, adolescent neglect
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November 2014 – Derbyshire – ADS
Death of a 17-year-old boy in January 2012.
Background: ADS was found with a ligature around his neck in a cell in the Young Offender Institute (YOI) where he had been detained for convictions of violence towards others. ADS died 4 days later as a result of injuries sustained. ADS was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and conduct disorder.
Key issues: risky behaviour; susceptibility to bullying and manipulation by peers; learning difficulties; aggressive and violent behaviour (seen as impulsive rather than premeditated); domestic abuse; and a brief period of homelessness. It was reported that ADS had caring responsibilities for his mother.
Learning: need for a multi-agency approach to the management of ADHD and children with complex needs; and the importance of all agencies reporting and exploring the impact of domestic abuse on children.
Recommendations: makes recommendations covering Derbyshire Safeguarding Children Board and the Youth Offending Service. Incorporates information and learning from the Prison and Probation Ombudsman’s Review and Clinical Health Review, relating to ADS’ care and treatment whilst in the YOI.
Keywords: Youth Offenders Institutes, suicide, ADHD
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November 2014 - Sunderland – Baby A and Child C
Death of a 1-week-old in April 2013. Coroner's Inquest concluded no explanation for cause of death.
Background: Baby A was admitted to hospital following a cardiac arrest and later died, following the withdrawal of life support. Mother had a history of abusive relationships and had received support for a long-standing heroin addiction for a number of years. Mother was well known to children's social care. Baby A was the subject of a Child Protection Plan at the time of the incident and had been discharged from hospital, post-birth, into the care of maternal grandparents. Mother's eldest child and Child C were also living with maternal grandparents at this time and mother's second eldest child was living with their father. Child C was subject to Child in Need or Child Protection Plans for most of their life prior to the incident.
Learning: identifies findings, covering: assessment and planning; collaborative working; practice and professional judgement; and management and supervision
Keywords: Substance misuse
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November 2014 - Torbay – C42
Death of 2 siblings and their mother. Child A and his mother died on the 12 July 2013 following a fall. The body of Child B was found later that same day at their home address.
Background: the inquest into the deaths found that the mother took her own life and that Child A was unlawfully killed. An open verdict was recorded in respect of Child B. Children were living with their mother following a short period in foster care whilst their father was charged with the assault of their mother.
Key issues: mother had a history of self-harm and suicide ideation, depression and anxiety, domestic abuse and childhood experiences of abuse.
Learning: a lack of management challenge within agencies; lack of rigorous risk assessment due to the use of different assessment tools, relying on self-report, across and between agencies; an over reliance on formal disclosure of abuse and a failure to recognise the potential impact of historical abuse on parenting capacity.
Model: uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to Torbay Safeguarding Children Board.
Keywords: suicide, filicide, maternal depression
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November 2014 – Tower Hamlets - Jamilla
Death of a 4-month-old girl in October 2013, suspected to be caused by malnutrition.
Background: Mother was charged with causing or allowing the death of a child and the neglect of Jamilla and her two older siblings; she pleaded guilty to manslaughter and cruelty. Mother was born in the UK to a Somali mother and white British father. Mother was taken to live in Somaliland aged 12 where it is understood that she was forced into marriage at 13 and experienced domestic abuse and rape. Mother was nearly 18-years-old and pregnant with Jamilla when she returned to UK with the help of the Forced Marriage Unit (FMU) and her father. Mother's care of Jamilla and siblings was assessed as good, despite her age and vulnerabilities.
Learning: identifies themes, including the rapid deterioration of home circumstances, highlighting that neglect can lead to risk within a very short period of time for babies and young children; and the impact and potential addictive features of social network use on parenting capacity. Identifies findings including focus of assessments on current levels of functioning within families, with insufficient consideration of the potential risks of ongoing vulnerabilities; practitioners not obtaining an understanding of the implications for mother of being dual heritage and lack of knowledge of family's views to mother having escaped a forced marriage; and the need for challenging the myth of persistence in neglect.
Recommendations: makes recommendations covering agencies including the FMU and housing services.
Model: used a locally developed systems approach, based on the Social Care Institute for Excellence (SCIE) model.
Keywords: culture, social isolation, neglect
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November 2014 – Wandsworth – Zara
Serious injury of a 4-year-old girl of mixed heritage, in March 2013.
Background: Zara was admitted to hospital suffering from stomach pains. Ruptures to her duodenum, thought to be non-accidental, were identified following surgery. Criminal charges have been brought against suspected perpetrators (not mother). Maternal history of challenging behaviour, drug misuse, social isolation, financial problems and homelessness. Paternal history of drug misuse, prolific offending and imprisonment. Family were known to a number of agencies, including children’s social care, housing services, police and probation services. Approximately a year prior to the incident, mother was the victim of what the police described as a racially aggravated common assault, which included a threat to burn mother’s flat down with Zara inside.
Key issues: mother’s intelligence, unusually good level of education and articulacy diverting the attention of professionals; insufficient exploration of the impact of ethnic, cultural and religious factors; assessments being treated in isolation leading to a limited understanding of cumulative risk; and insufficient exploration of the significance and impact of father.
Recommendations: makes recommendations, covering early years services, schools, children’s social care, health visiting, housing and rent collection services, probation, hospitals and GPs.
Model: uses some elements of the Learning Together methodology.
Keywords: teenage mothers, unknown men
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October 2014 – Bedford – Child A1301
Death of a 19-month-old child in April 2013, as the result of a non-accidental head injury.
Background: Child A’s mother and her partner were arrested but it was not possible to establish who caused the injury. Child A’s parents separated almost immediately after Child A’s birth and mother entered into a new relationship. Parents separation was acrimonious; allegations were made against father and against mother.
Key issues: preconception of father as controlling leading to his concerns over mother’s parenting being minimised; insufficient challenge to information provided by mother, which was later found to be untrue; and drink-driving allegations made against mother not being shared with the police agency responsible for assessing potential harm to children.
Model: uses the Social Care Institute for Excellence (SCIE) systems model to identify learning, covering: risks associated with delayed first presentation in pregnancy; and the mechanism for identifying and sharing safeguarding issues raised via Crimestoppers.
Keywords: non-accidental head injury, professional curiosity, fathers
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October 2014 - Gateshead – Baby T
Serious head injury of a 4-month-old boy in June 2013.
Background: Baby T had attended hospital 6-weeks prior to the incident with bruising, strongly suspected to be non-accidental. Mother and father did not live together and mother claimed to be the sole carer for Baby T leading up to this incident. A subsequent Working Agreement named father as the parent with supervisory responsibility for all contact with Baby T and his three siblings. Mother and father were arrested and later admitted causing or allowing physical harm; they received a Community Order and suspended sentence respectively.
Key issues: father had a long history of mental health problems including chronic and severe anxiety and depression. The depth of father's mental health problems, as told to his GP, were not known by mother or children's social care.
Learning: low GP attendance at child protection conferences and the implications of a series of strategy discussions or conversations replacing formal, face-to-face strategy meetings.
Model: Significant Incident Learning Process (SILP).
Keywords: non-accidental head injury, fathers, GPs
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October 2014 – Hampshire – Baby V
Death of a 4-month-old baby in Summer 2013.
Background: Baby V was admitted to hospital after suffering a cardiac arrest and died the next day. Tests revealed a rib fracture, which occurred somewhere between 10 days and 3 months prior to the incident, a linear skull fracture and brain damage due to lack of oxygen. Father was found responsible for causing the injuries and convicted. Family were known to universal services only. Mother had reported concerns to professionals that father was not bonding with Baby V and that Baby V was pinching itself, leaving scratches and bruising to its face.
Key issues: insufficient professional awareness and understanding of how to respond to bruising in non-mobile infants; need for greater clarity of the level of child protection training required by professionals and how this is monitored and compliance measured; need for respectful scepticism; and need for improved communication between GPs and community care.
Keywords: physical abuse, training, fathers
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October 2014 – Hull – Child T
Death of a 2-year-7-month-old boy in January 2013 as the result of drowning in the bath whilst left unattended.
Background: Post-mortem examination revealed hot water burns to Child T’s body, caused after his death. Mother was convicted of manslaughter and received a 3 year custodial sentence. Mother and father were both on methadone programmes; tests conducted after the incident showed mother had also recently taken a number of prescribed and illicit drugs. Family were well known to agencies including children’s services. Both parents had a significant history of drug misuse, there was a history of domestic abuse and father had spent time in prison for drugs related offences.
Key issues: insufficient focus on father’s role in Child T’s life; and poor prescription control practices leading to the over-prescription of medication.
Recommendations: makes recommendations including that the local Public Health Service should undertake a targeted public awareness campaign highlighting the risks associated with consuming a mixture of substances.
Model: uses the Significant Incident Learning Process (SILP).
Keywords: drug misuse, fathers
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October 2014 – Isle of Wight - Baby Z
Death of a 2-day-old baby in November 2013.
Background: Cause of death is unascertained but evidence suggests that safe sleeping and temperature control advice had not been followed. Post mortem examination revealed small doses of non-prescribed drugs in Baby Z’s blood, likely to have transferred via the placenta or breast milk. Maternal history of: substance misuse, mental health problems, housing problems, periods of homelessness and financial problems.
Key issues: reliance on informal systems for sharing and analysing information, limiting opportunities for critical reflection and case recording; assumption that because so many services were involved, any risk to Baby Z would be identified; failure to consider the role of the father; and insufficient information sharing between adult’s and children’s services.
Recommendations: makes various recommendations focusing on information sharing and interagency cooperation.
Keywords: substance misuse, co-sleeping, unknown men
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October 2014 – Norfolk – Family L
Chronic neglect of four siblings over a number of years.
Background: All four children were placed in foster care in April 2013, at which point they were assessed as suffering significant developmental delays and emotional difficulties. An older adult sibling remained with mother. Prior to their accommodation, all children had been diagnosed with some form of additional needs, resulting in the involvement of a large number of professionals, at different times. Referrals to children’s services were made on a number of occasions by a number of different professionals.
Key issues: chaotic family life, social isolation, domestic abuse, including an incident leading to children and mother briefly moving to a refuge.
Learning: identifies eight priority findings, including: lack of inbuilt review mechanisms in the Common Assessment Framework (CAF) process leaving cases susceptible to collusion and drift; CAF process being parent focused due to its voluntary nature, leading to inadequate assessment of the needs of individual children; focus on neglect in relation to poor home conditions rather than more general deficits in child-parent relationships; and diagnoses such as attention deficit hyperactivity disorder (ADHD) distracting attention from what could be the result of poor parental care.
Model: uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to Norfolk Safeguarding Children Board.
Keywords: child neglect, CAF
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October 2014 – Peterborough – Child A
Death of a 2-month-old baby girl in September 2013, as the result of severe head injuries.
Background: Post mortem examination revealed multiple non-accidental injuries. Father was charged with murder. Parents were Lithuanian nationals who had lived in the UK for 2 and 6 years. Family were known to universal services only.
Learning: uses a systems methodology to identify lessons learned, including: professionals communicating with a person for whom English is not their first language should consider the need for an interpreter even when one is not requested; midwives and health visitors should be aware of male figures within the family and, if they are present at appointments, try to engage them in conversation; and local arrangements in respect of staff seniority for making police referrals should be reviewed to prevent delay in notification of suspicious deaths.
Recommendations: provision of communication in hospitals in the key languages corresponding with the local population mix.
Keywords: physical abuse, interpreters
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September 2014 – Lancashire - Child R
Death of a 16-year-old girl, in January 2013, from multiple stab wounds.
Background: Adult 1 contacted Child R via social media and convinced her to go to a commercial premises on the pre-text of being offered a job. Adult 1 was convicted of murder and received a 35-year prison sentence. Child R experienced multiple traumas during her childhood, including witnessing the death of a friend, physical assault, cyberbullying and rape.
Key issues: identifies risk factors affecting Child R, including: going missing from home, sexual relationships with peers her own age, sexually exploitative relationships with adult males, preoccupation with fire, drug and alcohol misuse and self-harm. Adult 1 had a history of: physically and sexually abusive behaviour as an adult and child; cruelty to animals; and diagnosed child conduct disorder.
Learning: uses an adaptation of the Social Care Institute for Excellence (SCIE) systems model to present key themes for learning, including: recognition of abuse and risk to adolescents from outside the home; possible systemic bias in using safeguarding frameworks to assess risk to older children; compliance with missing from home (MFH) and child sexual exploitation (CSE) protocols in regard to young people resistant to help and intervention; and effective diagnosis and response to conduct disorder in childhood including the provision of evidence-based parenting programmes.
Keywords: child sexual exploitation, social media, post-traumatic stress disorder
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September 2014 – Oxford – Child H
Serious incident involving a 21-month-old boy, who was admitted to hospital in September 2013, after ingesting 40-50mls of opiate-based medication.
Background: Mother pleaded guilty to charges associated with her care of Child H and received a custodial sentence. Mother had been known to children’s services since she was 15-years-old. Child H was the subject of a child protection plan at birth; the case was later stepped down to a child in need plan, which was closed 5 months prior to the incident. Child H had an older sibling, who was removed from mother’s care due to concerns about substance misuse. Mother had a history of offending and was subject to a community order while pregnant with Child H. Mother was known to be using class A drugs, in addition to receiving methadone treatment, during pregnancy and after Child H’s birth.
Key issues: normalisation of mother’s drug misuse and acceptance of dishonest and manipulative behaviour; and widespread inward focus among agencies, leading to unjustified assumptions that other agencies or professionals were managing child protection concerns.
Recommendations: identifies service improvements made by agencies and makes various recommendations covering Oxfordshire Clinical Commissioning Group and health, police and probations services.
Key issues: drug misuse, professional optimism
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September 2014 – Surrey – Child Y
Serious non-accidental injury of a 6 week old boy in August 2013, suspected to be as a result of shaking. Child Y was in the care of his father for the weekend when he was admitted to hospital with bruising and cerebral haemorrhage resulting in significant disabilities. Father was charged with grievous bodily harm and found not guilty.
Background: there had been previous reports of neglect, physical injuries and multiple visits to hospital with injuries for Child Y and siblings including cigarette burns and an overdose. Father did not live with the family. He had previously taken overdoses and was known to the police for domestic abuse and possession of drugs. Mother was known to alcohol and drug services.
Key issues: gaps in communication between agencies specifically around the mother’s alcohol misuse and sharing safeguarding concerns that could affect siblings; individual referrals not meeting the threshold and cumulative patterns not identified; lack of continuity of professionals working with the family; limited involvement with the father; lack of professional curiosity; not following up non-attendance of appointments.
Recommendations: review of multi-agency practice around parental alcohol misuse and neglect; improvements to maternity booking forms to include space for father’s details and psychosocial concerns; children’s services to conduct regular audits of repeat contacts; and safeguarding to be considered in cases of child obesity.
Keywords: non-accidental head injury, fathers, substance misuse
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August 2014 – Reading – Child D
Partnership review into the support received by a 15-year-old girl, referred to children’s services in September 2013, following an allegation of sexual abuse.
Background: Child D became a looked after child following admission to an inpatient setting and received services from a range of agencies including schools, acute services and mental health services.
Key issues: review explored whether sufficient support had been offered to Child D during her childhood, which could have prevented the need for the most substantial level of state intervention during her adolescence.
Learning: identifies learning points, including: need for recognition of behavioural cues indicating abuse rather than relying on verbal disclosure; and need to use multi-agency safeguarding planning processes to address the variable pattern of cooperation in non-engaging families.
Recommendations: identifies service improvements made by agencies and makes various recommendations covering Oxfordshire and areas of improvement for various agencies.
Keywords: sexual abuse, resistant families
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August 2014 – Oxfordshire – Child N 
Death of a 1-year-old girl in May 2013 whilst in the care of her mother, recorded as unexplained death but treated as suspicious. 
Background: Parents grew up in Africa, mother was a naturalised UK citizen, but father was not. History of: allegations of domestic abuse first reported in pregnancy; mother's suggestion that she may put the child up for adoption at birth but later changing her mind; marriage breakdown; and mother moving around with no stable accommodation. Residence Order was granted in favour of father due to fear of mother leaving the country with Child N. The day after the order was granted mother left the country and Child N was found dead in her flat. 
Key issues: need for improved multi-agency management of risks arising from domestic abuse; learning for Cafcass in relation to private law cases, including undertaking a review into how it presents recommendations of a change of residence; engaging fathers in services; and service provision for minority ethnic populations. 
Recommendations: made for Thames Valley Police, Cafcass, children's social care, health services, and legal services. 
Keywords: contact, fathers, infant deaths
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August 2014 – Oxfordshire – Child Y
Updated report into the death of a young child, which occurred in November 2010, as the result of a serious head injury. 
Background: Father was found guilty of neglect on the grounds that he failed to notify medical staff that his child had sustained a head injury while in his care. He received a 15-month custodial sentence, reduced to 10-months on appeal. Maternal history of depression, abuse during her adolescence and a sexual relationship when 14-years-old. 
Key issues: missed opportunities for assessment and insufficient coordination between agencies; 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.
Recommendations: makes various interagency and single agency recommendations covering health services, children's services and police.
Keywords: non-accidental head injuries, maternal depression, debt
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August 2014 – Nottinghamshire – GN13
Serious physical injury and sexual abuse of a 22-month old child.
Background: Mother’s partner (Adult 1) was convicted of sexual assault and child cruelty and received a substantial custodial sentence. Mother was convicted of neglect and received a suspended prison sentence. GN13 had been known to children’s services since birth and was the subject of a child protection plan under neglect at the time of the incident. GN13 moved to Nottinghamshire 9 weeks before the incident; prior to this GN13 had lived in another county with Mother but had regular contact with Father. Father had begun the process of applying for a residence order at the time that Mother moved GN13 to Nottinghamshire. Parents had considerable problems but Father had been showing significant improvements in his caring of GN13 prior to the move; Mother had reportedly made negligible changes to her lifestyle and care routines.
Key issues: Mother’s manipulation and misdirection of professionals, including concerning the nature of her relationship with Adult 1; and degree to which professionals’ understanding of Father’s relationship with GN13 was shaped by Mother and the extent to which Father was kept at arm’s length.
Recommendations: adapts the Social Care Institute for Excellence (SCIE) systems model to provide reflections and challenges for Nottinghamshire Safeguarding Children Board, covering: use of social media to make enquiries relating to the safety or circumstances of children; and assessment in cases where children subject to a child protection plan move local authority.
Keywords: optimistic thinking, manipulation, fathers
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August 2014 - Manchester – Child C1
Death of a 2-year-old boy by choking. Child C1 had been left alone with his older sibling when he swallowed and choked on a small item. He later died in hospital.
Background: following his death some unexplained bruising was identified and Child C1's sibling was made subject to an interim care order. No charges were made against either parent.
Key issues: mother had a history of depression and suicide attempts. Father had a history of domestic abuse and substance misuse. Mother and children had spent some time in a homeless family unit following disclosure of domestic abuse by the father. Social workers had conducted two initial assessments of the family but did not identify any concerns.
Learning: parents were interviewed together during social work assessments despite allegations of domestic abuse; the overwhelming focus on Child C1’s medical care distracted attention from potential safeguarding concerns; police reluctance to share information from the criminal investigation with social services to help with care proceedings for Child C1’s sibling.
Recommendations: the common assessment framework should be actively pursued for homeless families with no formal social work intervention; the safeguarding children board should discuss with the crown prosecution service the possibility of children’s services providing advice on complex child protection cases; NHS trusts should review first aid education for parents.
Keywords: child deaths, parental supervision, injuries
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August 2014 - Hertfordshire – Child X
Death of a female child in June 2013 as the result of asphyxia caused by ligature strangulation.
Background: Child X's father was convicted of manslaughter. Child X's parents separated in 2008 but father remained living in the family home as a lodger. Father was due to move out on 1st June 2013 but, after failing to find alternative accommodation, it was agreed that he could remain in the house for a further month. Child X was killed during this month. Mother reported a change in father's behaviour over a period of years, from being outgoing and gregarious, to becoming more home-based and socialising very little. Mother maintains that, despite noticing a change in father's behaviour, she had no concerns about his ability to care for Child X. Following Child X's death, father was found with substantial injuries after his car had crashed; no other car was involved in the crash.
Recommendations: Makes recommendations, covering: record keeping and safeguarding training for GPs; and the need for a meta-analysis of research and reviews involving the death or serious injury of a child in the course of residence and contract disputes.
Keywords: fathers, contact disputes
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August 2014 – Gloucestershire – Abigail
Physical, emotional and developmental neglect of a 3-year-old-girl and her siblings.
Background: Abigail presented to hospital with serious concerns about her health and development in November 2012. Parents were charged with criminal neglect and Abigail and her siblings were placed in foster care. Family were well known to a number of agencies and there was a history of professional concerns relating to abuse and neglect. Both parents had significant physical and mental health problems requiring a high level of contact with health professionals.
Learning: identifies learning in relation to five key themes, including: limitations of an incident led approach to child neglect; professional challenge; and disguised compliance.
Recommendations: makes recommendations including Gloucestershire Safeguarding Children Board should undertake an audit of assessments and child in need and child protection plans to ensure that the child’s voice is heard and taken into account. Review was undertaken using the Significant Incident Learning Process (SILP).
Keywords: child neglect, disguised compliance, professional challenge
Read the overview report
Read the executive summary

July 2014 – Nottinghamshire – EN12
Serious injury of a 4-month-old baby boy in February 2012.
Background: EN12 was admitted to hospital with significant and chronic bleeds to the head and fractures to his ribs, shoulder blade and legs. Father was sentenced to three years, three months in prison; mother accepted a caution. EN12 has been placed with foster carers and plans for adoption are being sought. Father was suspected of harming two older half siblings of EN12; his oldest daughter in 2003 and his second child in 2009. EN12’s half siblings were made the subject of a child protection plan and a child in need plan, respectively. Key issues: paternal history of drug and alcohol misuse and offending. Maternal history of physically abusive relationships.
Learning: the challenge for health organisations in identifying and tracking men who have dangerous histories as information is held on the files of their female victims; and the need for recognition of the impact that parents can have on professionals and how this can affect their practice.
Recommendations: makes various recommendations for children’s social care, police and health services.
Keywords: abusive men, domestic abuse
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July 2014 – West Berkshire – Child G
Serious injury of an 18-month-old boy in June 2012.
Background: Mother initially said Child G had fallen down the stairs but later told paramedics she had deliberately thrown him. Crown Prosecution Service decided not to prosecute mother as the case failed the public interest test. Significant history of maternal depression. Mother was taken to accident and emergency, following an overdose, a week before the incident.
Learning: ensuring midwives and health visitors meet regularly to discuss families where there are mental health issues; and including discussion of families with children under 5 where a parent has a serious mental health diagnosis in monthly health visitor and GP meetings. Review was conducted using a systems approach based on the Welsh Government model for multi-agency child practice reviews.
Recommendations: makes recommendations including further consideration to be given to health visitor access to maternal mental health records.
Keywords: parents with a mental health problem, information sharing, health services
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July 2014 – Cumbria – Child J
Suicide of an adolescent girl in January 2013.
Background: Child J had been the victim of a sexual assault 18 months prior to her death, she had a history of bulimia, self harm and suicide ideation. Child J was seen as a high-achieving young person who quickly overcame her difficulties and who was actively engaged in school life.
Learning: insufficient professional knowledge to recognise the difference between potentially harmful behaviours and suicidal, potentially life-threatening behaviours; lack of professional understanding of the ‘inner world’ of adolescents, leading to an overly simplistic understanding of their lives; professional misperception that suicidal young people will exhibit symptoms of depression; insufficient processes in schools to challenge fixed thinking that has developed around a case; and pattern of agencies ‘investing in’ child and adolescent mental health services (CAMHS) as the solution to young people’s difficulties when they know the CAMHS service is not functioning adequately.
Model: Social Care Institute for Excellence (SCIE) systems model
Keywords: adolescents, suicide, child and adolescent mental health services (CAMHS)
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June 2014 - Coventry - Child A
Death of an 18-day-old baby in March 2012.
Background: Child A died while in bed with mother and her partner who had both consumed alcohol the previous evening; Child A’s death was considered accidental.
Learning: need for commissioners to be aware of what they can expect from services in terms of the methodologies used, what outcomes can be expected and how progress will be reported; need for health professionals to be aware of the wider safeguarding of children; and need for the flexible interpretation of ‘did not attend’ policies in order for the needs of individual children and families to be taken into account.
Recommendations: makes recommendations, covering children’s social care, health services and Coventry Safeguarding Children Board.
Keywords: infant deaths, co-sleeping, alcohol
Read the executive summary

June 2014Coventry – Child D
Death of a 3-year-old girl in November 2011, as the result of a traumatic head injury.
Background: Child D’s injuries occurred whilst she was in the care of a neighbour. Subsequent care proceedings for Child D’s sibling found that the neighbour inflicted Child D’s injuries but no judgement was made as to whether deliberately or accidently. Neighbour pleaded guilty to child neglect and was sentenced to two years ten months imprisonment. Mother and neighbour’s wife pleaded guilty to perverting the cause of justice and both received a suspended sentence. Family were known to universal services only prior to the incident. Mother came to the UK from Pakistan in 2008 after marrying father, who was born in the UK; mother did not speak English.
Learning: identifies good practice in the support services offered to mother and use of interpreters to communicate with mother. Concludes that there are no lessons to be learned from the case and makes no recommendations.
Keywords: interpreters, communication, culture
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June 2014 - South Gloucestershire – Child C
Death of a 17-week-old baby girl in November 2012; death was recorded as due to ascertained causes.
Background: Mother reportedly experienced sexual, physical and emotional abuse as a child. Mother was 15-years-old when she became pregnant with Child C’s older brother and still a teenager when Child C was born. Mother’s partner was known to police and children’s social care in a neighbouring authority. Significant maternal history of domestic abuse, inconsistent parenting, anxiety and low self-esteem.

Key issues: insufficient consideration of the connection between the arrival of mother’s boyfriend and the reported challenging behaviour of Child C’s brother and injuries to Child C.
Learning: adopts a systems approach to identify learning and recommendations, including: the vulnerabilities and service needs of children who become parents should be addressed from the perspective that they are children first.
Keywords: unknown men, adults abused as children, adolescent parents
Read the overview report

May 2014 – Lambeth – Child H
Death of a 3-year-old Somalian boy, and serious injury to his 2-month-old brother, in March 2013.
Background: Father has been charged with Child H's murder and his surviving siblings have been taken into care. Family had previously been separated by civil war in Somalia and spoke minimal English. Significant history of domestic abuse including an incident leading to mother spending three months in a women’s refuge.
Key issues: insufficient attention paid to past incidents of domestic abuse; professional focus on the emotional impact on children of living with domestic abuse, not on the increased risk of physical harm; lack of reassessment of the family's situation despite indicators of increased risk of harm including overcrowding and new and stressful family relationships; and inadequate range, availability and quality of interpreters.
Model: uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to Lambeth Safeguarding Children Board.
Keywords: domestic abuse, interpreters
Read the overview report

May 2014 – North East Lincolnshire – Baby H
Serious non-accidental head injury of a 3-month old girl, in December 2012, resulting in a life changing brain injury.
Background: Family were known only to universal services prior to Baby H's birth, at which time a referral to children's social care was made identifying a number of concerns relating to mother's vulnerabilities, including her age, the family's recent move to the area and having no electricity.
Key issues: both parents experienced turbulent childhoods. Father had nine children prior to meeting mother, some of whom had been removed from his care and adopted; mother had been known to children's social care and child and adolescent mental health services (CAMHS). Mother was taking medication prescribed for anxiety and had reported taking an overdose prior to the incident.
Learning: insufficient consideration of mental health issues in the context of parenting capacity; insufficient support for professionals working with challenging behaviour; and reliance on personal relationships and knowledge to obtain services of partner agencies.
Model: Social Care Institute for Excellence (SCIE) Learning Together.
Keywords: non-accidental head injuries, adolescent mothers, parents with a mental health problem
Read the overview report

May 2014 - Southampton - Child I and Child M
Deaths of a 2-year-old boy, Child M, in January 2011 and his 4-year-old half-brother, Child I, in April 2011.
Background: An open verdict was recorded for both deaths but subsequent care proceedings found that both boys had experienced neglect. Mother was arrested on suspicion of murder but charges were later dropped. Child I and Child M were subject to child protection plans at the time of Child M’s death. Mother was well known to adult and children's social care and received a wide-range of support services. Mother was diagnosed with a learning disability as a child and had a congenital health problem requiring her to take regular medication. Mother experienced trauma as a child and was accommodated by the local authority from the age of 15-17 years. Mother expressed worries about coping to agencies on a number of occasions and admitted not feeding and hitting Child I.
Learning: identifies 11 significant areas of practice in which professionals' actions to protect Child I and Child M were compromised, including: working across adult's and children's social care; understanding the impact of learning disability on parenting capacity; assessment of family carers and confusion regarding the legal status of Child I; and working with early years providers to assess risk.
Keywords: parents with a learning disability, neglect, kinship care
Read the overview report

May 2014 - Southampton - Child L
Injury of a 6-year-old girl in December 2012.
Background: Child L was admitted to hospital following the identification of bruises by police. Examination revealed 92 bruises of varying ages and traces of amphetamines in Child L’s urine. Mother and partner, Mr A, were convicted of criminal offences relating to injury and neglect. History of: maternal mental health problems; drug misuse and offending behaviour of mother, Mr A and father; domestic abuse. Mr A was known to children’s services in relation to one of his children but his connection with Child L was not known due to a misspelling of his surname when checks were undertaken. Father had contact with Child L for a number of months during her early childhood but this was stopped by mother, at which point father made application to the court for parental responsibility. Child L had a significant history of poor school attendance and concerns had been identified by school in relation to Child L’s inappropriate behaviour toward adults.
Learning: working with resistant parents; consideration of family history; professional challenge; and absence of fathers.
Keywords: parents with a mental health problem, drug misuse, domestic abuse
Read the overview report

May 2014 - Southampton – Family A
Severe and sustained physical and sexual abuse of 7 siblings between 6 and 14-years-old at the time of the review.
Background: Father admitted numerous charges of neglect, physical and sexual abuse and received a long custodial sentence. Father grew up in a travelling community; there is evidence that he was seriously harmed within his family as a child. Children lived with both parents in Norfolk until 2011 when parents separated and father moved to Southampton with all 7 children. A number of the children had Statements of Special Educational Needs and all were educated at home by the father, following their relocation; father was unable to read or write.
Key issues: education service officers focussing on an organisational tasks rather than on the well-being of the children; professional acceptance of lower standards of care because the children were Travellers; confusion within the local authority about the legal status of the children and the issue of parental consent to accommodation; poor interagency planning; and failure of agencies to engage specialist advice and input.
Recommendations: lack of research into the safeguarding of children from Gypsy and Traveller communities; and the definition of “suitable education” in relation to children educated otherwise than at school.
Keywords: child sexual abuse, Travellers/culture, home education, parents with a mental health problem, domestic abuse
Read the overview report

May 2014 – Surrey – Child S
Serious injury of a 2-month-old baby boy in September 2011.
Background: Child S was found home alone with visible bruising. Examination later revealed multiple injuries including fractures and a brain injury. Child S and both his half siblings were subject to child protection plans at the time of the incident. Mother pleaded guilty to wilful cruelty and grievous bodily harm, for which she received a community sentence. Mother was subject to a child protection plan as a child and lived in foster care for two years from the age of 5. Mother had learning and emotional difficulties and a history of domestic abuse and alcohol misuse. Mother told GP that Child S was unwanted and she was considering adoption. Mother was well known to agencies, including police, and was arrested two years prior to the incident for being drunk in charge of a child.
Learning: identifies lessons for practice concerning insufficient recognition and assessment of risk factors including: resistance, parental vulnerabilities due to childhood experiences, bruising to non-mobile infants, alcohol misuse, the impact of learning disability on parenting capacity and the meaning of the child to the mother.
Keywords: physical abuse, risk assessment, resistant families
Read the overview report

April 2014 – Bury - Child H
Death of an 8-year-old boy in April 2013, as the result of an asthma attack.
Background: Child H and his siblings were the subjects of a child protection plan under the category of emotional abuse at the time of the incident. Child H was diagnosed with moderate/severe asthma and experienced problems with his eyesight, nosebleeds and enuresis.
Key issues: paternal alcohol misuse; prolific domestic abuse; family debt and housing problems; and impact of stress associated with witnessing domestic abuse on Child H’s asthma.
Recommendations: children subject to a child protection plan should have an individual Health Plan; the impact of stress on asthma should be considered during risk assessments, particularly for children living with domestic abuse and parental alcohol misuse; and early consideration of the use of legal processes to clarify and restrict contact should be employed where appropriate.
Model: uses some elements of the Social Care Institute for Excellence (SCIE) systems model to present key learning.
Keywords: domestic abuse, alcohol misuse, stress, children with a chronic illness
Read the overview report

April 2014 - Derby - DD12
Death of a 5-month-old boy in May 2012, as a result of serious, non-accidental injuries.
Background: Father was charged with murder and subsequently pleaded guilty to manslaughter. DD12 was born with a heart defect requiring continuing medical support. Application for an emergency protection order was made several months before DD12's death following identification of significant bruising to his penis during a hospital visit. The injury was subsequently ruled accidental and the application dismissed.
Learning: identifies themes, missed opportunities and lessons learned, including: professionals should not treat court decisions as undisputable statements of the truth.
Recommendations: clear advice should be given to magistrates to help them assess emergency applications; and families of children with complex needs should, with their agreement, be subject to a Common Assessment Framework (CAF).
Keywords: children with a chronic illness
Read the overview report

April 2014 – Devon – CN08
Death of a 2½-year-old boy in January 2013.
Background: Mother admitted to killing Child A; she was convicted of manslaughter and received a hospital order. Mother was detained under the Mental Health Act 1983 for a period in 2011. Child A spent some time in the care of the Local Authority during this period before being returned to the care of his adult half siblings. History of domestic abuse and a Restraining Order against the father was in place at the time of the incident.
Key issues: arrangements for parents with mental health issues disproportionately favouring adult's rights over children's; insufficient professional understanding of other's roles and responsibilities leading to assumptions over levels of knowledge and inhibiting professionals' confidence to challenge other agencies/professionals; systemic concerns over assessment processes and inconsistent application of thresholds within the Multi-Agency Safeguarding Hub (MASH); and lack of robust assessment of risk to children at Multi-Agency Risk Assessment Conferences (MARACs).
Model: uses the Social Care Institute for Excellence (SCIE) systems methodology
Keywords: parents with a mental health problem, domestic abuse, interagency cooperation
Read the overview report

April 2014 – Devon – CN10
Significant and sustained sexual abuse of two female siblings by their step-father.
Background: Step-father was convicted of a number of offences in June 2013, including: rape and making an indecent photograph. He had a previous conviction for a sexual offence against a 7-year-old-girl and was placed on the sex offender register from 2000-2005. An initial assessment was made when step-father moved into family home in 2007. A number of further assessments were made between 2007 and 2012, following referrals from police, schools and children’s father. School made several referrals identifying concerns about relationships and behaviours within the family. In 2012, siblings’ brother was referred to the NSPCC for assessment and behaviour work. After reviewing the family case history, the NSPCC persistently raised concerns over: robustness of risk assessments; mother’s capacity to protect the children; risks and implications of children’s behaviour; and neglect issues. Following a review of the case and further investigation, step- father was arrested.
Key issues: misplaced assumption of mother as a protective factor; over-reliance on the children making a direct disclosure; and insufficient knowledge and understanding of sex offending, offender profiles and risk.
Recommendations: makes various interagency and single agency recommendations covering children’s services, the Local Authority, police and probation services.
Keywords: sex offenders, risk assessment, child sexual abuse
Read the overview report

April 2014 - West Sussex - [a number of young boys]
Serious and persistent sexual abuse of a number of young boys over a period of years, by another young person.
Background: Reviews the response of agencies to allegations made against John between 2011 and 2013. In 2013, John was convicted of 49 offences including rape and sentenced to 10 years in prison.
Key findings: insufficient knowledge of procedures for responding to sexually abusive children; lack of clarity in child protection roles and responsibilities when the threat to a child is extra-familial; inappropriate use of language in written records, downplaying the seriousness of allegations; and impact of non-specialist police officers responding to incidents in place of police child protection teams.
Model: uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to West Sussex Safeguarding Children Board. Includes response form West Sussex Safeguarding Children Board.
Keywords: sexually abusive adolescents, extra-familial abuse, language
Read the overview report

March 2014 – Anonymous – Child D
Serious injuries of a 3-week-old baby girl in October 2012.
Background: Mother admitted shaking and hitting Child D. Mother was arrested and remanded in custody until a Hospital Order was made under Section 37 of the Mental Health Act 1983. Mother was known to a wide number of agencies and experienced abuse and neglect as a child. She had a history of mental health problems including anxiety and depression.
Learning: identifies themes, missed opportunities and lessons learned, including: inadequate assessment of mother’s learning difficulties; lack of agency lead in response to mother’s multiple, overlapping needs; and unsupported assumptions that father was a protective factor to Child D.
Recommendations: makes various recommendations focusing on multi-agency working.
Keywords: adults abused as children, parenting capacity, shaking
Read the overview report

March 2014Anonymous – Child F and Child G
Serious injury of a baby girl in late 2011.
Background: Child F was stabbed by her father, described as suffering a severe psychotic episode at the time. Father was arrested and subsequently received psychiatric care in a secure setting. Father had intermittent contact with mental health services, which included episodes of drug-induced psychosis. He received a four year prison sentence for a serious violent crime prior to the birth of Child G.
Key issues: lack of access to significant history contained in court and prison psychiatric reports; pattern of agency involvement with the family by two distinct sets of professionals, focusing separately on the father and on mother and children; overreliance on self-disclosure in assessing risk; and lack of agency knowledge about role of father.
Recommendations: makes various recommendations covering GPs, probation services, accident and emergency, mental health and health services. Review was undertaken using elements of a systems approach.
Keywords: parents with a mental health problem, fathers, assessment
Read the overview report

March 2014 – Dorset – Family S11
Death of a 15-year-old boy in March 2013, as the result of an overdose of drugs prescribed to his father.
Background: Andrew’s family was well known to services including education, children’s social care, health and child and adolescent mental health services (CAMHS). Andrew’s parents were divorced and Andrew lived with his father, who was receiving services for long-standing mental health problems at the time of the incident.
Key issues: risky sexual behaviour, self-harm, significantly poor record of school attendance and previous overdose of prescription drugs.
Learning: challenges of working with hard-to-reach families; teenage neglect and the use of child protection procedures; teenage mental health and suicidal ideation; impact of adult mental health problems on parenting capacity.
Model: review was undertaken using the Partnership Learning Review model, jointly commissioned by Dorset and Bournemouth and Poole Safeguarding Children Boards.
Keywords: adolescent mental health, parents with a mental health problem, hard to reach families
Read the overview report

March 2014 - Nottinghamshire - Child 1, Child 2 and Child 3
Sexual and physical abuse and neglect of three girls over a period of many years.
Background: A number of allegations and disclosures were made, leading to seven police investigates, between 1997 and 2012. Mr A and Mrs A were arrested in 2013 and found guilty of various counts of serious sexual assault, including rape, and child cruelty.
Key issues: lack of sufficient evidence to proceed with criminal prosecution impacting on child protection decision-making; insufficient investigation into whether abuse was a factor in the injuries of a child with a physical disability; and lack of rigorous investigation following identification of sexually inappropriate behaviour.
Recommendations: clarifying the relationship between NSCB and the Crown Prosecution Service and considering obtaining their engagement in serious case reviews.
Keywords: sexual abuse, allegations, Crown Prosecution Service
Read the overview report

March 2014 – Surrey - Young person: Hiers
Suicide of a 14-year-old boy in April 2013.
Background: The Young Person moved to the UK from China three years prior to his death. The Young Person’s mother was returning from a month-long visit to China at the time of the incident, during which time the Young Person had been living alone at the family bedsit located in a shared house. Mother had made arrangements for the landlord and other residents to keep an eye on the Young Person and left adequate money for food and expenses. Police, children’s social care and the Young Person’s school were aware of his living arrangements.
Key issues: a need for greater awareness of private fostering regulations among social workers; and a need for professionals to ensure that information is understood by colleagues in the way in which it was intended.
Recommendations: makes various recommendations covering schools, police and children’s social care.
Keywords: suicide, culture, private fostering
Read the overview report

March 2014 - Walsall – Child W3
Serious multiple injuries of a 9-year-old British boy of Bangladeshi ethnic origin, in March 2013, believed to be caused by a knife.
Background: Mother was arrested and charged with wounding W3; Crown Prosecution Service later decided there was insufficient evidence to prosecute. Family were well known to, and in receipt of services from, over 20 different agencies. W3 and his siblings were subject to Child Protection Plans for a period prior to the incident. Significant history of domestic abuse allegedly perpetrated by mother and father.
Key issues: mother’s domineering behaviour eclipsing children’s needs; father’s level of English impeding his ability to communicate with agencies; and response of agencies made more challenging by the number of children in the household.
Identifies lessons learnt, including: the views of children and fathers are of critical importance in providing an holistic picture of a family; and parental insistence about a child’s special needs should not supplant evidence-based assessments.
Recommendations: makes recommendations covering children’s social care, health services, school and police services.
Keywords: disguised compliance, domestic abuse, language
Read the overview report
Read the executive summary

March 2014 – Windsor and Maidenhead – EY and OY
Death of an 11-month-old boy in March 2011, as the result of a serious head injury.
Background: Post mortem revealed older fractures and bruising. Mother was arrested under suspicion of causing EY’s death. EY was looked after by the local authority until 7 months-old and parents had indicated that they wished him to be adopted; his older brother had not been looked after but parents had considered adoption. Mother concealed both pregnancies, initially concealed the existence of EY from members of her family and later from professionals. Injuries to EY were observed by social workers, children centre staff, GP and Health Visitor in the weeks prior to his death.
Key issues: insufficient recognition of the risks associated with concealed pregnancy; underestimation of the risks associated with re-unification; and non-compliance with child protection procedures in relation to reporting suspicious injuries.
Learning: better coordination of health care for children who are discharged from being looked after; and need for investigation in cases of concealed pregnancy, including the psychological and psychiatric status of the parents. Makes various interagency and single agency recommendations.
Keywords: physical abuse, concealed pregnancy, optimistic thinking
Read the overview report
Read the executive summary

February 2014 – Bexley – Baby F
Death of a 5-month-old baby boy in June 2012 as the result of florid rickets caused by severe vitamin D deficiency.
Background: Following Baby F’s death parents reported that he had been unwell for three days; both pleaded guilty to manslaughter. Following his birth, parents initially refused consent to medical treatment for Baby F, leading to children’s services involvement. It is assumed that the parents’ spiritual beliefs informed their refusal however this was denied by both parents at the time.
Key issues: mother’s late booking and declining of screening during pregnancy; and failure to address the impact on the health of Baby F of mother’s diet and increased risk of vitamin D deficiency as a black African woman.
Learning: the need for agencies to consider the tension between remaining sensitive to equality and diversity issues and safeguarding children. Makes various single agency and multi-agency recommendations.
Keywords: religion, culture, medical care neglect
Read the overview report

February 2014 - Leicester - Baby Z
Serious head injury of a baby girl in October 2012.
Background: Medical examination revealed multiple injuries, thought to have occurred up to 3 weeks before the incident. Mother pleaded guilty to Section 20 Grievous Bodily Harm and received a 2 ½ year custodial sentence in September 2013. In December 2013, mother was removed from prison and sent to India as part of the UK Visa and Immigration Service’s Facilitated Return Scheme. Family were known only to universal services prior to the incident. Mother presented injuries to health visitor and GP in August 2012, which were not identified as non-accidental and not referred to children’s services.
Key issues: missed opportunities on the part of professionals, including: professional optimism; lack of professional challenge; and lack of professional curiosity.
Recommendations: makes recommendations covering GPs, health visitors and Leicestershire Partnership NHS Trust.
Model: review was undertaken using a systems-based methodology.
Keywords: physical abuse, GPs, health visitors
Read the overview report

February 2014 – Family V – Lincolnshire
Death of 1-year-old girl in July 2012, as the result of non-accidental injury.
Background: C2 sustained injuries whilst in the care of mother’s partner, A2. A2 was convicted of murder and sentenced to life imprisonment. Family were known to a significant number of agencies including a number of health services in different hospital settings. In the month prior to her death, C2 attended hospital with a head injury and what was identified as a possible bite mark, considered to be non-accidental. A Section 47 investigation was progressed but assessments did not involve all agencies with knowledge of the family and the case was closed. A2 had a previous conviction for criminal damage and possession of an offensive weapon, relating to an incident of domestic abuse with an ex-partner.
Learning: insufficient professional curiosity; lack of professional challenge; and need for robust and clear escalation procedures where there is disagreement between agencies.
Recommendations: review of the arrangements for taking photographs of possible injuries to ensure medical staff have access to this service at all reasonable times.
Keywords: non-accidental head injury, abusive men, professional challenge
Read the overview report
Read the executive summary

February 2014 – Northamptonshire – Child I – Kieran Lloyd
Death of an 8-week-old baby boy in March 2012 from a significant head injury.
Background: Both parents were arrested on suspicion of murder. Parents had troubled childhoods, characterised by: offending, violent behaviour, school absence and sexual and physical abuse.
Key issues: midwives’ practice of not accessing fathers’ medical records due to a misunderstanding of data protection laws; Responsible Paediatrician’s failure to identify significant child abuse injuries; and inability of the police Lead Investigator to challenge the Responsible Paediatrician.
Recommendations: makes recommendations covering health and police services.
Keywords: physical abuse, adults abused as children
Read the overview report
Read the executive summary

February 2014 – Northamptonshire – Leah Barnes
Death of a 19-month-old girl in November 2012, as the result of severe trauma received during a violent assault that occurred when she was 7-weeks-old.
Background: Post mortem revealed Leah had sustained injuries over a period of time prior to the assault. Father experienced abuse and neglect as a child and spent a number of years in the care of the local authority. Father served in the Army for eight years and was seriously wounded in action. He was medically discharged from the Army following the assault on Leah, at which time he received a formal diagnosis of post-traumatic stress disorder.
Key issues: insufficient understanding of father’s history and role; inadequate information sharing between Army medical services and civilian safeguarding agencies; and failure to identify injuries at the six week check.
Recommendations: safeguarding training for military doctors and information sharing arrangements between military and civilian social work teams.
Keywords: child abuse identification, unknown men, PTSD, military services
Read the overview report

January 2014 - Bolton - Child J
Death of a child as a result of a cardiac arrest, having received multiple injuries.
Background: Mother's partner, Adult Q, was convicted of Child J's murder and sentenced to life imprisonment. Mother was found guilty of causing or allowing the death of a child. Adult Q had a history of drug use and criminal convictions. Mother had one older child who had lived with maternal grandmother since infancy due to mother's inconsistent parenting and possibly ambivalent attachment. Mother was known to have experienced domestic abuse in previous and current relationships.
Key issues: maternal grandmother's confusion over her legal rights and responsibilities; and the role of safeguarding agencies in making judgments about parents' decisions about their personal and sexual relationships.
Recommendations: makes recommendations for Action for Children, housing, health, police and probation services. Presents challenges for Bolton LSCB in line with the SCIE systems model.
Keywords: domestic abuse, unknown men, kniship foster care
Read the overview report
Read the executive summary

January 2014 - Derby - ED12
Death of six sibling children in May 2012, as the result of a fire at their home where they lived with their father and mother A.
Background: Father and mother A and another adult were convicted of the manslaughter of all six children. Father lived simultaneously with his wife (mother A) and their six children and another partner (mother B) and their five children until February 2012. Family had appeared on television and had, at times, a high profile in the media. History of paternal conviction for attempted murder and wounding with intent in 1978; domestic abuse in mother A's previous relationship; and father and mother A's suicide attempts within 2-weeks of each other in February 2012.
Key issues: overcrowding, with periods where up to 15 people were living in the household at the same time; the adults' relationships; father's history of violence; father's controlling and manipulative manner; and the impact of media coverage on the family.
Recommendations: makes recommendations covering children's services, police, education, health, fire and rescue services and housing services.
Keywords: arson, media
Read the overview report

January 2014 – Derbyshire – BDS10
Death of a 22-month-old boy, as a result of stab wounds, in June 2010.
Background: Inquest found that BDS and mother had been unlawfully killed and that father had taken his own life. Father experienced deteriorating mental health in the period between BDS’ birth and death; he had significant contact with agencies and was detained under the Mental Health Act 1983. Despite their separation mother at times acted as an informal carer for father. Mother raised concerns with family and agencies regarding father’s behaviour and did not leave BDS unsupervised with him. The week before the incident mother reported to the police that father had made death threats. This followed father’s learning about mother’s new relationship and pregnancy.
Recommendations: improved support for informal carers of people with mental health problems.
Keywords: parents with a mental health problem, police
Read the overview report

January 2014 - Dorset - in respect of Family S4
Serious head injury of a 6-month-old baby boy in December 2010.
Background: Examination revealed that Bobbie suffered permanent hemiplegia as a result of his injuries. Mother’s partner was given a custodial sentence in relation to the incident. Mother was 19-years-old when Bobbie was born and initially concealed her pregnancy. Bobbie was seen by a number of medical practitioners in the weeks before the incident for various injuries.
Learning: need for greater professional awareness of issues related to concealed pregnancies; and need to ensure that childminders receive support and child protection training.
Keywords: non-accidental head injuries, concealed pregnancy
Read the overview report

January 2014 - Hereford – HH
Death of a 17-year-old boy in May 2013, as a result of diabetic ketoacidosis.
Background: HH and his family were known to children’s services and HH became a looked after child three months before his death.
Issues identified include: parental neglect of HH’s health needs not adequately acknowledged by professionals; HH’s disguised compliance in relation to the management of his diabetes; and lack of awareness of the need for HH to test his blood sugar regularly among non-health professionals.
Learning: non-medical staff need to ensure they receive advice and support from health colleagues when working with children with significant health issues; multi- agency training on neglect must provide a section on the specific issues for young people aged 14 and older; and agencies must recognise 16 and 17-year-olds as children.
Recommendations: makes various interagency and single agency recommendations.
Model: Review used the Significant Learning Incident Process (SILP).
Keywords: adolescents, serious health conditions, neglect
Read the overview report

January 2014 - Hull - Child L
Death of a 5-week-6-day-old baby girl in October 2012 as the result of a severe skull fracture.
Background: Mother admitted to a charge of infanticide due to post natal depression and received a community order with a supervision requirement for three years. Family were known to universal services only.
Learning: need for universal service practitioners' to recognise their role in safeguarding children; and consideration of the role of fathers and men in households in service provision and assessment.
Recommendations: makes recommendations for health services, midwives and ambulance services.
Keywords: postnatal depression, non-accidental head injuries, infanticide
Read the overview report

January 2014 - Suffolk - The Anderson Family
Death of three children and their mother in April 2013.
Background: Children were aged 3-years, 2-years and 13-months at the time of their deaths and mother was 7 months pregnant. Evidence suggests mother killed the children prior to committing suicide. All three children were subject to child protection plans under the category of neglect.
Key issues: adversarial relationship between parents and professionals; infrequent opportunities for children to socialise; and professional uncertainty over mother's mental health.
Learning: background information about parents' childhoods is essential to understanding their parenting capacity; and the Public Law Outline process requires strong management oversight and an understanding of the separate roles, responsibilities and accountability for decision-making of children's services and legal services.
Keywords: resistant families, child neglect, emotional neglect
Read the overview report
Read the executive summary

This list was last updated 17 August 2015.

Case reviews published in 2013

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