Case reviews Case reviews published in 2015

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 2015. To find other case reviews search the national repository.

2015 - Blackpool - Child BV
Death of a 1-month-old infant in Winter 2014. Ambulance service found Child BV unresponsive in 2-year-old sibling’s bedroom, lying between the bed and wall.
Background: both parents had consumed large quantities of alcohol the previous day and could not remember how or why BV was not asleep in usual place. Family were known to universal services only. Father attended Accident and Emergency and visited GP prior to BV’s birth and disclosed that he was a regular heavy drinker.
Key issues: alcohol use and the safe care of children; engaging with fathers; sharing of information about excessive parental alcohol use between professionals; safeguarding requirements for nursery providers; and safe sleep support.
Recommendations: safe sleep assessments by health professionals; campaigning to raise awareness of the risks of alcohol use when caring for young children; and engaging with new and expectant fathers.
Model: Welsh Model for case reviews.
Keywords: infant deaths; alcohol misuse; sleeping behaviour; nurseries.
Read the overview report

2015 – Essex – Child G
Serious brain injury to a 3-month-old girl in May 2013. Mother pleaded guilty to child neglect. The mother's partner was convicted of causing the injuries. Both received custodial sentences.
Background: prior to Child G’s birth her half-sibling had been subject to a child protection plan under the category of neglect. In the months before and after Child G’s birth, mother had attended hospital a number of times due to injuries to Child G’s half-sibling. Child G's mother had diagnosed learning difficulties and "extremely low" IQ classification. She had a history of difficult family relationships and mental health issues. Mother’s partner was known to the probation service and other local authorities due to a history of violence towards women and children.
Key issues: issues identified include the challenge of sharing information about vulnerable families across GP's, midwives and health visitors; the need to focus of the role of fathers/partners through pregnancy and early years; and the need for offender managers to report any safeguarding concerns when an offender starts a new relationship.
Recommendations: include the development of a system to allow tracking of offenders convicted of offences against children and reviewing and monitoring of information sharing in health services.
Keywords: brain injury, child neglect, unknown men, family violence, adults with learning difficulties, mental health
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2015 - Hull - Child W
Death of a 16-year-old girl on 16 November 2013 at a hostel where she was living. Coroner recorded the cause of death as hanging but unclear whether Child W intended to take her own life.
Background: Child W was removed from her birth family and adopted at 10-years-old with her younger brother. Adoptive parents struggled to cope with their behaviour. Prior to her death, there were concerns around self-harm, substance misuse and an alleged rape.
Learning: findings include: W was assessed as needing “intensive therapeutic support” but this support was not provided.
Recommendations: adoption support plans need to clearly detail how and by whom therapeutic needs will be met; attachment needs of adopted children should form part of specialist therapeutic services ; and local authorities should ensure that staff are clear about local guidance and support for homeless 16 and 17-year-olds.
Keywords: adoption support services; placement breakdown; hostels; homeless adolescents; self-harm
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2015 - Nottinghamshire - Child H
Death of a 4-month-old girl in December 2012. Child H died of unknown causes but had a number of injuries which were thought to be non-accidental.
Background: the family was known to a number of agencies due to the serious domestic abuse the mother had experienced with her previous partner, who was the father of Child H and her sibling. Mother had a history of mental health problems, abusive relationships and alcohol misuse.
Learning: identifies learning, including: holding a common assessment framework (CAF) meeting earlier would have helped clarify concerns, responsibilities and what needed to change and professionals should consider the impact of historic experiences of domestic violence.
Recommendations: share the learning from the review and commission a multi-agency case file audit of children subject to a common assessment framework (CAF) where domestic abuse is an issue.
Model: uses the Significant Incident Learning Process (SILP) to review the case.
Keywords: infant deaths, family violence, non-accidental injuries
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2015 - Salford - Child N
Overdose by a 17-year-old female leading to a profound brain injury. Review examines services provided to Child N between the ages of 14 and 17-years-old across two local authorities.
Background: N was a ‘child in need’ but children’s services lost contact after she left supported lodgings to move in with her boyfriend. He was 5-years her senior and they met in a sexual exploitation “hotspot”. N had a troubled adolescence with issues of self-harm, substance misuse and going missing. Mother proactively sought professional help to cope with N’s behaviour.
Learning: good practice highlighted includes the support provided by N’s senior school. Missed opportunities include: social workers should have worked to repair family relationships and greater consideration should have been made relating to child sexual exploitation.
Recommendations: include: early help services must be proactive in working with families with adolescents; local authorities must exercise their legal duties relating to homeless adolescents; and that a clear pathway of mental health services for 16-18-year-olds is created and disseminated to all agencies.
Keywords: homeless adolescents, child sexual exploitation, mental health services, self-harm
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2015 - Southwark – Child R
Rape of a 15-year-old girl in early spring 2014. The girl, who was in foster care at the time of the assault, reported that she had met the man in a hotel after a friend gave him her telephone number. The man involved was arrested and found guilty of a lesser offence against another young person.
Background: family history of: housing instability, drug dealing, child neglect and physical abuse. Child R was made subject to a child protection plan in 2009 and taken into care in 2010 after reporting that her mother had beaten her.
Key issues: whilst in care Child R had periods of: going missing, highly disruptive behaviour, multiple placements and exclusions from school.
Recommendations: makes recommendations covering: looked after children reviews and exploration of options for keeping children safe in emergency situations by police and children’s services.
Model: uses the Welsh Model for case reviews.
Keywords: organised abuse, foster care, placement breakdown
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2015 - Sunderland – Baby Penny
Death of a baby girl as a result of a drowning accident in May 2014. Mother found Baby Penny under water in the bath after she left her unattended to answer the door.
Background: mother had experienced significant mental health problems during a previous pregnancy following which her children were subject to child protection plans. During her pregnancy with Baby Penny mother had regular contact with her GP, community psychiatric nurse, health visitor and midwife. A pre-birth core assessment concluded that Children’s Services should close the case. Limited information about Baby Penny’s father, now know to have a history of domestic abuse with his previous partner and convictions for violent crime.
Key issues: delays in children’s services’ response to referrals from other agencies; lack of full consideration of the parents’ histories and the role of fathers; failure to escalate and challenge inaction by children’s services; and missed opportunities for early intervention.
Recommendations: for the safeguarding children board include: to ensure there is a clear contingency procedure and process for when it has been agreed that there should be follow up if additional information is identified; to design and develop regular multi-agency workshops; and to review the effectiveness of early help services.
Model: systems methodology
Keywords: infant deaths, hidden men, maternal mental health
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2015 – Tri-Borough (Hammersmith and Fulham, Kensington and Chelsea, Westminster) - Sofia
Death of a 1-year-old girl in October 2013 from asphyxiation due to choking on food. Autopsy findings found Sophia was significantly underweight and there were signs of historic untreated injuries. Parents may be charged with neglect.
Background: mother had no permanent address and received services from 7 local authorities. Sofia and her mother were known to medical staff, social workers, housing professionals and the police. There were no signs of physical injury or neglect and Sophia was not considered to be at continuing risk of significant harm. When Sophia was 3-months old they moved and were not seen by a professional until her death. Father was allegedly living overseas but was later found to be living with the family illegally on an expired visa.
Learning: findings include: complexity of legislation and lack of understanding around provision of housing and benefits for a European National; homelessness during pregnancy not being a trigger for assessment and not being considered a safeguarding issue after birth; assessments made on mother's intention rather than child's experience; strategy discussions conducted via telephone excluding some agencies; a focus on physical manifestations of neglect over more complex indicators; and avoidant families becoming ‘lost’ to services.
Model: SCIE's Learning Together systems model
Keywords: infant deaths, child neglect, transient families, hidden men
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December 2015 – City and Hackney - Children in a foster home
Sexual abuse of 5 girls of primary school age in their foster home between 1999 and 2008. Most of the girls had special educational needs or a learning disability. The male foster carer and a male family member were convicted of child sexual offences. There was evidence that the female foster carer was aware of the risk of sexual abuse.
Background: both foster carers had been abused and neglected as children. Male foster carer had sexually abused two young girls before fostering but this was not known until police investigations in 2012. Police received an anonymous allegation that the male foster carer had child abuse images on his computer in 1999. This information was kept on his record but was neither investigated nor shared. Some professionals expressed concerns about the quality of care provided but the foster carers manipulated professionals and presented themselves as “experts”.
Learning: issues identified include police non-disclose of unsubstantiated child abuse image allegations during checks on the foster carers; lack of professional curiosity about the reasons for a foster child’s sexualised behaviour; and the unwillingness of the fostering service to respond to concerns due to the foster carers’ reputation as a valued resource.
Recommendations: include police to ensure they consistently investigate child abuse images allegations and work with other agencies to safeguard children in such cases; NHS England to ensure GP contracts for counselling services include appropriate reference to safeguarding procedures; and the local safeguarding children’s board should monitor the council’s actions to implement recommendations from an independent review of its fostering services.
Keywords: foster care, sexual abuse
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November 2015 – Essex - John
Non-accidental head injury to a 10-week-old boy from a Gypsy, Roma, Traveller community, thought to be due to being shaken. Both parents were charged and care proceedings initiated.
Background: John was the subject of a child protection plan under neglect. Both parents had a history of drug addiction and criminal behaviour. 4 of the mother's older children had been removed from her care by a neighbouring local authority, including 1 child who was born with drug withdrawal symptoms. Father’s 2 older children had been subject to child protection plans, primarily because of his domestic violence.
Key issues: the significance of parental histories; the challenge of the family's frequent moves on effective information sharing; and the increasing focus of the father as the source of risk.
Recommendations: include, improve the sharing of historical information about parents; parenting capacity assessments to feature in all core and pre-birth assessments; GPs to be invited to attend all child protection conferences; and the strengthening of guidelines relating to missed appointments (“Did not attend” or DNAs).
Keywords: addicted parents, parental history, transient families, information sharing, missed appointments
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November 2015 - Harrow – Baby F
Death of an 11-month-old boy of Irish-traveller descent from a brain injury after being found submerged in water whilst unsupervised in a bath.
Background: Baby F and 2 half-siblings were subject to child protection plans under neglect. Mother given a 6-year custodial sentence after pleading guilty to manslaughter. Mother had a history of: substance misuse, self-harm, domestic abuse, lack of engagement with services, regular changes of address and periods of homelessness.
Key issues: include: a failure by midwifery services to identify and refer pre-birth safeguarding concerns; difficulties in contacting and assessing the family because of their transient lifestyle; and a lack of investigation by children’s services following referrals from the public.
Method: systems methodology.
Recommendations: for the local safeguarding children’s board (LSCB) include: ensure the involvement of the public in safeguarding children is fully valued; ensure practitioners routinely consider families’ histories of agency involvement; and raise staff awareness of the difference between Police Powers of Protection and Emergency Protection Orders.
Keywords: infant deaths, drowning, child neglect, transient families, history
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November 2015 - Kingston – Family A
Death of a 4-year-old girl and two 3-year-old twin boys who were smothered by their birth mother on 22 April 2014. The mother was given a hospital order in November 2014 after admitting manslaughter by diminished responsibility.
Background: Children P, Q and R all had spinal muscular atrophy type 2 (SMA2), a life shortening condition which causes severe muscle weakness. Due to the children's complex health needs many different health agencies were involved with the family.
Key issues: include: the parents' opposition to some medical interventions due to concern about the pain it may cause their children; the mother's low mood; staff commitment and the complexity of the case resulting in working outside professional boundaries; a focus on the possibility of using legal interventions rather than considering the wider child protection process.
Recommendations: parents should be offered counselling and information when their child is diagnosed with a disability and LSCBs should ensure that there is senior management involvement to consider the impact on the safety of the children in cases when the full care package isn't taken up over a prolonged period.
Model: uses a systems approach to focus on the strengths and weaknesses of the multi-agency system.
Keywords: child deaths, disabled children, maternal depression
Read the overview report

November 2015 - Sunderland – Baby N
Unexplained injuries to an 11-week-old baby in March 2014. Baby N was moved to a place of safety before being placed with the maternal grandmother. Father was charged with neglect/ill-treatment.
Background: father had a history of domestic violence and involvement with children’s services due to concerns about neglectful and abusive parenting.
Key issues: the failure of children’s services to conduct a pre-birth assessment based on concerns reported by health visitors; significant delays in children’s services conducting an initial assessment once Baby N was born; health professionals seeing their safeguarding role as primarily passing on or responding to information from children’s services; and an over willingness amongst professionals to accept what they were told by the parents.
Recommendations: frontline practitioners should be reminded of Unborn Baby procedures and specifically told a pre-birth assessment is required if a previous child of either partner has been made subject to child protection procedures; where Initial Assessments are undertaken, referring agencies should be informed in writing of the outcome of referrals so there is clarity between agencies about the rationale for the decisions taken; and referral forms and guidance should make clear the expectation that referring agencies gather background information from their own records.
Model: systems methodology
Keywords: infants, injuries, social work assessments
Read the overview report

October 2015 – Brighton and Hove – Baby Liam
Life-threatening injury to the head of a 7-week-old boy whilst in the care of his father. Father was sentenced to 12-years-and-6-months imprisonment for grievous bodily harm with intent.
Background: Father was a care leaver and had a history of substance misuse, volatile mood swings, petty crime and violence towards peers. Both parents were young and their relationship involved a number of incidents of domestic abuse.
Key issues: failure of care-leaving service to share father's childhood history with professionals working with Baby Liam; issues accessing care-leaving service records due to a change in IT systems; focus of information gathering by midwives on mother rather than both parents; delays by hospital staff in informing police that possible non-accidental injuries had been identified; and delays by police in arresting the parents due to an unwillingness to act before an updated medical report was written stating that the injuries could not have been caused accidentally.
Model: systems model based typology developed by Social Care Institute for Excellence (SCIE)
Keywords: infants, non-accidental injuries, domestic abuse, young parents
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October 2015 - Hampshire – Child F (Stanbridge Earls School)
Reviews the response of agencies to allegations of sexual assaults against a 14-year-old disabled girl by other pupils at an independent residential school.
Background: the girl, who had delayed social and emotional development, engaged in sexual activity with other pupils at the school. Staff were made aware of the sexual activity by her GP, but judged it to be consensual and a confidential medical matter. The girl later told her parents and further information came to light that suggested the sexual activity had been non-consensual. The police investigated the incident, the boy involved was arrested and the girl was also required to leave the school "for her own protection". Following a series of further child protection allegations the school was made the subject of an inquiry and due to declining pupil numbers closed in September 2013.
Key issues: the complexity of the regulatory safeguarding frameworks that apply to independent schools and confusion over how they work with Local Safeguarding Children Boards (LSCBs); a lack of awareness of how disability and gender imbalance impacted on female pupils' vulnerability to potential exploitation or bullying and a lack of information sharing between national and local agencies involved in the case.
Recommendations: Hampshire LSCB to: set out the responsibilities of school trustees to ensure safeguarding is assured and promoted; ensure that parents are always promptly and appropriately informed of safeguarding concerns and to ensure that child protection services in home and school localities work together in cases where children are in out-of-authority residential education.
Keywords: Independent schools, residential care, harmful sexual behaviour, children with disabilities
Read the overview report

October 2015 - Child O – Haringey
Suicide by a 16-year-old girl in January 2014 while she was staying at a therapeutic residential unit.
Background: Child O had a history of eating disorders, self harm and suicidal thoughts. She was in regular contact with health and social care services and spent time as a psychiatric in-patient. She spoke of sexual abuse/exploitation outside the family but agencies could not substantiate this nor persuade her to disclose details.
Key issues: delay in the local authority agreeing to the family's request that Child O be admitted into their care; no formal child protection investigation into O’s situation; and opportunities missed to assess whether thresholds for compulsory detention under the Mental Health Act were met.
Recommendations: Metropolitan Police Service to demonstrate that reports of child sexual exploitation are always followed up; local authority to demonstrate that child protection investigations and assessments are conducted and completed without delay and meet procedural and good practice requirements; and local safeguarding children board (LSCB) to ensure guidance is available for partner agencies on dealing with safeguarding situations relating to social media use.
Keywords: adolescents; suicide; mental health; sexual exploitation
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October 2015 - Luton – Child D
Death of an 11-week-old girl in January 2013, as the result of serious injuries consistent with violent shaking. Post mortem found subdural and retinal haemorrhages and signs of damage to the brain and spinal cord. Father was found guilty of Child D’s manslaughter.
Background: mother experienced abuse in the family as a child and, as a result, was made the subject of a child protection plan in 2006. During the review process a number of professionals expressed concerns that mother might have a learning difficulty; none of the professionals who had been in contact with mother in the 5-years previously felt she had a learning difficulty. Findings from a detailed assessment following Child D’s death identified mother as having an IQ score which placed her in the lowest 3% of the population and identified significant difficulties with memory recall. Father was seen by GP as a young adolescent, in relation to problems with his temper, depressed mood and verbal aggression. Following the incident father admitted assaulting mother on two occasions, neither of which was reported to professionals prior to Child D's death. Following Child D’s death, mother reported that Child D has been bruised on three occasions when in the care of father. One of these bruises was seen by 4 health professionals prior to Child D’s death.
Key issues: identifies themes including: how vulnerable young people who might need additional support when they become parents are identified and helped; the value of information, including social information, being held in GP records; engagement of the father and assessment of his role; professional responses to bruises in small babies; working arrangements between health visitors and GPs; and assessment of parental learning difficulties and their impact on parenting.
Recommendations: makes various recommendations.
Keywords: non-accidental head injury, adults abused as children, parents with learning difficulties, fathers
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October 2015 - Somerset – Child Y
Significant injuries to a 3-week-old child in October 2013. MRI scan indicated that Child Y had survived a subdural haemorrhage. Parents were arrested on suspicion of causing Grievous Bodily Harm; both parents were on police bail at the time review was published.
Background: father had been in care as a child and had a history of depression and anxiety and domestic abuse in relation to a former partner with whom he fathered two children. Father had no contact with either child and one of the children had been adopted. Mother had a history of domestic abuse as a child and was assaulted by her father when 10-weeks pregnant with Child Y.
Key issues: prior to the incident, father was noted to have been handling Child Y roughly by GP but was later observed by midwife to be handling Child Y more gently.
Learning: issues with maternity guidelines relating to domestic abuse in pregnancy including the absence of timely review, inconsistencies in advice given and insufficiently robust safeguarding supervision; importance of early handling and safety advice for parents; impact of the rule of optimism and clinical focus of midwifery services impacting consideration of social risk factors; and importance of identifying the role and impact of fathers.
Recommendations: increased home rather than clinic visits for new born babies, particularly for teenage and vulnerable parents; answerphones should not be relied on to disseminate information; and social care staff should be made aware of the implications of a further pregnancy where a parent has had a previous child adopted.
Model: uses a mix of traditional methodology and a new learning approach.
Keywords: non-accidental head injury, fathers, information sharing, domestic abuse
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September 2015 - Solihull – Child S
Death of a 22-month-old boy on 20 February 2013. Child S was taken to hospital after his mother found him lifeless. A post mortem examination established that he had suffered severe abdominal injuries. Mother and father were both convicted of causing or allowing the death of a child in December 2014.
Background: Child S had been the subject of referrals prior to his birth and had been subject to a child protection plan for emotional abuse since August 2012.
Key issues: mother had a history of substance misuse and mental health issues and father had a history of domestic abuse and drug dealing.
Learning: points identified include difficulties in working with individuals who disguise their compliance resulted in an overly optimistic view of outcomes for the child; problems were caused by misunderstanding between agencies about what and how information about adults who may post a risk to children could be shared; poor attendance by some agencies at initial child protection conferences.
Recommendations: development of clear joint information protocols for the police and children's social work services and a review of the booking system for initial child protection conferences to ensure a minimum notice period is given to professionals across all agencies.
Keywords: infant deaths, domestic abuse, substance misuse
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August 2015 – Anonymous – Child F
Death of a 5-month-old baby in September 2014. Child F was found unresponsive by mother after mother and baby had fallen asleep on a sofa when staying overnight at mother’s friend’s home. Ambulance crew noticed the smell of alcohol on mother and called police. Mother was arrested on suspicion of neglect, having thought to have unintentionally rolled on top of her baby; criminal investigation concluded with no charges being preferred.
Background: little is known about child F's father, beyond his extensive criminal history. Mother entered local authority care when 10-years-old, where she remained until discharge at age 18. Maternal history of: chronic neglect; disrupted placements; significant alcohol and drug misuse; domestic abuse; and offending.
Learning: identifies emerging lessons and reflections, including: the consequences of adverse childhood experiences such as chronic neglect and the inclination of individuals to deny or diminish these experiences; workload, difficulty in collating information or anxiety about challenging service users inhibiting professional recognition or exploration of patterns of behaviour such as missed appointments; invisibility of men; and obstacles to information sharing.
Recommendations: makes various recommendations covering: NHS, community health services and probation services.
Keywords: alcohol misuse, adults neglected as children, co-sleeping.
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August 2015 – Stockton-on-Tees – Child H
Serious harm caused to a 12-year-old, identified in July 2013 when serious concerns were raised over poor home environment and Child H’s presentation, including impaired vision. Child H was taken into the care of the local authority and mother and mother’s partner were charged and sentenced to 30-months imprisonment for child cruelty.
Background: Child H was diagnosed with Juvenile Idiopathic Arthritis (JIA) when 5-years-old. JIA can lead to eye problems, which, if not detected and treated early, can cause permanent visual damage, including blindness. Child H was found to have early indicators of uveitis at an ophthalmology appointment in 2011; Child H did not attend any further ophthalmology appointments until July 2013. Children’s social care received three referrals between 2011 and 2013 and concerns had been raised regarding Child H’s presentation, hygiene and attendance at school and medical appointments.
Key issues: the system for screening children with complex eye problems is not designed around the needs of the child: the appointment system implied Child H was making informed choices about not attending, rather than parents’ non-attendance being seen as an indicator of neglect.
Learning: children with medical needs necessitating a range of specialists, require a lead professional to maintain coordination of services, in particular, the role of the school nurse should be developed to engage with children and parents and to assist schools in understanding the impact of specific conditions.
Recommendations: makes various recommendations and includes a multi-agency action plan.
Keywords: child neglect, children with a chronic illness, start-again syndrome
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July 2015 – Anonymous – Subject Child
Death of a 6-7-week-old-girl in May 2012. Subject child was found by mother with her face pressed up against the back of the settee at home where she had earlier fallen asleep. Mother had just woken from sleep after having drunk alcohol earlier in the day.
Background: mother was arrested in 2011 for being drunk in charge of a child, leading to half-brother being placed in foster care. Half-brother was returned to mother’s care following assessments that recommended that there was no role for a social worker. Mother has a chronic abdominal condition, requiring abstinence from alcohol use to avoid the condition worsening and leading to hospitalisation.
Key issues: history of domestic abuse, alcohol misuse and referrals to children’s services concerning the care of half-brother.
Learning: assessment of the impact of chronic alcohol misuse usually takes place when the parent is no longer intoxicated, leading to insufficient understanding of potential risks to the child; lack of professional knowledge of parents’ persistent or long term medical conditions compromising understanding of the impact on parenting capacity; and professional response to incidents without consideration of previous concerns, leading to missed patterns and possibility of continued ineffective responses.
Keywords: alcohol misuse, risk assessment
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July 2015 – Peterborough – Child J
Significant, non-accidental injuries to a 5-month-old boy, identified in November 2013; injuries were diagnosed as suggestive of physical and sexual abuse. Father was charged with neglect, to which he admitted and received a community sentence; he denied and was not charged with sexually abusing child J.
Background: Child J’s mother had two older children, both of whom were living in foster care at the time of child J’s birth; Child J was discharged from hospital to foster care when 2-days-old before being placed in the full-time care of his father when 4-months-old.
Key issues: paternal history of: depression; committing domestic abuse; offending with minor convictions; drug and alcohol use; and allegations of inappropriate sexual behaviour. A number of injuries were identified by various professionals in the month prior to the incident.
Learning: identifies themes, including: optimistic thinking driving plans for Child J to be placed with his father to the exclusion of thorough exploration of risk; insufficient information sharing between agencies; and lack of holistic assessment of family leading to unacceptable evaluation of risk.
Recommendations: makes various recommendations including monitoring the use of escalation procedures.
Keywords: physical abuse, fathers, assessment
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July 2015 – St Helens – Child JSH
Death of a 17-year-10-month-old boy found hanged at home in January 2014. Inquest found that Child JSH had intentionally taken his own life.
Background: history of: domestic abuse; anti-social behaviour; violent behaviour leading to arrests; sexually intimidating behaviour toward members of school staff and female pupils; and stalking and threatening behaviour toward a fellow pupil with whom child JSH had a relationship. Child JSH was described as having had few close friends but a wide network of associates on social media and a high-profile locally in relation to fighting and anti-social behaviour. Police had intelligence that child JSH was receiving threats via social media 2-3-weeks prior to his death.
Learning: identifies four key findings, including: remaining child-centred in responses to older children who present with criminal and harmful sexual behaviours (HSB); and meeting the needs of children who experience severe behavioural difficulties through the system of mental health referral and triage. Identifies wider learning around: the risks presented by social media in relation to developing networks that promote and encourage HSB.
Methodology: systems methodology.
Keywords: suicide, harmful sexual behaviour, child and adolescent mental health services (CAMHS)
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June 2015 – Cambridgeshire – Child K
Death of a 2-year-old boy in January 2014. Primary cause of death was bacterial pneumonia infection with secondary causes of dehydration, failure to thrive, norovirus and cerebral palsy.
Background: following his death, mother received a police caution for cruelty against Child K contrary to Section 1 of the Children and Young Person’s Act 1933. Child K and his sibling had been subject to a child protection plan for neglect for a month prior to the incident.
Key issues: maternal history of: childhood abuse, time spent in the care of the local authority, offending, self harm and homelessness. Father was nine years older than mother and also had a history of childhood abuse and time spent in the care of the local authority. Child K was born 24-weeks prematurely, which affected his lung development causing chronic lung disease. Child K had additional complex needs resulting from a hole in his heart, concerns about his hearing and vision and a bleed in his brain resulting in him developing cerebral palsy.
Learning: analyses key themes, including: the impact of Child K's disabilities on assessment of risk and inconsistency in the level of professional concern; inconsistent perceptions of mother's understanding of Child K's needs or of her ability and commitment to meeting them; and lack of professional understanding of the interaction between Early Help, Early Support and Children in Need systems.
Recommendations: makes various recommendations, including the provision of training on neglect and disability.
Keywords: children with a chronic illness, child neglect
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June 2015 - Havering – Child Y, Child X and Child W
Chronic neglect and emotional abuse of 3 siblings aged 15-years-old, 11-years-old and 6-years-old, and the sexual abuse of 1 or more of the siblings.
Background: children were subject to child in need status and child protection plans at various points in their lives due to concerns around neglect. Concerns were first identified shortly after the birth of the first sibling in 1998, and eventually resulted in the local authority arranging for them to live with their grandparents in 2009. Concerns continued, and in September 2013 the siblings were taken into local authority care.
Key issues: the prioritisation of keeping the children in their family above child protection needs; a lack of communication between professionals and the family about concerns and the actions that needed to be taken; the lack of explicit reference to neglect in some assessments of the children's needs; the absence of a plan or appropriate monitoring of support once care of the children was transferred to their grandparents and delays in taking action due to the grandparents' "false compliance".
Recommendations: develop a multi-agency pathway for identifying and responding to children who may have weight faltering and develop a multi-agency case review and planning process for individual highly complex cases.
Model: uses a hybrid methodology, drawing on a variety of theoretical approaches and techniques.
Keywords: child neglect, emotional abuse, kinship care
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June 2015 - Kingston - Child B
Suicide of a 15-year-old South Korean boy in July 2014. Child B jumped from the top floor of an indoor shopping centre and died in hospital.
Background: Child B moved to the UK aged 6 to live with his father and older brother; contact with their mother was sporadic. Child B was made the subject of a child protection plan, when 10-years-old, for physical and emotional abuse and was briefly looked after. From 2012 the family were receiving support after the father had an accident at work and they became homeless. On the day he killed himself Child B spoke of wanting to take his own life.
Learning: Child B's voice and experience were not present in any reviews; limited exploration of the impact of mother’s absence; and copy and pasting of old information into new reports.
Methodology: systems approach.
Keywords: suicide, adolescent boys, physical abuse
Read the overview report
Read the executive summary

May 2015 - Blackpool – Child BT
Death of a young child in 2014. Initial post mortem proved inconclusive; second post mortem concluded that cause of death was inhalation of stomach contents with the underlying cause being poisoning by Methadone.
Background: Mother pleaded guilty to manslaughter; father went to trial and was found guilty of manslaughter and child cruelty. Family was known to children's services and both BT's sibling and step-sibling had previously been subject to child protection plans.
Key issues: both parents were engaging in drug treatment but mother was known, and father suspected, to have periods of illicit drug use. Both had a history of offending and problems with financial management. Father was suspicious of social care involvement and was rarely seen during home visits.
Learning: professionals in the area were used to working with complex families, which may have led to the 'normalisation' of issues; information on risk factors was not shared by all professionals and professionals did not always refer the family to children's social care when appropriate.
Recommendations: all agencies should fully engage with the Multi-Agency Safeguarding Hub (MASH); family assessments should involve the whole family, including the father; and parental non-compliance with drug services should result in immediate action to bring multi-agency professionals together.
Model: systems methodology
Keywords: addicted parents; poisons and poisoning; neglect
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May 2015 - Bristol – T
Death of a 3.5-month-old on 14 January 2013 from a non-accidental brain injury, consistent with shaking. Father was found guilty of manslaughter. Mother was acquitted of causing or allowing the death.
Background: evidence of possible physical abuse of T's older sibling who was a 'Child in need'. Both parents had been known to professionals since childhood. Parents’ relationship started when T’s father was 20-years-old and mother was 13-years-old. Charges against the father for sexual activity with a child were dropped due to lack of evidence. Father was a prolific offender and a drug user with a known history of domestic abuse. T's mother had a history of violent behaviour.
Key issues: the case was never seen as a child protection issue and learning from previous case reviews was not embedded in practice.
Recommendations: regular multi-agency meetings to consider possible victims and perpetrators of child sexual exploitation; the introduction of integrated chronologies; training for safeguarding leads on learning from previous local case reviews; advanced domestic abuse training for frontline practitioners; and a new protocol for the use of parent partnership agreements to ensure they are realistic.
Method: Social Care Institute for Excellence (SCIE) systems methodology.
Keywords: infant deaths, shaking, disguised compliance, child sexual exploitation, domestic abuse
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May 2015 – Bury – Baby I (Case I13)
Serious injury of a 6-week-old boy in October 2013. Baby I was made the subject of an emergency protection order following an examination that revealed he had sustained two broken ribs and a knee fracture.
Background: Mother and Father had been in a relationship for 3-months before Mother became pregnant with Baby I. Paternal history of: drug misuse; suicide attempt in adolescence; and self-reported thoughts of harming baby I to stop him crying. Maternal history of: psychotic depression, previous suicide attempts and incidents of self harm. Father was recorded as mother’s carer.
Key issues: issues identified include: insufficient exploration and understanding of the impact of high energy drink consumption on father’s mood and anger responses; and practitioners’ belief that father belonged to a particular sub-culture possibly inhibiting them from challenging father’s behaviour as they wished to appear non-judgemental.
Model: uses some elements of the Social Care Institute for Excellence (SCIE) Learning Together model.
Keywords: parents with a mental health problem, substance misuse
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May 2015 - Enfield - CH
Life imprisonment of a 15-year-old boy convicted of killing a 21-year-old man. CH stabbed Mr Z, a stranger, following a confrontation on a residential street.
Background: CH was subject to a child protection plan at the time of the incident. His case was being coordinated by Haringey children and young people’s services as a transfer case conference had not been arranged following family’s move to Enfield one year earlier. Family history of: mental health problems; alcoholism; domestic abuse; criminal behaviour and anxiety around their immigration status (they were originally from Jamaica). CH had a history of offending, self-harming; and running away from home. He had previously been subject to a care order.
Key issues: mother's problems distracted from the needs of her children; support for the family ended abruptly following the cessation of a care order; and domestic abuse between mother and female partner was not treated as seriously as heterosexual partner violence.
Recommendations: information coordinators should be appointed within teams working with families with complex needs, to compile a family history and facilitate information sharing; the Safeguarding Board should create a simple chronology tool that could be completed across agencies; and the Safeguarding Board should explore custodial and residential approaches to working with young people with severe behavioural problems.
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April 2015 – Croydon – Child M
Death of a 14-year-old black boy in September 2012, as the result of a fatal stab wound to the heart. Child M was stabbed by another teenager, following an altercation. Child S was found guilty of murder and sentenced to life imprisonment, to serve a minimum of 14-years; the Judge referred to the incident as a “revenge killing”.
Background: At the time of the incident, Child M had been missing from home for nine weeks. Child M attended college a week after he was first reported missing. Police and children’s social care were informed and told that Child M did not want to return home as he was scared he would be beaten by his stepfather; neither agency visited the college nor investigated this disclosure and Child M was allowed to leave college without confirmed arrangements for his care.
Learning: passive response from police and children’s social care to a missing 14-year-old child; passive attitude of police to communicating with parents; and insufficient involvement of mother’s partner in assessments.
Recommendations: makes various recommendations covering: professional challenge and escalation; communication between schools and colleges and other agencies during school/college holidays; and whether child protection services received by older children are robust and the extent to which gender and ethnicity effect them.
Keywords: adolescents, runaway children, escalation
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April 2015 – Croydon – Josh
Death of a 3-year-old boy in March 2013. Mother carried Josh into the path of an oncoming train, killing them both.
Background: Mother had a history of severe anxiety disorder and had been receiving treatment from her GP and various mental health services in the months preceding Josh’s death.
Key issues: procedural failure responding to a children’s social care referral made by Mother’s psychiatrist; a culture of overreliance on children’s social care for actions regarding a child; and perceived inconsistent and misleading advice from mental health services leading Mother and Family to continue accessing private mental health providers as they lost trust in NHS providers.
Model: review was undertaken using the Significant Incident Learning Process (SILP).
Keywords: adult mental health services, suicide, referral procedures
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April 2015 – Fife and Edinburgh Child Protection Committees – Child MK
Death of a male child in January 2014. MK was reported missing by his mother on 16th January; his body was found on 17th January following a police search. Mother pleaded guilty to culpable homicide and was sentenced to 11-years imprisonment.
Background: MK entered foster care in July 2012 following a notification received by social work services that mother had left her children unattended. MK returned to the care of his mother under a supervision order in August 2013. Family was receiving support from Fife Social Work Services on a voluntary basis at the time of the incident.
Learning: identifies areas for future learning and action including: Scottish government should consider the need for the development of national guidance for the transfer of non-child protection cases across local authority areas; and NHS Fife should review how information, which is below the child protection threshold but which impacts on child wellbeing, is shared between GPs and health visitors.
Keywords: assessment, case transfer
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April 2015 - Lambeth – Child I
Death by drowning of a 20-month-old boy in July 2013.
Background: Child I and his two older siblings were subject to child protection plans under the category of neglect at the time of the incident. Parents both had learning difficulties and at times reacted with anger and hostility to professional interventions. Child I was found face down in the bath; mother reported she had left Child I in the bath, informing father she had done so, before leaving the house. Parents were subject to police investigation as alleged perpetrator and witness throughout the case review process.
Key issues: professional emphasis on investigating physical injuries at the expense of considering indicators of neglect; and overreliance on written agreements with parents to support child protection arrangements.
Model: Social Care Institute for Excellence (SCIE) Learning Together model
Keywords: adults with learning difficulties, neglect and interagency cooperation
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April 2015 – Lancashire – Child L and Adult L
Death of a 6-year-old boy and his mother and the attempted suicide of his father in April 2013. Father was diagnosed with a psychotic mental illness and detained under the Mental Health Act 1983.
Background: Child L and parents were not known to any specialist services. Previous contacts with health services for injuries to Child L and Adult L were judged to be accidental. The day before the father consulted his GP about feeling in low mood and hearing voices. There had been no previous mental health issues. GP requested an assessment by a mental health practitioner and a meeting was scheduled for the next day.
Learning: identifies good practice including the GP’s referral to mental health services and school support to pupils and families after the deaths.
Key issues: missed opportunities for sceptical and curious enquiry by health professionals; no enquiry about Child L by GP; ‘shortcoming of human inference’ leading mental health specialists to think a GP would rate a case high risk to get a quick assessment; use of a telephone triage system for mental health assessment.
Methodology: joint serious case review and domestic homicide review. Uses a systems framework to present the key learning.
Recommendations: questions for consideration cover: overcoming cognitive influence and human bias in information sharing; ensuring sufficient enquiry and recording of any presentations for medical treatment; use and availability of tools and frameworks for assessing risk.
Keywords: parents with a mental health problem, family annihilation/familicide
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April 2015 - Lancashire – Child N
Death of a 4-year-old boy and his mother in May 2014 as the result of a house fire in Liverpool. Coroner's verdict was that Child N had been unlawfully killed and mother had taken her own life after deliberately starting the fire.
Background: parents separated acrimoniously prior to Child N's birth. Mother requested a termination, but was refused due to the late stage of her pregnancy. After the birth, the mother briefly went missing which resulted in Child N spending a short time in foster care. Due to concerns about his safety and on-going contact disputes, Child N’s care was subject a number of court proceedings. The court’s decision in the second case resulted in the father, who lived in Lancashire, being granted a residence order and the mother a contact order. During the fourth and final set of proceedings, whilst Child N was on a contact visit, the mother made allegations of child sexual abuse which resulted in Child N staying with her in Liverpool.
Key issues: family history of: maternal mental health problems, domestic violence and multiple parental allegations and counter allegations of poor care and abuse. Challenges identified include: language and translation issues when communicating with maternal grandparents; and the lack of means for professionals to enforce court imposed decisions regarding child contact.
Learning: parental mental health assessments should be shared with all professionals involved in the child's life; and when closing a case social workers should ensure they inform all professionals working with the child.
Recommendations: LSCBs to explore options to help frontline practitioners understand and assess behaviour of a parent who causes concern but does not have a recognised mental illness.
Keywords: filicide, suicide, parents with a mental health problem, contact
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April 2015 - Lincolnshire – Baby W
Death of a baby boy during the hours following his birth in September 2013. Mother was 16-years-old at the time of the incident; she had concealed or denied her pregnancy and given birth, unassisted in her bedroom at home. Post mortem revealed that Baby W died from a tissue blocking his airway; mother pleaded guilty to infanticide and was sentenced to a 2-year Youth Rehabilitation Order (YRO).
Background: mother was known to universal services only; she did not present with any physical symptoms of pregnancy prior to Baby W’s birth. During her pregnancy mother presented to GP a number of times with concerns of low mood and depression and self-referred to an Improved Access to Psychological Therapies (IAPT) service for support with her anger as a result of depression. Mother was asked and denied her pregnancy on a number of occasions, by professionals and family members.
Learning: identifies one missed opportunity to provide mother with age appropriate advice around sexual activity, contraception, sexual health and healthy relationships. Identifies lessons to be learnt, including: need for awareness raising and development of procedures and guidance around concealed or denied pregnancy; importance of young people receiving sexual health and contraception advice; and increased GP knowledge of the support that school nursing services can provide young people.
Recommendations: makes various recommendations.
Keywords: concealed or denied pregnancy, teenage pregnancy
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April 2015 - Tameside – Child M
Death of a 17-year-old girl in December 2013. Child M's body was found in a garden with a ligature around her neck; there was no evidence of any third party being involved.
Background: Child M was never identified as a child in need or requiring protection, but did receive support from Child and Adolescent Mental Health Services (CAMHS), although she was never diagnosed with a mental health condition. She also received support from: young people's services (YPS); the Crisis Resolution Home Treatment Team (CRHTT) and a drug and alcohol treatment charity.
Key issues: Child M had a significant history of self-harm, alcohol and drug misuse, truancy, school exclusions and verbal and physical violence. Child M disclosed to professionals an experience of being inappropriately touched by an adult and her feelings of distress over her father's use of alcohol and violent behaviour during her early childhood.
Learning: Child M’s school interpreted her age, intelligence and social background as evidence she had the capacity to change her behaviour, and so their response focussed on behaviour management rather than assessing her support needs; her parents were not always consulted or kept informed about professionals’ concerns for Child M’s welfare; and police were not aware that, due to her complex needs, a social worker rather than a volunteer appropriate adult should have been allocated to Child M whilst she was held in custody.
Recommendations: the police and the council should confirm what arrangements are in place to ensure relevant protocols, including the use of appropriate adults, are known and used by both services.
Model: systems based approach
Keywords: suicide, self-harm, risk assessment
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March 2015 – Blackpool – Baby Q
Serious unexplained head injury of an infant, under 4-weeks-old.
Background: Mother found guilty of causing or allowing her baby to suffer serious physical harm. Baby Q was removed to permanent care of an approved family member.
Key issues: family's transient living arrangements, lack of engagement with antenatal care, substance misuse, domestic abuse, maternal depression and high levels of parental anxiety.
Learning: importance of midwives and health visitors co-planning and coordinating responses and need to routinely and confidentially ask parents about domestic abuse, mental health and substance misuse.
Recommendations: put in place a mechanism to reduce the risk of confusion caused by recording the same case under multiple surnames and ensure there is full consultation with other agencies before a diagnosis is changed from non-accidental injury to medical cause.
Keywords: head injuries, infants, non attendance.
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March 2015 – Bromley – Child E
Death of a 12-week-old boy in March 2014 as the result of Sudden Unexpected Death in Infancy (SUDI).
Background: Child E was Looked After at the time of the incident and had been placed, with his twin brother and two older siblings, in the care of his maternal aunt. Both parents had been arrested for burglary offences and were remanded in prison at the time of the incident. Family are from an Irish Traveller background and had lived in a number of different Local Authorities. History of: parental offending; parental drug and alcohol misuse; and maternal mental health problems.
Issues: children’s poor school attendance; flawed decision not to hold a pre-birth assessment; ineffective case transfer process; and the impact of culture on the decision to place Child E and his siblings with maternal aunt.
Recommendations: London local authorities to develop a collective and holistic response to safeguarding transient families; NHS England – London to review the format of Root Cause Analysis reports, which did not fully lend themselves to the serious case review process.
Keywords: sudden infant death, co-sleeping, transient families
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March 2015 - Cambridgeshire – Child H
Death of a 2-year-old girl in November 2013 as the result of non-accidental injuries, including a lacerated liver. Post mortem identified older injuries including a broken wrist. Mother’s 19-year-old boyfriend was caring for Child H alone at the time of the incident. Mother’s boyfriend was convicted of Child H’s murder and sentenced to life imprisonment. Mother was acquitted of causing or allowing Child H’s death but admitted two charges of neglect in relation to Child H’s older siblings.
Background: mother’s boyfriend had a troubled childhood, which included: child in need involvement with children’s social care; homelessness; offending; conduct problems; serious childhood illness; and significant involvement with child and adolescent mental health services (CAMHS),for which he was prescribed medication until his discharge from CAMHS at the age of 17. Family became known to children’s social care following a referral made by Sibling 1’s school, identifying a number of concerns linked to mother’s boyfriend’s involvement with the family, including the deterioration of Sibling 1’s presentation, her hygiene and hunger.
Key issues: timeliness and responsiveness of early help arrangements; use of ‘what if’ consultations to discuss whether concerns meet the threshold for a referral to children’s social care and the need to clarify where there is an apparent misunderstanding about agreed actions following consultation; effectiveness of verbal action plans; and the role of Cafcass in private law cases.
Learning: identifies themes in the case, including: professionals seeing family members as individuals and not recognising the potential impact of concerns on the family network as a whole; insufficient consideration of the role of men in the children’s lives; and the over-representation of children from minority ethnic backgrounds in serious case reviews.
Recommendations: makes recommendations covering: interagency working, Cafcass, children’s social care and schools.
Keywords: information sharing, interagency cooperation, non-accidental head injuries
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March 2015 - Cambridgeshire – Child J
Serious sexual and physical assault of a 4-year-old girl in August 2013. Child J was presented at hospital with bruising to the trunk and arms, a bite mark and evidence of significant trauma to the genital area. Stepfather was convicted of the offence of sexual assault and sentenced to 17-years imprisonment.
Background: Child J moved to the UK from an EU country with mother and older sibling in 2010 and took up temporary residence in a Midlands town. Family returned to the EU country when mother’s relationship with her partner, a UK citizen, broke down. Mother married Child J’s stepfather in 2012 and family moved again to UK. Child J was presented to GP, and subsequently the hospital, several times in the months prior to the incident. During the final hospital visit before the incident symptoms were identified including a rash to scalp, swelling to eyes and face and bruising on trunk, arms, feet and wrists. Child J was discharged following examination with the conclusion that it was likely that the swelling was due to an acute allergic reaction to antibiotics prescribed for the rash. Child J was taken to hospital in August 2013, where injuries prompting a Section 47 enquiry were identified.
Key issues: identifies themes in the case, including: impact of ethnicity, identity and language; mother’s history of marriage and relationships; inconsistent identity checks across agencies; and communication within and between agencies.
Model: Significant Incident Learning Process (SILP) methodology
Keywords: communication, interagency cooperation, professional curiosity
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March 2015 - Coventry – Child T
Death of a 3-week-old girl in June 2013; coroner classified cause of death as ‘unascertained’. 
Background: Following Child T's death, a home visit found that the family were living in dirty and unhygienic conditions. There had been no previous concerns about the mother's care of her children and they were not known to children's social care. 
Key issues: issues identified include confusion across partner agencies about when the Common Assessment Framework was open and when it had been closed and a failure to check the room in which the child was to sleep during the community midwife’s home visit. 
Recommendations: simplify the Common Assessment Frameworks’ management system and always check the room in which the child sleeps in the day and night.
Keywords: infant death, neglect, home environment
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March 2015 - Haringey – Child D
Serious injury of an 11-week-old baby.
Background: Mother took Child D to hospital with a fractured arm. X-rays identified a number of old fractures sustained when Child D was about 1-month-old. Child D was taken into foster care; mother and father were arrested and charged with neglect and causing or allowing Grievous Bodily Harm (GBH). The case was later dismissed due to the non-availability of a key witness.
Key issues: mother was physically abused and neglected as a child and had spent time in care. Family history of violence and criminal activity.
Learning: focus on targets led to lack of critical assessment and professional desensitisation of the environment of violence and criminal activity the baby was growing up in.
Model: Social Care Institute for Excellence (SCIE) Learning Together model
Keywords: infant; injuries; adults abused as children.
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March 2015 - Harrow – Child R
Death of a 16-year-old boy of Eastern European descent in November 2013 as the result of an overdose of a combination of prescribed and illegal drugs.
Background: Child R came to live in the UK when he was 9-years-old. Family received support from a significant number of services. In 2010 Child R and his younger siblings were made the subject of child protection plans because of neglect. Between 2011 and 2013 Child R spent time in a number of types of placements including foster care, secure and residential accommodation. The lengths of placements ranged from between 2-days and 6 1/2-months and were in a number of locations including Harrow and neighbouring boroughs, North Wales, the Midlands and the North West.
Key issues: Child R had a history of substance misuse, mental health problems and involvement in gangs.
Learning: the difficulties of managing risk and personal choice when working with troubled adolescents; confusion caused by a large number of services providing different interventions focused on different objectives and risks; and information sharing, coordination and timeliness issues caused by placing a child in care outside their local area.
Recommendations: local authority should ensure that systems are in place to allow full details of every looked after child, including a recent photograph, be made available to the police if a child goes missing; and local authority and the clinical commissioning group should ensure that all looked after children have access to timely and comprehensive health assessments and receive the health care they need.
Keywords: substance misuse, children in care, adolescent mental health
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March 2015 – Isle of Wight – Q Family
Long term physical, emotional and sexual abuse and neglect of several children within a family.
Background: Family had complex needs, requiring the involvement of multiple agencies over a period of nearly 20 years. Children were exposed to a highly sexualised environment and had unsupervised contact with an individual believed to be a risk to children. For 2 brief periods some or all of the children were placed on the child protection register. Care proceedings were initiated in 2013.
Key issues: domestic abuse; inter-sibling violence; parental alcohol misuse; and an aggressive, manipulative and litigious paternal response to professional interventions.
Learning: need for supervision and use of discretion in excluding hostile parents from child protection conferences.
Recommendations: multi-agency meetings should be convened if any agency has major concerns; records should be easily accessible and processes should allow multi-agency discussion of chronic cases without a single trigger event.
Keywords: repeated abuse, disclosure, hostile behaviour.
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March 2015 - Kirklees – A young person
Attempted suicide of an adolescent boy in September 2013.
Background: The young person's attempt on his life has been linked to a drug influenced psychotic episode. Family were well known to agencies and there had been professional concerns around neglect of the young person and his siblings since 2005. Between 2009 and 2011 the young person was the subject of a child in need plan, a child protection plan, care proceedings and a supervision order.
Key issues: poor school attendance; offending; substance misuse; mother and young person's lack of engagement with professionals; mother's non-compliance with parenting orders and school attendance; and challenges associated with the significant number of professionals and agencies involved with the family.
Learning: need for professional awareness about the link between substance misuse and mental health problems and the link between long term neglect and suicide ideation; and need to maintain focus on older children when there are younger children in the family.
Recommendations: the development and implementation of a toolkit to help professionals engage with 'hard to engage' young people.
Keywords: suicide, adolescent boys, substance misuse.
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March 2015 - Kirklees – Subject child
Death of a 1-year-9-month-old child in February 2012 as the result of severe brain damage. Police were unable to establish how the subject child sustained the fatal head injuries however medical evidence indicated that they were inflicted non-accidentally.
Background: Maternal history of depression and concerns raised by father and paternal grandparents relating to an unexplained burn to subject child’s hand and a bruise.
Learning: identifies analysis and learning, including: focus on parental behaviour sometimes diverting professional attention away from the child; GPs treating episodes of maternal depression in isolation with insufficient attention to broader issues of family life, parenting capacity and child wellbeing; and need for professionals to remain alert to safeguarding issues and to think critically and reflectively whilst performing routine professional activities
Keywords: NAHI, maternal depression, optimistic thinking, professional curiosity
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Read the executive summary

March 2015 - Leeds – Child V
Death of a 17-year-old boy, as a result of hanging. Ryan was found with a ligature around his neck in a cell in a Young Offender Institute (YOI); Coroner's inquest concluded accidental death.
Background: Ryan had been in the care of Leeds City Council since he was 16-months-old; when he was 13-years-old his long-term foster placement broke down and he did not have another stable placement.
Key issues: history of extensive record of offending; chaotic lifestyle and risk-taking; aggressive behaviour; and frequent movement between accommodation.
Recommendations: corporate parenting responsibilities for promoting education, training and employment; and provision of suitable, specialised accommodation for young people with high support needs
Keywords: adolescent boys, young offenders, suicide
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March 2015 – Nottingham City – Child G
Death by drowning of a 10-month-old baby girl in May 2012.
Background: Mother stated she briefly left her infant unsupervised in the bath and pleaded guilty to involuntary manslaughter. Family were known to a number of services, including: police, health visitors, social care, probation services and Cafcass.
Key issues: professionals didn't consider the impact of parents' mental health, domestic abuse and substance misuse on children and some decisions were based on self-reported information from the parents as opposed to thorough assessments.
Recommendations: incidents of children being left home alone must be treated as a child protection issue and all appropriate family members should be included within risk assessments.
Model: systems methodology.
Keywords: infant deaths, family violence, optimistic behaviour.
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March 2015 – Oxfordshire - Children A, B, C, D, E and F
Sexual exploitation of 6 girls aged 12-16 who were the victims of offences between May 2004 and June 2012.
Background: 9 men were charged with offences, of which 7 were convicted on 14 May 2013. Girls targeted had complex needs, and many were known to children's services or in care. They were groomed by older men who supplied them with drugs and alcohol.
Key issues: lack of understanding of child sexual exploitation, insufficient use of child protection processes, lack of organisational overview, difficulty managing missing children and a focus on young people's behaviour rather than their risk of being harmed.
Recommendations: review escalation procedures, clarify agencies' child protection roles and review national guidance on the use of disruption techniques in safeguarding children.
Keywords: child sexual exploitation, grooming, professional attitudes.
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March 2015 - Sutton – Child E
Death of a 16-year-old of dual heritage, in May 2014, as the result of an accidental overdose.
Background: Child E was born with serious narcotic withdrawal symptoms and went on to suffer chronic neglect and possible sexual abuse in early childhood. A pre-birth child protection conference decided it was not necessary to make Child E subject to a protection plan. Child E's siblings were made briefly subject to child protection plans in 2000 and the police twice exercised their powers of protection to remove the children before care proceedings were initiated for Child E and siblings in 2001. A final care order was obtained in 2002 and Child E was placed for adoption in 2004. This placement broke down in 2008 after which Child E had a number of placements in a range of settings, including secure units.
Key issues: Child E’s birth parents had a history of substance misuse, violent and criminal behaviour. Child E had a history of: fire starting; self-harm and suicide attempts; substance misuse; mental illness and emotional dysfunction.
Learning: optimistic interpretation by professionals of birth family’s ability to care for Child E; high risk matching of Child E with a lone female adoptive parent with a medical condition; lack of formal adoption support plan; dispute between local authorities over who was responsible for Child E; ongoing uncontrolled contact between Child E and birth family; and poor discharge planning from residential mental health care.
Recommendations: mental health trust should develop and maintain a risk register of looked after children from each of the local authorities; and contact with birth parents should be carefully monitored by social workers and action taken if it starts to negatively affect the child or placement.
Keywords: drug misuse; child neglect; attachment behaviour; contact
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February 2015 - Hertfordshire – Young Person B
Suicide of a 17-year-old girl in April 2013. Child B was an inpatient in a specialist adolescent mental health clinic under Section 3 of the Mental Health Act 1983 at the time of her death.
Background: B was admitted to the clinic due to concerns that she had an eating disorder and because she had been self-harming. B lived with mother and step-father until January 2012 when she moved in with her boyfriend and then later her father. Although B's living arrangements were initially agreed by mother, she soon afterwards wanted B to return home. Family were known to services including Targeted Youth Support Service (TYSS) who worked with B, her mother and step-father to try to rebuild their relationship.
Learning: contact with children's services should be considered when a young person presents with significant mental ill-health and where there are concerns about the impact of family dynamics on protective factors; and formal consideration should be given to sharing the details of Community Treatment Orders (CTOs) with agencies providing services to young people placed on CTOs, including schools.
Model: Partnership Learning Review model
Keywords: suicide, self-harm, anorexia, Mental Health Act 1983
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February 2015 – Nottingham – Child H
Death of a 7-month-old girl in September 2013; inquest concluded with a finding of unlawful killing. Mother pleaded guilty to infanticide and was made the subject of a hospital treatment order under the Mental Health Act 1983.
Background: a psychiatric assessment completed during criminal proceedings described mother to be suffering from the following at the time of the incident: schizoaffective disorder for which mother had avoided treatment through her lifestyle choices and use of alternative coping mechanisms; personality disorder; and mental and behavioural disorders due to use of alcohol-dependence syndrome. Child H was living with mother, father and sibling at the time of the incident.
Key issues: father was considerably older than mother and was receiving ongoing treatment for chronic obstructive pulmonary disease (COPD). Mother had a history of anxiety and depression and was noted to have little support in England; mother was father’s sole carer.
Learning: identifies themes, including: insufficient assessment with regard to the impact of mother caring for father upon her and her care of the children; focus of the discussions between agencies in relation to Child H focussing on the mental health needs of mother and physical health needs of father; recognition of symptoms of emerging mental health issues; lack of understanding and use of carer’s assessment and the Common Assessment Framework (CAF); and lack of consideration of mother and father’s self-identification as ‘Spiritual Teachers’ on family functioning and family culture/norms.
Recommendations: makes various single and multi-agency recommendations.
Keywords: parents with a chronic illness, parents with a mental health problem, assessments
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February 2015 – Southampton – Child K
Death of a 7-year-old boy in December 2011, as the result of a serious head injury.
Background: Mother's partner, Mr X, and Mr X's brother, Mr Y, were arrested following Child K's death however no prosecutions were made. This decision was reviewed in April 2014 and mother, Mr X and Mr Y were arrested; in December 2014, the Crown Prosecution Service decided that no further action would be taken in relation to Child K's death. Family were well known to agencies and Child K and his siblings had been the subjects of Child Protection plans for a period in 2011. History of: significant and sustained domestic abuse; repeated witnessing of injuries to Child K; concerns from school over Child K's sexualised behaviour, poor attendance, attention-seeking behaviour and temper outbursts; and inadequate response to repeated referrals from maternal grandmother to children's social care.
Key issues: possible low expectations of professionals in relation to the quality of life Child K and his siblings could expect; and failure of practitioners to make connections between being intimidated by Mr X and the probability that Child K would feel similarly threatened.
Recommendations: raising public awareness locally of the links between domestic abuse and safeguarding of children.
Keywords: domestic abuse, physical abuse, scapegoating
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January 2015 - Hampshire – Child X
Death of a 2-year-old girl in the summer of 2013, as the result of serious, non-accidental injuries. Child X had been in the sole care of mother’s partner immediately prior to admission to hospital with head injuries. Police investigation was instigated following the incident; the Crown Prosecution Service (CPS) later concluded there was insufficient evidence on which to mount a prosecution.
Background: soon after birth Child X was diagnosed with congenital myotonic dystrophy, a life-limiting condition in which muscles are poorly developed, resulting in profound weakness. Family were well-known to health and social care services as a result of Child X’s condition; there had been contact with children’s social care prior to Child X’s birth in relation to concerns in respect of older sibling.
Key issues: identifies issues, including: lack of clear planning and management of the case and failure to include the family who were seen as passive recipients of a "package of care"; repeat concerns about cleanliness and disorder in the family home; and the extent to which the principal reason for agency involvement being Child X’s complex health needs, may have affected assessment of her need to be safeguarded.
Recommendations: makes recommendations, covering: arrangements for multi-agency audits of work with children with disabilities including arrangements for appropriate lead professionals; and guidance about identifying and assessing concerns arising from poor home environment.
Keywords: children with disabilities, non-accidental head injuries, interagency cooperation
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January 2015 - Leeds – Child Y
Death of a 14-week-old girl in March 2012. Post-mortem examination jointly conducted by two pathologists resulted in the recording of two different probable causes of death: Sudden Infant Death Syndrome and unascertainable.
Background: Child Y lived with mother, father and five older siblings in a three bedroom property at the time of the incident. Family had been known to children's services since 2003 and children were subject to Child in Need and Child Protection plans at different times before and after Child Y's death. Professionals' concerns primarily related to home conditions, children's personal hygiene and school attendance.
Key issues: poor assessments, not carried out in a timely manner contributing to 'drift'; and lack of appreciation of the long-term impact of neglect and belief that better outcomes would be achieved by maintaining parents' cooperation
Recommendations: various, focusing on conflict resolution, multi-agency working and training.
Model: systems model.
Keywords: child neglect, drift, co sleeping
Read the overview report

January 2015 – Liverpool - Maisie
Death of a female infant in December 2013 as a result of Sudden Infant Death Syndrome
Background: Family were known to children's services in a neighbouring local authority where one of Maisie's siblings, Sibling 4, had been subject to a Child Protection plan.
Key issues: maternal alcohol misuse; domestic abuse; volatile relationship between mother and older sibling, Sibling 1; and deaths of two of mother's previous children from natural causes, the second of these deaths having been the subject of a serious case review (SCR).
Learning: need for clarity in relation to specialist roles such as the Enhanced Midwife, including clear expectations in relation to safeguarding; and changes in legislation, whereby previous contacts with children's services will be a contributory factor in granting Legal Aid, acting as a possible incentive towards making anonymous referrals.
Model: Uses a systems approach to present findings and questions for Liverpool Safeguarding Children Board.
Keywords: Sudden Infant Death Syndrome (SIDS), alcohol misuse, Common Assessment Framework (CAF)
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January 2015 – Liverpool - Mary
Death of a 6-month-old girl in July 2013, cause of death unascertained. Post-mortem recorded that Mary was a well-nourished child and found no past or current injuries; a number of risk factors for sudden infant death syndrome were identified, including prematurity and parental smoking.
Background: History of family violence; parental substance misuse; and professional concerns about school attendance levels and the health of Mary's two older siblings who were significantly overweight.
Findings: lack of a common language and understanding between agencies; insufficient professional recognition of parental failure to meet a child's education or health needs, as significant indicators of neglect; and ineffective follow-up from health services for a baby with on-going health needs in the care of parents with a poor history of engagement.
Recommendations: raises issues of consideration for Liverpool Safeguarding Children Board based on the review findings.
Model: uses a systems approach.
Keywords: Sudden Infant Death Syndrome (SIDS), child neglect, professional challenge
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January 2015 - Oldham – Child D
Death of a 7-week-old English/Polish child in January 2014, as the result of a severe head injury and multiple other injuries.
Background: Mother, mother's boyfriend and another adult male were arrested on suspicion of murder. All adults were sentenced for Perverting the Cause of Justice; sentencing Judge commented that at least one of the adults must have been responsible for the injuries.
Key issues: mother emigrated to the UK from Poland in 2010. Mother reported not knowing she was pregnant until 2-weeks before Child D's birth and did not engage with community-based ante-natal services. Mother was known to police following a number of allegations of assault and domestic harassment.
Learning: insufficient professional curiosity given the concealment or denial of mother's pregnancy; and the use of two different formats for inputting dates of birth onto electronic systems contributing to an error that prevented sufficient sharing of information
Recommendations: the use of genograms by community-based practitioners as a tool to gather information and to prompt practitioners to be inquisitive; and simplification and consistency in data inputting formats and processes.
Keywords: professional curiosity, concealed pregnancy, domestic abuse
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January 2015 - Surrey – Child X
Serious, non-accidental injury of a 4½-week-old child in November 2012. Child X was admitted to hospital with injuries including: up to 8 rib fractures, retinal haemorrhages, traumatic subdural haematoma, and leg and foot fractures. Mother and father were convicted in relation to the injuries.
Background: mother was 18-years-old when Child X was born; maternal grandmother reported that mother had witnessed sexual abuse against her sister by her father and was physically abused by her father as a young child. Bruises and haemorrhages were seen by a number of professionals in the days prior to the incident including: hospital staff, during two separate admissions; GP; and health visitor.
Key issues: identifies issues including: insufficient knowledge of parental history; administrative weaknesses including the loss of papers and delayed transfer of information; insufficiently robust assessments; failure to follow procedures in relation to bruises in non-mobile children; optimistic thinking, failure to revise judgments and insufficient professional challenge; invisible fathers; and failure to undertake multiagency discussions.
Recommendations: makes recommendations covering Surrey Safeguarding Children Board, health services and children’s services.
Keywords: physical abuse, interagency cooperation, professional challenge
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January 2015 - Tameside – Child F
Death of a child as the result of non-accidental head injury.
Background: Mother was on holiday and the time of the incident and Child F had been left in the care of mother's partner, MP1. MP1 was arrested on suspicion of murder.
Key issues: MP1 had a history of threatening and controlling behaviour.
Learning: strengthen safeguarding in the private housing sector and consider the risks posed by mothers' intimate partner relationships.
Recommendations: change police policy to ensure that any threats made indirectly or directly to children get a high risk rating and result in immediate action and ensure that child health checks and follow-ups are conducted in an effective and timely manner.
Keywords: child deaths, non-accidental head injuries, family violence.
Read the overview report

January 2015 - Walsall – W4
Death of an adolescent girl in December 2012, caused by inhalation of the products of combustion.
Background: The Young Person had barricaded herself into her bedroom and set fire to a mattress following a dispute with her carers. At the time of her death, the Young Person was living in a care home where she was the only resident with two adult carers. When the Young Person was 3-years-old, she and her three siblings were removed from the care of their parents due to neglect and placed with their paternal uncle and aunt. The Young Person became a Looked After Child in the care of Walsall Children's Social Care when 15-years-old, during which time she experienced five placements, some of which were out of borough. Significant history of: aggressive and violent behaviour; offending; frequent absconding from placements to return to family; risk-taking; and fire-setting
Recommendations: the option of secure accommodation must be regularly and robustly considered when the frequency and intensity of violent behaviour and absconding increases.
Keywords: adolescents, risk assessment, allegations of abuse
Read the overview report

This list was last updated 1 July 2016.

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