Case reviews Case reviews published in 2016

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 2016. To find other case reviews search the national repository.

2016 – Anonymous – Child BS
Death of a 2-year-1-month-old girl in 2016 in hospital as the result of multiple injuries. Child died from a serious brain injury sustained whilst in the sole care of mother's new partner. The partner was charged with murder and was sentenced to 9 years' imprisonment. The mother was placed on police bail.
Background: family were known to universal services only. Child had a bruise to the face the week before the incident which was recorded by the nursery.
Key issues: the significant impact of the change in the mother's relationship on her children's safety, a lack of robust recording by the nursery following an injury to Child BS and a lack of robust evidence behind Ofsted's positive rating of the nursery's safeguarding provision leading to a misplaced confidence in their procedures.
Recommendations: develop common guidance and supporting documentation for local nursery providers; develop public awareness of domestic abuse and the risks to children at the points of parental separation and newly formed relationships.
Keywords: partner relations, family violence, separation.
Read the overview report

2016 - Anonymous – Child N
The harmful sexual behaviour of a 16-year-old child, who was briefly made subject to a children in need plan following 2 allegations of child sexual abuse. The second allegation led to conviction and imprisonment for sexual assault of an under 13-year-old.
Background: history of disrupted education due to difficulties in concentration and attainment; diagnosis of Attention Deficit Disorder (ADHD); statement of Special Educational Needs; concerns about inappropriate sexual behaviour; and going missing from home.
Key issues: include: lack of supervision for vulnerable children using shared school transport; lack of policy and procedures to guide children's social care professionals; limited professional understanding of sexually harmful behaviour.
Learning: identifies significant learning about responding to children at risk of sexually harmful behaviour.
Recommendations: makes various recommendations including ensuring that multi-agency practitioners are better equipped to work as part of a multi-agency approach in cases of harmful sexual behaviour and review the risk and safety for children who use local authority school transport.
Keywords: adolescents, children in need, harmful sexual behaviour, peer groups, risk assessment, risk management
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2016 – Birmingham – BSCB 2011-12/1
Death of a 21-month-old boy from serious injuries in June 2011. Following the child's death, the mother's boyfriend was sentenced to 8 years for manslaughter and the mother to 15 months for child cruelty.
Background: mother had recently moved out of maternal grandmother’s home into her own tenancy and her new partner spent significant amounts of time there. Mother had a history of: mental health problems, childhood sexual abuse and abusive relationships. Partner had a history of substance misuse.
Key issues: include GPs didn’t consider safeguarding issues when treating parents of vulnerable children and inadequate screening of referrals of concern to children’s social care.
Recommendations: include: the Safeguarding Board should routinely evaluate measures taken by Children’s Social Care to improve the screening of referrals; the Mental Health Trust should promote guidance on protecting children and young people for doctors who treat adult patients.
Response: Birmingham Safeguarding Children Board’s judged that the review was “unfairly unbalanced” and made the decision not to fully accept the review’s findings and recommendations.
Keywords: child deaths, physical abuse, referral procedures
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2016 – Bournemouth and Poole – Baby N
Death of a 17-week-old boy in summer 2015 from sudden unexplained death in infancy (SUDI). Baby N died whilst co-sleeping with his mother. The coroner’s report indicated overheating through being over wrapped as a contributory factor.
Background: mother had been in care during her childhood and became pregnant at 16-years-old. Father had Attention Deficit Hyperactivity Disorder (ADHD), a history of drug abuse and violent behaviour and was known to the Youth Offending Service (YOS). Maternal grandmother had a history of hoarding behaviour, leading to cluttered home conditions in which Baby N slept. Baby N had been subject to a child protection plan due to neglect at the time of his death.
Recommendations: points identified for the Local Safeguarding Children’s Board (LSCB) include: the LSCB should satisfy itself that all agencies share information; protocols for the protection of the unborn child need to be fully understood by practitioners; the LSCB should consider including risk of SUDI in child protection planning for under ones at risk for neglect; and the LSCB should ensure clarity about health visitor’s role in safeguarding babies with regard to sleeping arrangements.
Keywords: teenage pregnancy, child neglect, sleeping behaviour, youth offending
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2016 – Bristol - Operation Brooke 
Sexual exploitation of children between 2011 and 2014. The police investigations, known as Brooke 1 and Brooke 2, resulted in the successful prosecution of 15 offenders for crimes including rape, paying for the sexual services of a child and trafficking for sexual purposes
Background: investigation Brooke 1 involved the sexual exploitation of a 16-year-old looked after child and a further 3 children aged between 14 and 15-years-old. Brooke 2 involved the sexual exploitation of 6 children. The perpetrators, who were all in their early 20s, used drugs, alcohol, money and the children themselves to attract and groom new victims.
Key issues: the multi-agency system was not set up to respond quickly and flexibly to adolescents with complex needs; professionals struggled to distinguish between sexual abuse, sexual exploitation and/or underage sexual activity; working methods and recording systems did not reliably identify patterns in individual and group behaviour which made it harder to detect victims and perpetrators of CSE.
Model: systems based approach based on the Social Care Institute for Excellence (SCIE) framework.
Keywords: child sexual exploitation; organised abuse; sex offenders; children in care; alcohol misuse; substance misuse; child abuse identification
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2016 – Cheshire West and Chester - Bryony
Death of an adolescent girl from an overdose in February 2015. There were no suspicious circumstances surrounding Bryony’s death and she left a note expressing her distress and desire to take her own life.
Background: Bryony was subject to a Child in Need plan and spent time in foster care placements under Section 20 arrangements. Before she died, Bryony had returned to live with her mother under a care order. Family history included: domestic abuse and mother’s disability resulting in Bryony spending a lot of time caring for her. Bryony faced difficulties including: severe emotional distress; self-harm; offending behaviour; school refusal; going missing; and risks around child sexual exploitation and harmful sexual behaviour. A number of services supported the family including: children’s services and Child and Adolescent Mental Health Services (CAMHS).
Key issues: included the mindset of some professionals was skewed towards risk, resulting in them viewing Bryony as a perpetrator rather than a vulnerable child; there was a lack of focus on working with the whole family (including father and grandparents); and Bryony’s views were not sought consistently enough.
Recommendations: LSCB to undertake focused work on bringing risk assessment, risk management and safeguarding practice together across children’s and adults’ social care.
Keywords: suicide, children with a mental health problem, adolescent girls, child sexual exploitation, harmful sexual behaviour, foster care, placement breakdown, parental illness
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2016 - City and Hackney - Ms AB and Child D
Death of 22-month-old Child D and her mother, Ms AB, in March 2014. Child D’s father and Ms AB’s ex-partner, Mr YZ, was convicted of their murder and sentenced to life imprisonment. Combined domestic homicide review and serious case review.
Background: in February 2014 Ms AB reported serious domestic abuse to the police. Prior to this, there were no records of Ms AB and Child D having contact with any agencies other than universal health services. Father had a previous conviction for drug offences and was known to drug and alcohol services and the Probation Service.
Key issues: Ms AB’s disclosure to the police of Mr YZ’s threat to kill her and her 3 children did not result in a thorough investigation and action to protect them; there were missed opportunities to refer the case to children’s services who could have made their own risk assessment.
Recommendations: the Metropolitan Police Service should review its electronic crime reporting system to ensure that: any threat to life in a domestic abuse case is reviewed by an inspector who will be responsible for implementing and directing actions; and when children are named as victims or witnesses in a domestic abuse case, a pre-assessment checklist is shared with children’s services. The College of Policing should commission research to identify a model of safe exit planning for victims of domestic abuse. 
Keywords: child deaths, filicide, family violence, homicide, police.
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2016 – Newcastle – Child J
Death of a 15-week-old baby girl, J, in May 2014. A post-mortem confirmed she died of a head injury and further tests concluded this was likely to have been as a result of shaking. J's mother and her partner were convicted of causing or allowing her death and given custodial sentences.
Background: J was born prematurely with suspected foetal alcohol syndrome. A month before her birth, she and her 3 siblings were made the subject of child protection plans for neglect. Family had a history of: domestic abuse, alcohol abuse; animosity over contact arrangements; children's social care involvement during mother's and partner's childhoods; and offending behaviour and cannabis use by partner.
Key issues: recording systems did not include fit-for-purpose chronology templates, making it harder for practitioners to understand a family's history; standardised tasks and contracts of expectation were used too routinely and without consequence in child protection plans making them ineffective at tackling deep-rooted, learned behaviour.
Model: systems approach based on the Social Care Institute for Excellence (SCIE) framework.
Keywords: abused infants; alcohol misuse; head injuries; foetal alcohol syndrome; intergenerational transmission of abuse
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2016 - Suffolk - Baby D
Death of a 12-week-old baby boy whilst co-sleeping with his mother. Police arrested the parents, following anonymous allegations of heavy drinking and drug taking in the family home, but there was insufficient evidence and no further action was taken.
Background: no concerns were identified about the care of Baby D before or after his death. A range of agencies had been working with the family due to the increasingly challenging behaviour of Baby D’s half-sibling Child P. Mother had reported feeling overwhelmed by Child P’s behaviour and a social work assessment had taken place the day before Baby D’s death.
Key issues: issues identified include: need for some improvement in agencies’ delivery, recording and coordination of advice about safe sleeping and need for improved public and professional awareness of the issue of safe sleep.
Recommendations: recommendations for the local safeguarding children board (LSCB) include: consider introducing consistent safe sleep assessment and recording arrangements for health professionals; carry out regular audits to evaluate the delivery and recording of safe sleeping advice.
Keywords: infant deaths, sleeping behaviour
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[2016] - Surrey - Child AA
Serious, non-accidental head injuries to a 10-week-old baby, Child AA, whilst in the care of parents. The parents were arrested and bailed pending further investigation and Child AA and an older sibling were taken into care.
Background: sibling was subject to a Child in Need plan which continued following Child AA's birth. Team around the child and professionals meetings were convened following Child AA's birth. Concerns about the family included: young age and immaturity of parents; lack of support from family or friends; dependence on professionals for money, food and equipment for the children; poor living conditions. Mother was a young carer for her mother, was subject to a Child in Need plan and received services from Child and Adolescent Mental Health Services (CAMHS).
Key issues: there were differences of opinion between children's social care and the community health services; this was compounded by a lack of clear and current assessment and co-ordinated planning.
Recommendations: guidance for social workers on assessment should include joint visiting with other professionals to share perceptions and views; risks to new born babies should be fully understood with the expertise of community health professionals in this area acknowledged; inclusion criteria for the Family Nurse Partnership should be revised to include young parents who have a second or subsequent child.
Keywords: infants; non-accidental head injuries; physical abuse; poverty; teenage pregnancy; interagency cooperation.
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December 2016 - Herefordshire – Family HJ
Concerns of neglect and possible physical abuse of a period of 5 years of a minority community sibling group, with mobility, sight and learning difficulties and health challenges.
Key issues: children known to children’s social care and the police. Concerns around missed or cancelled appointments for weight checks and immunisations, sight and delayed development checks and lack of cooperation by the parents. The youngest child was briefly taken into foster care following concerns of possible sexual abuse.
Learning: themes identified include: identification of neglect and children with disabilities; lack of cooperation by family; consideration of each child individually; internal and external escalation and professional disagreements; specialist social work provision and legal processes.
Recommendations: to provide an effective multi-agency childhood neglect strategy; to request that NHS England reviews its commissioning arrangements for child sexual abuse medicals in the local area; provision of training in culturally competent practice.
Model: sets out key findings using the Significant Incident Learning Process (SILP) methodology.
Keywords: child neglect, children with disabilities, children with learning difficulties, culture, disguised compliance
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December 2016 – Thurrock - James
Death of a 17-year-old boy of Ghanaian heritage in July 2015 in North London. James was found collapsed with a sheet tied around his neck. The Coroner recorded an Open Verdict on his death.
Background: James was a looked after child in semi-independent accommodation, following a breakdown in relationships with his family. He was known to the police and children's services in a number of local authorities.
Key issues: James had a history of: running away; violent and criminal behaviour; sporadic school attendance; non-engagement with services; drug misuse; self-reported mental health issues; and suspected involvement in gangs.
Learning: issues identified include: looked after child placements situated too close to areas where gangs operate; incomplete mental health assessments; insufficient work by professionals on understanding family dynamics and rebuilding family relationships; and the absence of a positive action plans in response to concerns raised in looked after child reviews.
Recommendations: include: review safeguarding arrangements for children in custody and young people presenting as homeless; widen the remit of looked after children inspections nationally to include semi independent placements; embed a more robust record keeping and follow-up process for health assessments; assess the risk posed by any condition disclosed by a child or young person in custody to a forensic medical examiner and develop a matrix for identifying and escalating concerns about children in care.
Model: uses a mixed methodology to identify factors that influenced how agencies and professionals worked together.
Keywords: adolescent boys, child behaviour problems, children in care, residential care, runaway adolescents, young offenders
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November 2016– Anonymous – Child G
Death of a 3½-year-old African boy in November 2015. There were indications that there might have been some degree of force feeding causing ingestion of food into the lungs.
Background: the father was found guilty of manslaughter and child cruelty. Family was known to children’s services and children had previously been subject to child protection plans for neglect, physical and emotional abuse and children in need plans.
Key issues: lack of recognition of the impact of the mother’s ill health on her parenting capacity; insufficient awareness of father’s lifestyle and the reliance placed on Child G’s step-sister to provide family care; parental inhibition of their children’s voices; problems in information sharing following the family relocation; and professionals overlooking the needs of the children.
Recommendations: amending the neglect toolkit to include feeding issues and dental health; practice tool to be used by the health visiting service to ensure systematic and robust information capture for new families.
Keywords: child protection registers, children in need, dentists, disguised compliance, feeding behaviour, HIV and AIDS, information sharing
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September 2016 - Brighton and Hove - Child E
Death of a 17-year-old boy from injuries sustained by hanging in December 2014. Coroner returned an open conclusion on whether E’s death had been an accident or suicide.
Background: the local authority looked after E from when he was 3-years-old in a ‘Family and Friends’ placement with his maternal aunt and her partner. He spent time in respite foster care and before his death moved to the same area as his birth father. Family history includes: mother’s mental health and substance misuse difficulties; mother’s death from an overdose when E was 8-years old and absence of E’s birth father for much of his childhood. E faced difficulties including: emotional distress; challenging behaviour at home; being known to the police and alcohol and substance misuse.
Learning: there was a tension between the roles of the local authority as corporate parent and ‘Family and Friends’ carers who can be seen as ‘parents’, this can result in blurred boundaries and difficulties asserting the local authority’s statutory responsibility for a child when this is needed. Due to inconsistent standards in transfer summaries and chronologies, new social workers did not always receive enough background information to gain an holistic understanding of the needs and risks facing young people and their carers.
Model: uses the Social Care Institute for Excellence (SCIE) learning together systems model and poses questions for the local safeguarding children board based on the findings.
Keywords: adolescent boys; kinship foster care; children with a mental health problem; suicide
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September 2016 - Hammersmith and Fulham - Rose
Death of “Rose”, a 9-week-old baby girl, in January 2015. Rose’s mother pleaded guilty to manslaughter by diminished responsibility. The plea was accepted following psychiatric reports and she was sentenced to remain in a mental health facility with an unlimited restriction order.
Background: mother received antenatal services from her GP and Chelsea and Westminster Hospital (C&WH) maternity services until the 29th week of her pregnancy. GP also referred mother to the perinatal psychiatry service but she returned to her home country to give birth before they could see her.  Mother came back to the UK with Rose shortly before her death. Risks identified include: mother’s anxiety and low mood related to her pregnancy; previous request to terminate the pregnancy; isolation from her family; low income; and separation from Rose’s father.
Key issues: communication across and between health services and professionals was fragmented. Professionals did not fully understand procedures for making referrals and the geographical areas covered by the C&WH midwifery service.
Recommendations: perinatal and maternity services must audit referrals to ensure the new system is robust and vulnerable women are identified and followed up. Health services should work together to develop a communication pathway locally to improve outcomes for service users.
Keywords: infanticide, parental mental health, postnatal depression, antenatal care, interagency cooperation, information sharing
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September 2016 – Sunderland – Baby E
Death of a 4-month-old girl in September 2013 whilst sleeping in her parents' bed. The inquest concluded there was no evidence that drugs caused or contributed to the death and the medical cause was recorded as unascertained. Parents were convicted of Child cruelty and received a 6 month custodial sentence suspended for 2 years.
Background: mother had a history of non-engagement with professionals, substance misuse and a violent relationship with the father of her first 3 children. The role the mother's new partner, the father of Baby E, played in her children's lives had not been assessed by professionals.
Learning: failure to engage effectively with fathers or significant males; concerns not given high enough priority; professionals were too parent-focused; wishes of older children were not considered; lack of multi-agency collaboration and risk assessment tools; and conflicting professional views about the impact of illegal substances on parenting capacity.
Model: systems model based typology.
Keywords: children’s attitudes, drug misuse, family functioning, fathers.
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September 2016 – Sunderland – Baby O
Non-accidental injuries to a 6-month-old baby girl in August 2013 who was admitted to hospital a fractured femur and bruises.
Background: mother became seriously ill following the birth and Baby O and her older sister spent a brief period living with their paternal grandmother. Following the mother’s hospital admission, Baby O and her sister became the subject of care proceedings and were removed into the care of their paternal grandmother. Following the injury of Baby O in August 2013, paternal grandmother was convicted of child cruelty and neglect in 2015.
Key issues: include pattern of neglectful parenting not consistently monitored; some positive examples of escalation but also failure to escalate and challenge inaction by children's services; lack of clarity about legal and safeguarding issues related to placement with grandmother; mother's vulnerability and health condition and father's involvement not sufficiently shared or considered.
Recommendations: implementation of Graded Care Profile (GCP) for interagency use in cases of neglect; regular multi-agency workshops; audit of Section 47 enquiries.
Keywords: child neglect, fractures, infants.
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September 2016 – Sunderland – Baby W and Child Z
Non-accidental head injury to 11-week-old baby boy admitted to hospital in November 2012. Baby W and his 3-year-old brother Child Z were taken in to care, and later adopted, following the incident.
Background: mother was 17-years-old when she first became a parent and living with her grandparents but moved into her own accommodation following the birth of Baby W. Child Z had previously been identified as a Child in Need due to concerns about neglect. Maternal history of concealment of pregnancies, lack of engagement with professionals and neglectful parenting.
Key issues: include lack of detailed awareness of unborn baby procedures and their relationship to child protection procedures; limited professionals' understanding of the impact of neglect on children's development; poor record keeping; and a lack of supportive opportunities to reflect on practice.
Recommendations: include practitioners should have access to information about the tools to use in assessment; partner agencies should ensure chronologies of significant events are used and maintained; and a multi-agency neglect strategy should be developed.
Keywords: child development, child neglect, head injuries, infants.
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July 2016 – Mid and West Wales - CYSUR 2/2015
Death of an 8-year-old boy in December 2011. Post-mortem found he had been suffering from gross anaemia, dental abnormalities and soft tissue haemorrhage in the lower legs. He had not received medical treatment. The Crown Prosecution Service (CPS) decided not to prosecute the parents and an inquest reached a verdict of open conclusion.
Background: the child had no direct contact with health, education or child care after being immunised aged 13-months. His parents declined his 3 year developmental check and were home educating both their children. Family had a history of: mother’s deteriorating mental health; father’s poor health and combined role as a home educator and carer for his wife and children; longstanding litigation claims against mother’s former employer; reclusive lifestyle; and lack of engagement with agencies.
Learning: always consider children’s needs when a parent has a mental health problem; share knowledge and experience with other agencies as part of a holistic family assessment.
Recommendations: Welsh government to consider changing legislation to require parents to register children receiving home education with the local authority on an annual basis and to ensure the children are seen and spoken to and their wishes recorded annually.
Keywords: child deaths, neglect, parental mental health, home education
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June 2016 – Gloucestershire – Ben
Death of a 9-month-old baby boy from brain damage assessed to be a non-accidental head injury. At the time of review inquiries were ongoing. 
Background: Ben’s half-sister was living permanently with her grandmother due to concerns around the mother’s neglectful parenting. Ben was born prematurely and remained in hospital for the first 6 weeks of his life. Following his discharge home, the family received regular home visits. Mother had a history of: emotional abuse in childhood, substance misuse, parental neglect and homelessness. Little was known about the father. 
Key issues: issues identified include: lack of professional knowledge of or focus on the father, lack of a pre-birth risk assessment and lack of consideration of the potential impact of the past on present or future parental care.
Learning: findings include: the need for evidence-based multi-agency pre-birth or at-birth assessments; the importance of involving fathers in the antenatal and postnatal period; the need for a Lead Professional to support parents whilst their baby is in neonatal care; the need to take into account the additional vulnerabilities of premature babies; and the importance of all agencies, not just children’s social care, seeing themselves as having a responsibility for safeguarding children. 
Model: review undertaken using the Learning Together systems model developed by the Social Care Institute for Excellence.
Keywords: infant deaths, non-accidental head injuries
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June 2016 - Gloucestershire  - Lucy
Death of a 16-year-old girl and her unborn child in 2014. Lucy died as a result of an assault by her partner Daniel, who was found guilty of her murder and given a life sentence.
Background: Lucy was made subject to a Child in Need plan but social care decided to close her case when her unborn child was made subject to a child protection plan under the category of physical and emotional abuse. Lucy became homeless at 15 after relationships with her family deteriorated. After a brief period staying with her partner Daniel, the couple separated and Lucy returned to live with her mother. Lucy presented with multiple risks including: emotional difficulties; self-harming; challenging and risky behaviour; school refusal; estrangement from family members; homelessness; pregnancy and being in an abusive and violent relationship. Services supporting Lucy and her family included: child and adolescent mental health services (CAMHs), family support services and a voluntary sector organisation specialising in young people’s mental health.
Learning: when safeguarding teenagers, there was a tension between respecting their autonomy and keeping them safe; the Domestic Abuse, Stalking, Harassment and Honour Based Violence (DASH) form did not capture all critical information for under-18s; there was a lack of understanding of how to recognise key features of domestic abuse between young people, leaving child victims and child perpetrators without the necessary support and protection.
Model: uses the Social Care Institute for Excellence (SCIE) learning together systems model and poses questions for Gloucestershire Local Safeguarding Children Board based on the findings.
Keywords: partner violence, family violence, children with a mental health problem, homeless adolescents, adolescent mothers
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June 2016 – Peterborough - Operation Erle
The sexual exploitation of young people in Peterborough over the period 2010-2016.
Background: focuses on learning from Operation Erle, a multi-agency investigation which resulted in ten male defendants being found guilty of 59 offences against 15 girls. 
Key issues: issues identified include: lack of robust response to disclosures of sexual activity at a young age; lack of robust response to the assessment and safety planning of missing episodes; difficulties in transitions between children's and adult's services and a tendency to see young people as adults capable of choosing to be in abusive relationships. Also identifies examples of good practice, including close co-ordination and joint working between children's social care and the police.
Learning: includes: the need to produce and share victim contact strategies with all members of a joint enquiry; the importance of considering the needs of the family as a whole and the need for young people to talk to an independent person when returning home after a missing from home episode.
Recommendations: includes: local safeguarding children board (LSCB) to undertake an audit of provision of child sexual exploitation interventions within educational establishments; all agencies should ensure that the voice of the child is central to all child sexual exploitation work and the safeguarding board to use multi-agency data to map and evaluate high risk areas for child sexual exploitation to inform early identification of perpetrators and victims.
Keywords: child sexual exploitation, runaway adolescents
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June 2016 – Sutton  – Child D
Death of a 6-year-old girl in October 2013 from a head injury. Father was charged with her murder and child cruelty. Mother was charged with intending to pervert the course of justice and child cruelty.
Background: Child D had previously been on the child protection register under the category of physical abuse, after being hospitalised with head injuries in February 2007. Child D's father was convicted and Child D was placed in the care of her maternal grandparents. Following new medical evidence, father's conviction was quashed and a high court judge ruled the parents were not culpable. The judge appointed an independent social work agency to work with the family and Child D returned to live with her parents in November 2012.
Learning: advises professionals to: focus on the child's needs and experiences at all times, regardless of how demanding the parents are; and when working with independent social work agencies, consider issues around quality assurance of practice, accountability, how they are selected and how they work in a multi-agency context.
Recommendations: clarify the courts' responsibility to LSCBs in respect of serious case reviews; following an unexpected court judgment, which has the potential to raise concerns for children, convene a multi-agency meeting to discuss future actions, roles and responsibilities and establish the means by which agencies can share information about and respond to any escalation of concern.
Keywords: physical abuse; family reunification; independent social workers; judges; expert witnesses; kinship foster care; legal judgements
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April 2016 - City and Hackney - Child H
Death of a 6-week-old baby in Spring 2014 caused by inflicted injuries. Following a review of the evidence, parents were informed they would not be the subject of any further enquiries.
Background: family had been referred to children's services but were not assessed as in need of intervention. Parents and Child H lived with the mother's adoptive parents. Mother had a history of: childhood abuse and neglect which resulted in her being taken in to care, anger management issues, mental health issues and special educational needs.
Key issues: failure to share information about bereavement and illness in mother's family, which should have led to a re-assessment of parenting capacity; confusion around whether the mother was eligible for support from the Learning Disability Service; over-estimation by social services of the role of the hospital's psychosocial meetings with mother in monitoring the family's support needs; and incomplete record keeping within children's services.
Recommendations: Local Safeguarding Child Board to promote understanding of adult learning disability and eligibility for services and the Borough should ensure its quality assurance arrangements are sufficiently robust.
Keywords: infant deaths; adults abused as children; mental health; learning disabilities; parenting capacity
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April 2016 - Wiltshire - Baby J
Suspected non-accidental injuries to a 6-week-old baby boy whilst in the care of his parents in September 2014. Baby J recovered and was placed with foster carers. No one was charged with any criminal offence.
Background: during the mother’s pregnancy the family were subject to the Common Assessment Framework (CAF) pathway because of the mother’s young age (17-years-old) and a Team around the Child (TAC) meeting. Mother’s history included: parental neglect; exposure to parental substance misuse and children’s services interventions. Baby J’s father had a history of substance misuse and had witnessed domestic abuse as a child. Services working with the family included: midwives, health visitors, children’s centre outreach and substance misuse support.
Key issues: there were 2 referrals to children’s social care. Concerns included: homelessness, reliance on a food bank and J’s faltering weight gain. The second referral, shortly after Baby J’s birth, met thresholds for a single assessment.
Learning: practitioners should: remember that assessment is a dynamic process and new information or changes to family circumstances may affect the nature and degree of risk; make more use of the Multi-Agency Pre-Birth Protocol to Safeguard Unborn Babies - this is a valuable tool for all practitioners assessing risk and protective factors and making or deciding the outcome of referrals.
Recommendations: local safeguarding children board (LSCB) should investigate ways of embedding, improving and sustaining the CAF process without resorting to further guidance and more onerous expectations.
Model: uses the Partnership Learning Review.
Keywords: adolescent parents; teenage pregnancy; infants; physical abuse; homeless families; low income families; poverty; substance misuse
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March 2016 – Cheshire West and Chester – Child A
Serious head injury of a primary-school-aged child in October 2014.
Background: family had significant contact with a wide range of agencies and were receiving support from a Team Around the Family (TAF) due to concerns about home conditions and the children’s failure to thrive. Mother had a history of childhood sexual abuse, a lack of emotional warmth towards her children and suspicion of services and professional involvement with her family. Father had a history of alcohol misuse, domestic violence and controlling behaviour.
Key issues: include: parents were able to dominate and manipulate TAF meetings by disputing points, creating diversions and feigned compliance with recommendations; no formal parenting assessment was made of parenting capability or motivation to change; professionals struggled to distinguish between parental neglect and emotional abuse; assessment tools were not always used effectively; and the escalation policy was not used by professionals to challenge decision making following referrals.
Model: uses a systems based approach to analyse information and present the findings. Poses questions for the Local Safeguarding Children Board to address.
Keywords: head injuries, child neglect, emotional abuse, disguised compliance
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March 2016 - Lambeth with Islington and Kent - Child J
Suicide of a 14-year-old Black British girl in the Summer of 2014 while living in foster care in Kent.
Background: Child J had a history of suspected emotional, physical, sexual abuse and neglect and complex mental health needs including suicide ideation, self harm and an eating disorder. She suffered acute and chronic bereavement after her mother's death. Supported as a Child in Need before being looked after by the local authority. She also received adolescent acute and community mental health services.
Key issues: the significant impact of bereavement, transitions and loss; the need for J's history and the impact of her experiences to be taken into consideration in risk assessments and planning and treatment arrangements; the need for agencies to be clear about the legal concept of parental responsibility and when young people can make decisions; care planning for looked after children in receipt of mental health services. Also considers social media and pro-anorexia or 'Pro-Ana' websites.
Keywords: adolescents; suicide; bereavement; mental health; looked after children, anorexia
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March 2016 - Lancashire - Child O
Death of 22-month-old Child O in August 2014 at the hands of their mother who then killed herself. A post-mortem concluded mother and child died of carbon monoxide poisoning.
Background: parents were separated and mother and Child O had moved to a number of places around the country. At the time of their death in Lancashire, they were not known to any statutory or other agencies within the county. Father had made an application for contact with Child O and a Cafcass children’s guardian was working with the family. Mother had made unsubstantiated allegations to Devon and Cornwall police of domestic violence and sexual abuse against Child O’s father. The coroner’s inquest concluded there was no substance to the mother’s belief that she was being pursued by Child O’s father and he had acted appropriately throughout. Mother had a history of possible post-natal depression and personality problems and giving misleading information to statutory services to conceal the whereabouts of herself and Child O.
Learning: there were organisational weaknesses in the approach to working constructively and proactively with fathers; professionals needed to be encouraged to balance respect for women who talk about domestic abuse with appropriate scepticism and curiosity where allegations are denied.
Recommendations: made multi-agency recommendations including developing knowledge and awareness of the nature of homicide in the context of parental conflict.
Keywords: contact; deception; family courts; family violence; fathers; infanticide; suicide; wrongful accusation of child abuse
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February 2016 - Bracknell - Child C (born 2013), Child C sibling (born 2010)
Non-accidental injury to 14-week-old baby in October 2013, admitted to hospital with a fractured femur. Parents were charged with grievous bodily harm but no convictions resulted. Both children were subsequently permanently removed from their care.
Background: Child C and Sibling were subject to child protection plans under emotional abuse. Sibling had previously been a Child in Need. Family issues including violence and domestic abuse; alcohol and drug misuse by parents and maternal grandmother; mental health; and unstable housing arrangements leading to frequent moves.
Key issues: discusses family history and its impact on parenting; parental alcohol misuse; the involvement of fathers and the extended family in assessments; and the role of staff supervision across agencies.
Recommendations: Local Safeguarding Children Board to: review the sharing of domestic abuse notifications between the police and partner agencies; promote the "Think family" approach; and ensure that multi-agency training covers the impact of domestic abuse, mental health and substance misuse on parenting.
Model: Significant Incident Learning Process (SILP) methodology.
Keywords: infants, domestic abuse; substance misuse; mental health; staff supervision
Read the overview report

February 2016 - Greenwich - Child T
Suicide by hanging of a 15-year-old girl at her school in June 2013.
Background: Child T and her siblings were the subject of child protection plans in Greenwich and Lewisham. Family had a history of: domestic violence, sexual abuse, parental neglect, regular house moves and changes of mother’s partners. Child T disclosed self-harm to teachers and was supported by the school's pastoral and counselling services and later child and adolescent mental health services (CAMHS).
Learning: poses questions for the Local Safeguarding Children Board to consider, including whether professionals are well equipped to understand and respond to self-harming behaviour in adolescents.
Method: uses the SCIE Learning Together method.
Keywords: suicide, self harm, adolescents, sexual abuse, schools
Read the overview report

February 2016 – Manchester – B1
Death of 10-day-old baby of Black and Asian British descent in August 2013. Father had lain on top of B1 while in bed. He was convicted of neglect in 2015.
Background: B1 and 2 older siblings were the subject of child protection plans under emotional abuse. Both siblings had been on a plan before and had been looked after in 2010. Family were well known to agencies because of parental alcohol misuse, domestic abuse, concerns about neglect and father's criminal behaviour.
Key issues: professional focus on domestic abuse as an anger management issue; parental fear of statutory intervention; manipulative and obstructive parental behaviour; delays in follow-up to incidents; lack of recognition of indicators of neglect such as dental cavities; the limited use of assessment tools or frameworks; and the impact of excessive workloads and reconfiguring of services on the capacity of professionals.
Model: systems based approach based on the Social Care Institute for Excellence (SCIE) framework.
Keywords: infant deaths, neglect, co-sleeping, parental alcohol misuse, dental neglect, domestic abuse
Read the overview report

February 2016 – Manchester – D1
Death of an 8-month-old baby of Black Caribbean and White British heritage on 5 July 2014. Child D1 was found lifeless on the floor after co-sleeping with mother who had consumed alcohol the previous night.
Background: D1 was a 'Child in need', the subject of a Supervision order and had previously been the subject of child protection plans under neglect and emotional abuse. Mother was a looked after child with a history of alcohol and drug misuse, antisocial behaviour and going missing from care. Father had convictions for drugs offences and was suspected of gang links and domestic abuse.
Key issues: the risks presented by the father and the extent of parental substance misuse were not fully known.
Recommendations: Local Safeguarding Children Board (LSCB) to conduct a thematic review of looked after girls focusing on teenage pregnancy; consideration to be given to the multi-agency response to looked after children and care leavers who have children removed from their care; and partner agencies to review their practice relating to fathers and significant males.
Model: uses elements of the Social Care Institute for Excellence (SCIE) Learning Together systems model.
Keywords: infant deaths, parental substance misuse, co-sleeping, fathers, looked after children, teenage pregnancy
Read the overview report

February 2016 - Oxfordshire - Child J 
Murder of a 17-year-old female by her ex-partner who received a life sentence in 2014. Child J had recently told her ex-partner she thought she was pregnant with his child, resulting in him threatening her.
Background: Child J was a vulnerable adolescent who was known to children's services and other agencies, including a period with ‘child in need’ status. Professionals were aware that she had been in an abusive, controlling relationship with an adult male. He had been a looked after child and had a known history of violence. J had a history of mental health problems, suicide attempts and self-harm, non-engagement with services, drug misuse, going missing and a difficult relationship with her mother.
Key issues: Child J was often viewed as “difficult” and not as a child in need of safeguarding; processes and procedures for 16-18-year-old victims of domestic abuse were still under development; and the police response when she was reported missing failed to recognise the serious threat posed by her ex-partner.
Recommendations: local safeguarding children board (LSCB) and Community Safety Partnership to act as a strategic lead on domestic abuse to ensure a unified approach to young victims and/or perpetrators; schools to cover healthy relationships in the context of domestic abuse; and systems to be put in place to ensure that Multi Agency Risk Assessment Conference (MARAC) referrals are shared with all relevant frontline professionals.
Keywords: adolescents; murder; domestic abuse; risk assessment; adolescent-professional relationships
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February 2016 – Thurrock - Megan
Chronic neglect of a 17-year-old girl who was admitted to intensive care after collapsing at home on 27 November 2013.
Background: Megan and her sibling spent periods subject to child protection plans because of physical abuse and neglect and as Children in Need. Family issues included: chronic neglect, domestic violence, housing eviction, poor home conditions and financial problems.
Key issues: lack of effective information sharing and analysis; lack of professional understanding of adolescent neglect; lack of professional consideration of Megan’s lived experience; and professional focus on the level of service provided to the family as opposed to the impact of services.
Model: hybrid model combining information from Individual Management Reviews with frontline practitioner engagement.
Keywords: adolescents, neglect.
Read the overview report

January 2016 – Anonymous – Child U, B and V
Death of a 6-week-3-day-old baby boy and neglect of his older half-siblings (13 and 15-years-old). Ambulance service was called by parents on 29 November 2015 as Baby V was not breathing. Parents had been drinking heavily. Both parents pleaded guilty to child neglect and received a custodial sentence.
Background: all 3 children were subject to child protection plans for neglect and physical abuse. Parents of Baby V and father of half-siblings (U and B) all had histories of alcohol misuse, mental health problems and domestic abuse. U and B had poor school attendance.
Key issues: the needs of adults dominated the work undertaken; increasing concerns about the children's wellbeing failed to trigger intervention via the Common Assessment Framework (CAF); and adults' accounts were accepted without reference to other available information.
Recommendations: the local safeguarding children board (LSCB) to review and report on the effectiveness of early intervention; LSCB to ensure commissioning arrangements for assessing substance misusing parents are in place and a clear pathway to accessing services for families; and all agencies to consider information on fathers and other significant males during assessments.
Keywords: infant deaths, child neglect, alcohol misuse, early intervention, fathers
Read the overview report

January 2016 – Enfield - AX
Death of a 17-year-old boy of Afro-Caribbean heritage on 3 December 2013 following an altercation with three other adolescents. Courts later found that the three assailants were acting in self-defence.
Background: AX was homeless and had been provided with accommodation and emergency funds by his local authority in Barnet. AX had a history of: emotional and physical neglect, behavioural and emotional problems and involvement in criminal activity.
Key issues: professionals responding to discrete episodes of anti-social behaviour as opposed to addressing the broader concerns around an increasingly dangerous lifestyle; the failure of youth offending teams to update assessments as new information emerged; a lack of information sharing between schools and youth offending teams; and a failure to properly monitor and enforce attendance and curfew orders.
Recommendations: review mechanisms for sharing intelligence between agencies and put mechanisms in place to allow the prompt and effective transfer of oversight and supervision of young people on court orders who move between boroughs.
Keywords: adolescent deaths, risk-taking, neglect
Read the overview report

January 2016 - Greenwich - Child S
Death of a 13-month-old girl of Somalian heritage in February 2013. Post-mortem found evidence of fractures, indicative of a non-accidental injury. Both parents convicted of neglect.
Background: family known to universal services only. Mother arrived in UK seeking asylum while pregnant. Father and siblings joined them at a later date. All injuries to Child S occurred after family were reunited.
Key issues: limited knowledge of family's history in Somalia; family moved regularly between local authorities making it harder to share information and provide support; mother's family sometimes interpreted rather than an independent interpreter being provided.
Recommendations: a single system for London to ensure health visiting services are notified by GPs of new children who move into the area and a notification system to ensure that universal and children's services are informed about any housing moves of vulnerable families.
Keywords: child deaths; neglect; asylum seekers; transient families; interpreting services; housing services; health visiting
Read the overview report

January 2016 – Milton Keynes - Child A
Death of a 7-week-old baby boy of mixed parentage whilst co-sleeping with mother who had consumed alcohol and cocaine. Mother was arrested but no charges brought.
Background: Child A's older sibling had died in 2007 when 2-weeks-old from sudden infant death syndrome. No concerns about the child’s care were identified. Mother was known to police as both a perpetrator and victim of crime and was supported by domestic abuse services. Mother had issues related to: alcohol and drug misuse; housing; mental health problems; and lack of engagement with professionals.
Learning: includes: professionals working with adults must understand parental behaviour in terms of the impact on the child; risky behaviour in pregnancy should be seen as a potential child protection issue; and threat of withdrawal from engagement should be seen as an indicator of risk.
Method: uses the Significant Incident Learning Process (SILP).
Keywords: infant deaths; co-sleeping; parental substance misuse; domestic abuse
Read the overview report

This list was last updated 18 April 2017.


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