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 – 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 – Bristol - the Brooke serious case review into child sexual exploitation
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 – 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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July 2016 – Mid and West Wales
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 – Sutton Local Safeguarding Children Board – 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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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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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
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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
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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
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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.
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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
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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
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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 15 September 2016.

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