Case reviews Case reviews published in 2017

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 2017. To find other case reviews search the national repository.

2017 – Anonymous - Child AB
Life threatening attempted strangulation and suffocation of child by mother, followed by mother's suicide attempt, in 2014 and 2015. Child AB became subject to child protection investigation and child in need plan.
Background: no indication of child abuse prior to the first event. Maternal history of mental illness, self-harm, disclosed attempts to harm husband and attempted suicide.
Key issues: include: management of screening for maternal mental health and domestic abuse not fully embedded in practice; lack of direct questioning regarding thoughts to harm others; professional decision-making impacted by affluence and status of family.
Recommendations: include: strengthen professionals' understanding of the negative impact of professional biases and beliefs in safeguarding practice; review procedures to improve understanding of the child as a protective factor, risk of filicide and harm to others in cases of parent mental illness.
Keywords: parents with mental health problems, filicide
Read the overview report

2017 - Anonymous - Child F and Family
Harmful sexual behaviour and death of 17-year-old boy in 2015 as the result of stab wounds.
Background: Child F was assessed as a Child in Need in 2011. Behaviour and attendance at school erratic, and several incidences of involvement with others in minor and serious offences, including rape of a 12-year-old and 14-year old. Decision made that prosecution relating to first rape was not in public interest.
Key issues: include: when cases are not pursued in the public interest it is still necessary for the young person to be given a full understanding of the implications of their actions; lack of support for mental health needs due to referrals to and from between agencies; good chronologies of key events would help spot risks; agencies should take great care when describing sex as consensual when in law it cannot be; young teenagers are often unclear about consent.
Recommendations: include: review safeguarding approach to young people with harmful sexual behaviour; encourage education providers to ensure law around consent is explained clearly; ensure that a young person’s concern about violent risks to them is taken seriously by agencies.
Keywords: harmful sexual behaviour, adolescents, consent
Read the overview report

2017 – Anonymous - Considering child sexual exploitation
Child sexual exploitation of 3 girls by a young adult female who was involved in sexual activity with them and recruited them in abusive sexual behaviours by a number of older adult males between January 2013 and August 2015.
Key issues: all girls had complex needs and missing from home episodes. The alleged perpetrator was part of a wider network of predominantly male operatives.
Learning: difficulty in identifying the alleged perpetrator as a risk to children; the need for services to work with parents to strengthen parental confidence as perpetrators set out to deliberately drive a wedge between child and family; importance of early intervention in responding to sexual exploitation; the need to understand children as victims without choice or informed consent.
Recommendations: introduce a process for responding to vulnerable children/young people which incorporates child sexual exploitation and: identifies and minimises the risk from a non-familial source; builds on factors that increase resilience; facilitates a multi-agency team around the child; and facilitates partnership with key people in the life of the young person.
Keywords: alcohol misuse; child sexual exploitation; grooming; harmful sexual behaviour; runaway adolescents
Read the overview report

2017 – Anonymous - Martin
Death of a 14-year-old boy in February 2016 initially thought to be due to suicide but, before the review was completed, an inquest determined the cause to be misadventure.
Key issues: Martin was an adolescent with mental health needs. His parents separated following domestic abuse by the father. Although there were concerns about his emotional wellbeing at home and school in December 2015, a referral to children’s social care was not made.
Learning: the challenge for professionals working with families where members have a range of complex needs; need for coordination in provision of services across local authority boundaries; specific practice issues were found which highlight the dilemmas faced by front-line practitioners when exercising professional judgement in their safeguarding practice.
Recommendations: to strengthen the sharing of information to ensure a whole family approach when working with children in blended families; to re-launch the CAMHS pathways within the borough; for the London Safeguarding Children Board to work with organisations across London to mitigate the risk to children where there is a lack of clarity associated with localised commissioning arrangements; partner agencies should be asked that contracts with service providers include an expectation that they should fully participate in any serious case review process.
Keywords: child deaths, child mental health services, disguised compliance, emotional disorders, parents with a mental health problem, self harm
Read the overview report

2017 - Bedford - Baby Sama
Death of a baby girl under 2 months old of white British/Pakistan origin, in October 2015 as a result of fatal injuries received after falling from her car seat. The Coroner’s Inquiry found her death was a tragic accident that could not have been predicted.
Key issues: mother was 20 and father 28 when Sama was born. Mother spent time in foster care and had had witnessed domestic abuse against her mother when she was a child. Mother was looked after for 4 months when she was 15 when concerns were raised that she was involved with a 23 year old male (Sama’s father) who was known to be violent. Father had convictions for domestic violence, assault, drug dealing and breeding dogs for fighting. Concerns identified about father being involved in the sexual exploitation of two looked after children. In July 2015 Salma was made subject to a Child Protection Plan under the category of neglect.
Learning: issues identified include: recognising and addressing the impact of child sexual exploitation (CSE) in assessments and plans to safeguard children; understanding the dynamics of domestic abuse including perpetrator behaviour; recognising the links between animal abuse and child abuse/domestic abuse.
Recommendations: makes recommendations relating to the safeguarding of babies from domestic abuse.
Keywords: child sexual exploitation, grooming, infant deaths, children in violent families, official inquiries, partner violence, drug misuse
Read the overview report

2017 – Blackpool - Child BW
Death of 3-month old child in 2015 due to medical causes.
Background: Child BW lived with mother and two siblings. A child protection plan had been in place for all children 1 year before the death due to concerns of neglect. 
Key issues: include: views on a good enough home environment can be subjective and complicated by working in a deprived area; mother’s disguised compliance may have added to the optimistic view of her intentions and capacity to change. Good practice identified: robust information sharing processes and good local professional relationships.
Recommendations: include: wider promotion and clarification for staff of neglect assessment tool; audit on how expected outcomes are recorded on Children’s Services’ documentation; audit of pre-birth child protection processes to ensure that when siblings are on a child protection plan the needs of an unborn baby in the family are considered separately; review progress of earlier recommendations of safe sleep assessment.
Keywords: infant death, neglect, disguised compliance, sleeping behaviour.
Read the overview report

2017 – Birmingham – Shi-Anne Downer [birth name]: AKA Keegan Downer
Death of an 18 month-old-girl from a white British and black African background in September 2015. The post mortem revealed over 150 internal and external injuries that had been caused over a number of months. Shi-Anne’s guardian was subsequently convicted of murder.
Background: mother had a history of drug abuse, mental health issues, reluctance to engage with services and time in prison; father was in prison at the time of her birth; 5 older siblings had previously been taken into care. Shi-Anne was made the subject of a child protection plan before her birth and was placed in foster care after birth. In January 2015, Shi-Anne became the subject of a special guardianship order (SGO).
Key issues: the pre-birth decisions made about Shi-Anne’s care followed the same approach as decisions made for her older sibling, without considering whether this was also appropriate for Shi-Anne 5 years later; the assessments for the special guardianship order (SGO) were flawed and incomplete; professionals had little or no contact with Shi-Anne after the SGO; risk factors for the guardian’s reduced parental capacity, such as becoming pregnant and the breakdown of her relationship, were not recognised and acted upon.
Learning: all relevant checks should be carried out and the need for a period of monitoring should be considered before a special guardianship order is finalised.
Model: blended methodology.
Keywords: infant deaths; physical abuse; selection procedures; special guardianship orders
Read the overview report

2017 – Bradford - Jack
A teenage boy, Jack, was sexually abused over several years from the age of 13, by multiple adult males. He was visiting adult chat rooms, being groomed and meeting individuals who posed a severe risk to him.
Key issues: there was significant multi-agency support for Jack but services were not effective in keeping him safe from abuse. Good practice identified by the school and GPs.
Learning: lack of understanding of technology-assisted abuse and its effects; restricting a young person’s access to technology will not keep them safe, we must educate children, young people, carers and parents in how to keep safe whilst online; child protection procedures were inconsistently applied; a lack of coordinated support for families and young people; absence of leadership and planning.
Recommendations: the need to investigate technology-assisted abuse and consider local responses to protect children and young people; to seek assurance from police and children’s social care that child protection processes are fit for purpose and that issues relating to practice identified by this case are being dealt with.
Model: Partnership Learning Review
Keywords: child sexual exploitation, Childline, online grooming, sex offenders
Read the overview report

2017 – Brighton and Hove – Siblings W and X
Reported deaths of 2 brothers in Syria in 2014; it is understood they went with a friend to join their elder brother fighting for the Al-Nusra Front. Child W died soon after his 18th birthday (but travelled when he was under 18) and Child X died aged 17.
Background: the children had several siblings and grew up in Brighton but spent considerable periods in their parents’ North African/Middle Eastern country of origin. It is understood that the family came to the UK because they opposed the regime in their country and at least 1 family member was killed for his political beliefs. The family left the UK for several years and experienced racism when they returned. The children disclosed physical and domestic abuse by their father and became subject to child protection plans; the mother separated from the father who spent long periods overseas. Child W and his sibling Q began behaving antisocially and became involved with Youth Offending Services. Siblings W and X left the UK in January 2014.
Learning: professionals do not have effective ways to intervene in families who have suffered long standing trauma: this can increase the risk of young people being vulnerable to exploitation; efforts to support children so they are less likely to become vulnerable to radicalisation do not seem to address all the core issues.
Recommendations: practitioners need to have a greater understanding of, and curiosity about, the role and potential impact of culture, identity, gender, religion and beliefs on children.
Model: SCIE (Social Care Institute for Excellence) Learning Together methodology.
Keywords: muslim people, racism, radicalisation, runaway adolescents
Read the overview report

2017 – Buckinghamshire – Child sexual exploitation 1998-2016
Discusses all the cases of child sexual exploitation (CSE) in Buckinghamshire from 1998-2016. Since 1998 there have been more than 10 Thames Valley Police operations across the county involving up to 100 children and young people. In 2013 a serious case review was undertaken to examine the response to 1 young person (J), but the impact of CSE on the other young people has not been reviewed.
Key findings: looks at the chronology of events starting in 1998 and the operations and reviews since then. Outlines reviews carried out by Thames Valley Police, Children’s Social Care and Buckinghamshire Safeguarding Children Board and the Misunderstood audit of peer-on-peer sexual exploitation. Explores the voice of those affected including interviews with 16 young people and 2 parents.
Learning: identifies what needs to change in order to improve agencies’ response to children, young people and adults facing CSE.
Recommendations: makes 14 recommendations including Buckinghamshire Safeguarding Children Board and Children’s Social Care should facilitate discussions with organisations such as Young Carers, Youth Clubs and the Youth Service to ascertain how they can better engage with statutory agencies to safeguard young people at risk of CSE; Buckinghamshire Safeguarding Adults Board should bring agencies together to ensure there is an appropriate, effective and coordinated response available to victims of CSE as they become adults.
Model: draws on information from agencies about past performance and assesses this against their current performance. Points out where practice has improved and identifies gaps and learning that still need addressing.
Keywords: Local Safeguarding Children Board, case studies, child protection, child sexual abuse, child sexual exploitation, children’s services, local authorities, sex offenders, England
Read the overview report

2017 - Croydon - Claire
Review of the responses of agencies between 1 January 2012 and 31 January 2014 to a young girl who was found to have contracted two sexually transmitted infections whilst in local authority foster care. 
Background: Claire was known to multi-agency services from the age of 5 months and had previously been the subject of a child protection plan. At 6-years-old she was sexually abused by a member of the household and became a looked after child in the care of her paternal grandmother. This placement broke down and Claire was placed in foster care. Claire was removed from the placement after 15 months when she was diagnosed with chlamydia and gonorrhoea. 
Key issues: lack of assessment, support and guidance for kinship foster carers; absence of scrutiny and challenge when assessing and approving new foster carers; lack of collaboration between social workers representing different teams within the looked after child service; the importance placed on performance indicators compromised the role of the Independent Reviewing Officer. 
Recommendations: strengthen the contribution of family members in looked after child reviews and child protection conferences; review how agencies are kept informed of planned changes for a child and consider adapting processes to facilitate the involvement of partner agencies; put processes in place to embed challenge as an accepted responsibility in safeguarding children.
Model: uses the Social Care Institute for Excellence (SCIE) methodology.
Keywords: child sexual abuse, children in care, foster parents, placement breakdown, professional collaboration, sexually transmitted infections. 
Read the overview report

2017 – Halton – Young Person
Life-threatening asthma attack experienced by a teenaged boy in December 2014; at the time he was visiting relatives who did not seek medical help for around 18 hours. After being treated in hospital he was taken into care due to concerns about his health and the cumulative effects of neglect.
Key issues: Young Person lived with his mother and her partner, and did not know his father. He suffered from long-term asthma and severe eczema which was being treated at a satellite dermatology clinic. He and his mother had Common Assessment Framework (CAF) support between 2009-2012.
Learning: from early age, professionals held information about Young Person which was not shared; professionals had limited understanding of the young person’s lived experiences; treatment for the young person’s eczema was provided by a medical team that primarily worked with adults, and had limited knowledge of how chronic conditions can affect a child’s life and age appropriate pathways for support.
Recommendations: identifies findings for the local safeguarding children board (LSCB), which can be used as a basis to make the local safeguarding system safer. These include: professionals need to be confident to raise questions about family or household members who could pose a risk of harm to a child.
Model: Social Care Institute for Excellence (SCIE) Learning Together model.
Keywords: child neglect, children with a chronic illness, disguised compliance, health services.
Read the overview report

2017 - Merton - Child B 
Serious physical assault in September 2015 of a 16-year-old girl whilst she slept. B's mother pleaded guilty to grievous bodily harm and was sentenced to a Hospital Treatment Order under the Mental Health Act, 1983. Child B became a looked after child.
Background: long history of mother's poor mental health, reports of excessive alcohol consumption and tensions in the parental relationship resulting in disputes which sometimes escalated to possible domestic abuse. B was subject to a child protection plan for emotional abuse, later becoming a child in need and finally a vulnerable child, supported by universal services. She was also a young carer for her mother.
Learning: a holistic 'Think family' approach had not been embedded across multi-agency children's and adults' services; young carers were not always recognised as such and their needs were not always understood or attended to by the whole multi-agency system; recognition of trends or patterns of risk, or changes in risk and when to 'step up' or 'step down' a case were not robust with a lack of confidence in escalating concern. 
Model: Multi-Agency Child Practice Review methodology
Recommendations: review how the principles of the holistic 'Think Child, Think Parents, Think Family' approach are operating and how they are embedded in commissioning and leadership of frontline practice and its management, with joint working and understanding of mental ill-health and parenting.
Keywords: mental health problems; alcohol abuse; domestic abuse; physical abuse; emotional abuse; risk assessment; interagency cooperation; holistic approach 
Read the overview report

2017 – Nottingham – Child J
Death of a 7-year-old girl in July 2014. Her aunt, who she lived with under Special Guardianship Order (SGO), and paternal grandmother were both sentenced to imprisonment for child cruelty.
Key issues: Child J was born with mild learning disabilities and a kidney condition. Her mother was a single parent and had poor mental wellbeing; her father had several other children and had spent time in prison. Mother disclosed having thoughts of harming Child J and made allegations of abuse against the paternal grandmother, father and father’s new partner. Child J became a Child in Need. She was placed with a foster family at 4-years-old and received support from child and adolescent mental health services (CAMHS) after showing signs of having experienced significant early trauma. She was placed permanently with her aunt (her father’s sister) under an SGO, with support under a Family Assistance Order (FAO). During this time the aunt stated Child J was self-harming and deliberately misbehaving. Several concerns were raised about the aunt’s punitive parenting style, including a referral to the NSPCC helpline.
Learning: includes: there was a lack of understanding about the impact of early emotional abuse and neglect on young children and the likely manifestation of this in their behaviour; a full assessment which brought together all the available information on Child J in the context of possible physical abuse was needed; the importance placed on engagement with parents/carers can mistakenly leave children at risk.
Recommendations: include: professionals should not accept the term self-harm in children under 10 without a consideration of potential wellbeing or safeguarding concerns.
Model: uses a hybrid systems methodology
Keywords: child deaths, physical abuse, punishment, special guardianship orders
Read the overview report link 

2017 – Rochdale – Child K
Death of a baby girl, Child K, who drowned in a bath in the presence of her older brother and sister. The 3 young children were left alone in the bath while in the care of their mother. Child K was taken to hospital by ambulance where her death was confirmed.
Background: history of domestic violence between Child K's parents, her brother was subject to a child protection plan in Bury because of this. The family had professional involvement from specialist services in Bury. Following their move to Rochdale the family lived in separate households with extensive contact and shared care. Child K was born in Rochdale where family accessed universal services. An offer of family support services was declined as Child K's mother was suspicious of social workers.
Learning: the police decision to interview Child K's brother shortly after the incident reflected poor communication between the police and children's services and poor judgement on the part of officers involved; engagement with families who have additional need but who don't reach the threshold for extra help or reject it.
Recommendations: the LSCB to conduct a multi-agency practice and service review on how agencies meet the needs of families who are reluctant to engage with services.
Model: Rochdale Borough Safeguarding Children Board Systems Model.
Keywords: sudden infant death, drowning, infant death, partner violence, maternal depression
Read the overview report

2017 – Staffordshire – Child B
Death of a 14-month old girl in July 2014. Cause of death was not ascertained but there were concerns she had died while co-sleeping with her mother and maternal grandmother who were both believed to have been under the influence of alcohol.
Key issues: Child B and her siblings were on a child protection plan under the category of neglect. There were 5 critical incidents related to the mother’s alcohol misuse.
Key findings: there were a number of missed opportunities to safeguard Child B and her siblings; there was a tendency to parent-centred practice; professionals did not listen to the views of Child B’s siblings; birth fathers were not involved in assessment and planning.
Recommendations: involving fathers and other significant men connected to a child in child protection cases; listening to the voice of the child; interagency communication.
Model: Uses the Social Care Institute for Excellence (SCIE) Learning Together systems methodology.
Keywords: child neglect, alcohol misuse, optimistic behaviour, children’s views
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2017 – Surrey – Child BB
Death of a 23-month old child in May 2014 due to non-accidental injuries.
Key issues: Child BB was taken to hospital in a state of extreme physical collapse, with bruises and burn marks, and died the following day. Criminal charges were brought against the mother and her partner in March 2015, but the partner committed suicide before the trial. Mother was found not guilty.
Learning: better interagency work and closer communication between police, probation services and children’s services could have resulted in a better understanding of the behaviour of the mother’s partner; safety messages on dating websites focus on the users’ personal safety but not on potential risks after a relationship is established.
Recommendations: include: police, probation service and children’s services to review processes for liaison about incidents and call-outs in relation to domestic violence; national consideration be given to how mothers can be alerted to the need for caution when engaging in new relationships with previously unknown men, potentially with an emphasis on relationships made through internet dating sites and social media.
Keywords: child deaths, physical abuse, online safety, domestic abuse
Read the overview report

2017 – Swindon - Child S
Death of an 8 week old girl in October 2015 whilst sleeping with her mother on the sofa. Child S was taken to hospital following a cardiac arrest and life support was withdrawn after three days.
Background: Child S was subject to an interim supervision order and a child protection plan at the time of her death. The family was known to Swindon Borough Council Children, Families and Health; Great Western Hospitals NHS Foundation Trust; CAFCASS.
Key issues: neglect, the impact of time spent in hospital on ability to care for children, communication gaps between organisations, health visit delays. 
Learning: The impact of time spent in hospital on ability to care for children.
Recommendations: include: make training available to Children and Families staff regarding the effects of long term drug use on the brain and to consider the impacts on patient’s ability to care for their family after a discharge from intensive care.
Keywords: sleeping behaviour, child neglect, depression
Read the overview report

2017 - Thurrock - Harry
Death of a 16-year-old Black British boy of West African parentage in a young offender institution (YOI). He had a history of epilepsy and a post-mortem examination confirmed death from natural causes.
Key issues: a formal diagnosis of epilepsy was made at age 7. The diagnosis was not recorded by either primary or secondary school and prescribed medication may not have always been ingested. His aggressive behaviour caused concern from age 13; he was excluded from school on several occasions and 2 separate assaults of railway ticket inspectors led to his detention in the YOI.
Learning: possible side effects of medication (aggression, impulsivity, violence) should have been explored; annual reviews by the GP practice of medication should follow practice policy; response times to medical emergencies in the YOI should be reviewed; internal information sharing within the YOI should be improved.
Recommendations: the YOI should strengthen procedures around medical risk factors of under-18-year-olds; the health provider at the YOI should undertake an audit of the ordering of medical tests to ensure procedural compliance; school nurses should alert teaching staff if a pupil has a diagnosis of epilepsy; NHS England should ensure that GP practices have policies in place with respect to regular medication reviews for children with epilepsy.
Keywords: aggressive behaviour, detention centres, exclusion from school, information sharing
Read the overview report

2017 - Waltham Forest – Child S
Death of 3-year-old Child S, cause unknown, in summer 2014, 6 months after moving to a London borough.
Background: Child S’s mother had a history of long term substance misuse. Child S, a sibling Child Y and the mother were known to Children’s Social Care, universal and specialist health and disability services, pre-school support services and drug support services in both local authorities. Child S had been the subject of a Child Protection Plan in 2013 but removed from the plan in the same year. Child S had serious health concerns from birth, eventually identified as cerebral palsy. Contact with all agencies featured many missed appointments. The family moved to a London borough soon before Child S’s death.
Learning: escalation of concerns; core and follow up assessments; continuity in social work practice; healthy scepticism about long term drug use; reporting and sharing information in drug services; experience of the child; transferring information between areas; hidden men; safeguarding children with disabilities; police sharing information.
Recommendations: pre-birth planning and assessment appropriate with drug using parents; Children in Need meetings properly recorded and CSC assessments up to date; compliance with 2009 guidance on safeguarding children with disabilities; review compliance on transferring cases; embedding healthy scepticism about long term drug using parents.
Keywords: cerebral palsy, addicted parents, non-attendance
Read the overview report

This list was last updated 6 June 2017.

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