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 - Alex
Death of 11-year-old child with complex medical needs requiring a high level of input from a variety of practitioners and putting a high level of demand on those caring for the child, making it difficult to define the threshold for neglect.
Key issues: Alex was diagnosed with cystic fibrosis (CF) at a year old. The parents separated when Alex was 5. There was evidence that the mother had experienced domestic abuse, coercion and control which continued with a partner who became Alex’s stepfather. The stepfather had considerable influence in decision making and gave the impression of having parental responsibility. Alex’s health deteriorated from age 6 and hospital admissions increased due to CF. Clinical staff were concerned about carers’ capability to deliver the care needed.
Learning: the importance of the child’s wishes and feelings to influence their care; practitioners had varying levels of knowledge in relation to the child’s clinical needs; the cumulative nature and clinical implications of his illness were not fully understood by those working with the child; the formal escalation procedure in place at the time was not used.
Recommendations: the importance of the voice of the child; the importance of supervision in social work; the need for formal processes and procedures to be in place to share information about children who meet the LSCB threshold level 3 criteria; decision making in practice should include the history of the family dating back at least one year.
Keywords: cystic fibrosis, emotional neglect, optimistic behaviour, parenting capacity
Read the overview report

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: 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: 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-Child Y
Serious health and developmental impairment of a teenage boy due to fabricated or induced illness (FII) over a number of years.
Learning: the difficulties faced by professionals in working with a family when FII is suspected.
Recommendations: development and implementation of pathways for the early identification and management of perplexing presentations, including suspected cases of FII, and for the management of identified cases of FII, including those who are subject to child protection plans; the Department of Health and the Department for Education should be asked to commission national research to establish the prevalence, incidence and case characteristics and outcomes for children who have perplexing presentations or FII.
Keywords: fabricated or induced illness, emotional abuse, adolescent boys
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 – Birmingham - Child D
Death of a 5 month old child of Lithuanian parentage from a brain injury in March 2015. Father was found guilty of murder of Child D in February 2016 and also found guilty of injuries caused to siblings DD and LD.
Key issues: Child D was a twin who was born prematurely and spent 2 months in hospital after their birth. Child D's sibling had further health complications that required hospital appointments. The family were not known to children’s social services until the death of Child D. The family were under financial pressures and away from the main support system of their extended families. There was contact with health visitors, GPs and hospitals before the birth of the twins.
Learning: considering all children in a family, fathers must be included in assessments and plans for children, highlights the importance of interpreters.
Recommendations: improved arrangements would not have prevented the death of Child D but there are opportunities for services to make some changes to develop their services.
Keywords: physical abuse, family violence, non-accidental head injuries
Read the overview report

2017 – Birmingham – Child S
Death of a 15-month-old child in January 2015 as a result of multiple non-accidental injuries.
Key issues: Child S had been brought to live in the UK by his mother from the Czech Republic who left him in the care of his adult half-sister and her partner. He was not known to any services. During the 3 months that he was in their care he sustained significant injuries that led to his death. A number of friends and relatives were aware of the injuries to Child S but did not report it.
Learning: the importance of using interpreters when working with families whose first language is not English, need for information in a number of languages, challenges of international migration for safeguarding children, work needed to address the lack of knowledge or trust of professionals and services within migrant communities.
Recommendations: makes a number of recommendations related to working with migrant families.
Keywords: abandoned children, child death, physical abuse, migrants
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 – 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 – 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
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2017 – Brighton and Hove - 'A'
Death by suicide of a 17-year-old boy in January 2016. 'A's' mother had mental health problems and 'A' had been exposed to physical and emotional abuse and witnessed domestic violence from an early age.
Learning: identifies learning under three headings: choice and initiation of placement; issues arising during placement, such as identifying the need for additional therapeutic support; and transition towards greater independence including help with coping with change and his move from therapeutic care.
Recommendations: the need for training around the vulnerability of care leavers for Brighton and Hove Children's Social Care; all care and placement plans should include a contingency position; and the therapeutic unit should review organisational capacity to challenge care plans if they deem it necessary.
Keywords: child mental health, children in violent families, family violence, harmful sexual behaviour, parents with a mental health problem, suicide
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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 - Central Bedfordshire - Nolan
Death of a 1-year-old boy, Nolan, in 2015 as a result of serious head injuries with the explanation inconsistent with the injuries sustained.
Background: Mother's childhood included exposure to domestic abuse and neglectful care and she was on the Special Educational Needs register at school. She lived with her mother and partner. Her first child was born when she was 16 and Nolan was born when she was 17. Both infants were born prematurely and had medical problems. Nolan’s father had mental health issues, a permanent movement disorder and lived in supported housing. Reluctance by mother to engage with services, including late booking for pregnancies and missed medical appointments for the children. 5 referrals were made to Children’s Social Care, the last 8 days before Nolan’s injuries.
Key issues: lack of curiosity about late booked pregnancy; no recognition of the impact of prematurity, unexpected home birth and illness on the parents’ ability to cope and implications of any rejection of help; challenges to parenting capacity should be communicated; the need to follow up referrals with checks and a visit.
Recommendations: make the reporting of bruising to non-mobile babies mandatory; ask member agencies to report on how they ensure the role of fathers and wider family members in the household are properly assessed; ask the police to review its internal handover processes; the LSCB should demonstrate the essential value of professional curiosity.
Methodology: follows a systems-based methodology which maximised staff involvement and kept the depth of the inquiry proportionate to the complexity of the case.
Keywords: infant deaths, non-accidental head injuries, non-attendance, parenting capacity
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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 - Croydon and Lewisham - Children R, S and W
Life-threatening injuries of a 6-month-old girl, Child W, in April 2015. The injuries remain unexplained but were suspected to be non-accidental. Mother and her partner were arrested on suspicion of grievous bodily harm but not charged. Child W and her siblings, aged 1 and 4, were placed in foster care.
Background: all 3 siblings were subject to child protection plans for neglect. During this process they moved from one local authority area to another. The case transferred between local authorities but the family were reported as missing. Mother was vulnerable, her own mother had suffered serious mental illness and she had spent much of her childhood in the care of her grandmother. There were concerns about domestic abuse, lack of engagement with services, mother’s young age and her mental health problems associated with childhood trauma.
Learning: responses from children’s social care were incident-led. Opportunities were missed to assess the children’s needs over time to assist in measuring the impact of the help already offered. Local authorities needed to have clear ‘step up / step down’ procedures for families who reject Early Help services.
Recommendations: make sure multi-agency training ensures the voice of the child is central to any contact or assessment. Develop a range of resources for practitioners to use when assessing children’s needs, including very young, pre-verbal children.
Keywords: child neglect, non-accidental head injuries, family violence, parents with a mental health problem; non-attendance; early intervention
Read the overview report

2017 - Derbyshire - Polly
Death of a 21-month-old girl, Polly, in May 2014 after attempts of resuscitation in hospital failed. Polly’s mother was convicted of murder and child cruelty, and her boyfriend of allowing the death of a child.
Key issues: Polly was subject to a child protection plan at birth due to pre-birth concerns about possible neglect. Polly was in foster care for a period in 2013 following a reported incident of domestic violence at home. Polly was returned to her mother’s care in October 2013 with a supervision order which included regular contact with her birth father. Between January and April 2014 Polly was involved in a number of medical incidents. Reports of domestic abuse referred to agencies and the family moved from supported living arrangements to rented accommodation in a neighbouring county.
Learning: the child protection plan did not assess the implications of the mothers mental health needs on her capacity to parent; lack of authoritative professional practice that saw Polly as the primary client; lack of understanding by some professionals about their role and responsibility when Polly was subject to a supervision order; little recognition of the role the boyfriend and father were playing in Polly’s life; and medical staff did not consider the possibility of child abuse or neglect when Polly presented with medical issues.
Keywords: family violence; child death, foster care, neglect incidence, mental health, medical practitioners
Read the overview report
Read the executive summary

2017 – Dudley – Child P and Child H
Death of a 2-year-4-month-old child (Child P) and a 7-month-old child (Child H) at home in unrelated incidents, with no specific cause of death identified.
Key issues: agencies had been involved with their families because of concerns about neglect and welfare of the children.
Learning: inadequate and adult focussed assessments, failure to incorporate males in assessments, lack of professional curiosity and an over-optimistic view of parental ability to effect change, effects of substance misuse overlooked and poor information sharing.
Recommendations: requiring the preparation and consideration of an up to date genogram for all interagency meetings concerning a child’s welfare. Carry out an audit of cases to form a judgement on the impact of the Neglect Strategy. Review arrangements for the timely completion of serious case reviews. Ensure more effective consideration of mental health issue within assessments of the needs of children.
Model: Significant Incident Learning Process.
Keywords: child deaths, disguised compliance, parenting capacity, parents with a mental health problem, sleeping behaviour, unknown men
Read the overview report

2017 – Durham – Baby Bailey
Death of a 7-week-old boy in November 2015. Baby Bailey had been co-sleeping on the couch before being found in the Moses basket. The post-mortem gave the cause of death as “unascertained”.
Key issues: parents were known to police due to the supply and use of drugs and related offences; the family was known to multiple agencies due to concerns about the neglect of 2 older siblings. Parents were arrested and interviewed but there was insufficient evidence to substantiate criminal neglect. Mother declined support from the Education Welfare Officer and Parent Support Adviser. She didn’t present for antenatal care until she was over 26 weeks pregnant with Bailey and did not attend several medical appointments for herself and her children. Home conditions throughout the period under review fluctuated from “just good enough” to “unsafe”.
Learning: drug use and related offending were not recognised or responded to as a child safeguarding issue; there was no multi-agency strategy meeting following the parents’ arrest for alleged neglect; the implications of denied or concealed pregnancy were not understood; the day-to-day lived experiences of Bailey’s older siblings were not sought.
Recommendations: implement a protocol for concealed and denied pregnancy; provide guidance for instances when children are not brought to medical appointments; ensure there is a standardised approach to strategy meetings.
Model: uses the Child Practice Review process to identify how agencies worked together.
Keywords: antenatal care, child neglect, infant deaths, newborn babies, non-attendance, substance misuse
Read the overview report

2017 – Enfield – Child YT
Death of 17-year-old boy after his arrest for illegal entry into the UK and subsequent placement in foster care the day before.
Recommendations: reviewing out of hours emergency child protection to record all aspects of vulnerability; ensure the voice of the child is heard.
Keywords: suicide, adolescent boys, unaccompanied asylum seeking children
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 – Hertfordshire – Child G
Death of a boy aged less than 1 year from unknown causes. A post mortem examination identified seven fractures which predated the death.
Learning: reluctance to name neglect by professionals involved with the family; the crucial importance of the assessment process to ensure appropriate intervention; the need to review the types of cases that are discussed in supervision.
Recommendations: the need to challenge agencies to demonstrate they are working in line with its strategic approach to neglect; to ensure that those families and children managed under Children in Need are the correct ones and are properly reviewed; the need to deliver safe and effective services for children within its traveller communities and to use this learning to enhance services to other minority communities.
Model: uses a systems approach.
Keywords: child assessment orders, student social workers, substance misuse, travellers, unknown men, violence towards professionals
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2017 – Hull – Baby J
Death of Baby J aged 4 weeks in summer 2014 owing to head injuries associated with being shaken. Baby J's father, FJ, was later convicted of manslaughter.
Key issues: Baby J's parents had both received support from mental health services prior to and after Baby J's birth. FJ had a history of domestic abuse with a previous partner and increasingly with Baby J's mother. Both parents were homeless and living in separate hostels throughout the pregnancy although Baby J's mother moved to her parents after the birth. An initial assessment was carried out in November 2012. Although recommended, a pre-birth risk assessment was not carried out.
Learning: no single agency had a full picture of the parent's history of mental health issues and drug and alcohol misuse; the risks posed by domestic abuse and coercive control by perpetrators were not understood; written agreements with families need to be monitored.
Recommendations: improving information sharing, communication and record keeping in relation to domestic abuse and mental health issues and involving fathers in risk assessments.
Keywords: family violence, homelessness, non-accidental head injury, parents with a mental health problem
Read the overview report

2017 - Isle of Wight – Child G
Death of a 6-year-old girl, Child G, in summer 2016. It appears that her father killed her and her 2 dogs before killing himself.
Key issues: Child G had never had any direct contact with children’s social care. Some professionals described the father as having a learning disability although this was not formally diagnosed. He had regular periods of depression and had been referred for psychotherapy following 3 bereavements and the loss of his job. Child G and her mother were also referred for mental health support. The parents separated and mother had twice reported to the police that the father had gone missing because she was concerned about the risk of suicide. He was assessed by a psychological therapist as being at moderate risk of causing himself harm.
Learning: professionals working with the father needed to consider how his mental health problems might affect Child G and what her needs might be. Risk assessments need to be continually updated as circumstances change. Having a child should not in itself be seen as a factor which can reduce a parent’s risk level.
Recommendations: the safeguarding adults board and the safeguarding children board should develop a shared strategic approach to “Think Family”. The joint working protocol for safeguarding children and young people whose parents/carers have problems with mental health, substance misuse, learning disability and emotional or psychological distress should be reviewed and made more accessible to practitioners from the multi-agency partnership.
Keywords: child deaths, fathers, filicide, parents with a mental health problem, suicide
Read the overview report

2017 – Kent – Child C
Death of a girl aged 2 years-and-four-months in June 2015 caused by accidental ingestion of her mother's methadone.
Learning: no documentary evidence about the views of the children or the ability of the mother to prioritise her children; potential neglect not identified; not every agency had a full picture of the children's needs and their reactive working was not conducive to identifying long term neglect; there was lack of clarity about the safeguarding risk assessment process.
Recommendations: update training on resistant and hostile parents; all agencies should use chronologies when carrying out risk assessments; KSCB to review and update the training programme for working with substance misusing parents.
Keywords: addicted parents, assessment of children, children of addicted parents, parenting capacity, substance misuse
Read the overview report

2017 - Liverpool - Chris
Subdural haematoma suffered by Chris, a baby under 6 months old, in September 2015. Further examination revealed recent and old injuries including rib and leg fractures. Chris’s injuries will have a life-long impact.
Background: Chris’s mother is a migrant to the UK. Her husband, MH, is also a migrant. MF is the birth father of Chris and sibling CS. Both MH and MF had access to the children. Family had contact with services including the GP, health visitors, midwifery and maternity services and the police. Police attended incidents involving the family on 5 separate occasions and notified children’s services each time. Referrals were also made by maternity services and the health visitor following Chris’s birth. Concerns included domestic abuse, the family being victims of anti-social behaviour and mother’s rough handling of CS during a medical appointment.
Key issues: safeguarding children in migrant families could be improved by addressing cultural competence in understanding family dynamics and more effective use of interpreters; services are too reliant on self-report information from migrants due to a lack of robust historical health, social care and criminal records.
Recommendations: the LSCB should ensure that professional interpreter services are always used by agencies - the use of family members or others is not acceptable; LSCB should contact the relevant government department to highlight poor availability of historic health and social care records for migrants to the UK.
Model: systems methodology developed by the Social Care Institute for Excellence.
Keywords: infants, non-accidental head injuries, physical abuse, family violence, immigrant families
Read the overview report

2017 - Luton - Child J
Death of a 13-month old boy in November 2015 from non-accidental head injuries inflicted on the day of his death.
Key issues: Child J lived with his parents for the first weeks of his life. Parents had a history of domestic abuse and separated in Spring 2015. They were known to children’s social care services. Mother became involved with a new partner and moved to a new area where children’s social services were informed about the family. Child J died of non-accidental head injuries and a post-mortem found several fractures. Mother and her partner were imprisoned for offences connected with his death.
Learning: transfer arrangements within health visiting and between Family Nurse Partnership and health visiting assume a degree of cooperation from families, which may leave children of avoidant parents at risk of harm when families move; professionals may underestimate the risk of physical harm to children in domestic abuse situations involving physical violence.
Recommendations: effective transfer arrangements between local authorities to avoid losing sight of vulnerable children when families move; and transfer of information between health visitors where families are transient.
Model: SCIE Learning Together systems model.
Keywords: physical abuse, family violence, head injuries
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 - North East Lincolnshire - Child T
Death of a 4-year-1-month-old girl as a result of non-accidental head injuries and ingestion of a range of illegal drugs.
Background: Child T was subject to a Child in Need plan for 13 months following her birth. For at least 6 months before her death, she was exposed to and ingested heroin, methadone, ketamine and various benzodiazepines. Mother and partner were charged with neglect, child cruelty and drugs offences. First child was taken into care before the birth of Child T as a result of domestic abuse and drug misuse by both parents; father was in prison at the time of death.
Key issues: the need for robust assessment to understand family functioning and assessing parental capacity to change; where siblings are born to children subject to a Child Protection Plan, a proactive decision is needed about the unborn or newborn baby; all contacts from family members raising concerns about the welfare of a child should automatically be treated as a referral; the need for multi-agency professionals to develop tools and skills to combat disguised compliance, particularly where parental substance misuse or domestic abuse are key causes of concern.
Recommendations: all children identified as a Child in Need should have a multi-agency plan with a level of management oversight equal to children subject to a Child Protection Plan; multi-agency professional meetings should ensure attendees understand the status and range of kinship care arrangements and their implications for the child; practitioners should develop increased skills in analytical thinking to apply at points of assessment and decision making.
Keywords: drug misuse, family functioning, parenting capacity, partner violence
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: 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 – Nottingham - Baby ON16
Non-accidental injuries of 16-week-old baby which resulted in admission to accident and emergency.
Learning: the need for practitioners to be aware of the significance of early life experiences, drug use and mental health problems in parents and their impact on the children; the need to understand normal child development which would have improved the quality of decision making; inter-agency cooperation; the need for effective supervision and managerial oversight. Examples of good practice were noted by the GP, the housing support worker and the health visiting service.
Recommendations: reviewing procedures for children cared for by extended family members and undertaking a learning exercise to improve responses to injuries and bruises in young babies.
Keywords: siblings, family Violence, physical abuse
Read the overview report

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 – Rochdale – Child L
Death of Child L aged 14 in 2016. A coroner's verdict found the cause of death to be 'death by misadventure'.
Background: Child L was found hanging in her home in February 2016. Child L had attempted suicide in the previous 2 years by overdose and had a history of self-harming from the age of 7. She had witnessed persistent domestic abuse from an early age. Child L had contact with Child and Adolescent Mental Health Services (CAMHS) and Children's Social Care (CSC). A common assessment framework (CAF) and a Child in Need assessment were completed.
Learning: keeping the focus on the child at risk when dealing with resistant parents or assessing parental capacity; critical thinking skills are necessary when assessing families with complex dysfunction; remaining attuned to the presence of unknown men.
Recommendations: all children assessed as medium to high risk through self-harm or suicide are referred directly to CSC to coordinate multi-agency working.
Keywords: alcohol misuse, parenting capacity, self-harm, suicide
Read the overview report

2017 - Somerset - Child L and Child J
Non-accidental injuries to 6-week-old Child J, sustained on at least two separate occasions. Child L, aged 5-months, half-sister to Child J, had a mouth injury and bruising 10 months earlier and had been subject to a Child Protection enquiry but after a Child and Family assessment the case was closed.
Learning: the need for practitioners to be aware of the significance of early life experiences, drug use and mental health problems in parents and their impact on the children; the need to understand normal child development which would have improved the quality of decision making; inter-agency cooperation; the need for effective supervision and managerial oversight. Examples of good practice were noted by the GP, the housing support worker and the health visiting service.
Recommendations: the strengthening of interagency procedures for the police, children’s social care, housing providers and the NHS Foundation Trust.
Keywords: disguised compliance, fractures, parenting capacity, teenage pregnancy
Read the overview report

2017 - Somerset - Child Sam
Severe and irreversible brain damage caused to a 6-month-old boy as a result of non-accidental injury.
Learning: importance of professionals working with families to recognise the increasing risk factors within the family and the impact these might have on the parents' ability to care; importance of information sharing.
Recommendations: ensuring that agencies identify and respond to risks and vulnerabilities within families where domestic abuse is a concern; appropriate training given about the importance of measuring and recording growth measurements; and training for health care professionals to highlight the signs and symptoms of brain injuries in young babies.
Keywords: infants, physical abuse, non-accidental head injury
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
Read the overview report

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 – Surrey - Child GG
Concerns about child sexual exploitation (CSE) of a 16-year-old girl.
Learning: lack of recognition among professionals of the risk of CSE as well as 'drift'; lack of coordination of services; the importance of relationship-based practice with children who have been involved in CSE; the need to avoid blaming or holding children responsible for the abuse and CSE; the importance of information sharing.
Recommendations: audit the extent to which children involved in or at risk of CSE are no longer blamed or held responsible and that records are respectful about the child and their family; raise awareness of CSE with taxi drivers, hotels, after school clubs, youth groups, park wardens and sports clubs.
Keywords: adolescents girls, behaviour, child sexual exploitation
Read the overview report link

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 – Trafford – Child N
Circumstances around Child N becoming a looked after child at the age of 7. Following placement in foster care after the father’s physical assault of an older sibling, Child N and siblings disclosed physical, sexual, emotional and psychological abuse.
Learning: identifies learning lessons in relation to multi agency working maintaining the child as the focus.
Recommendations: focused outcomes and plans for children; the value of multi-agency working; undertaking a thematic audit on working with violence and aggression; and developing a strategy to hear the voice of a child for children subject to multi agency procedures.
Keywords: physical abuse, disguised compliance, listening
Read the overview report

2017 – Trafford – Child PB
Alleged sexual abuse of an adolescent boy by foster carers in 2 separate placements between 2013 and 2015. A criminal investigation was initiated but neither foster carer was charged with criminal offences.
Key issues: Child PB became looked after aged 12 due to behavioural problems. His first long-term foster carer (FC1) requested that the placement be ended, citing ill health. PB was placed in a residential educational setting, living with a second foster carer (FC2) during weekends and holidays. His behaviour deteriorated and he was moved to a permanent residential placement. PB went missing several times, returning to FC2 although this was not always reported. On one occasion FC2 told police he hadn’t seen PB, but PB was found hiding undressed at FC2’s home. Despite FC2 being suspended as a foster carer, PB was persistently found at FC2’s home. Weeks later, following therapeutic support, PB disclosed sexual abuse by both foster carers.
Learning: although these disclosures have not led to prosecutions, the actions and behaviours of both foster carers should have led professionals to consider at a much earlier stage whether they could keep children in their care safe and whether they posed a risk to children placed with them.
Recommendations: ensure foster carer assessments and reviews are robust, thorough and appropriately challenging; ensure supervision files have carefully maintained chronologies to support supervision and review so that any emerging concerns or issues can be addressed; ensure all practitioners have a sound understanding of the range of characteristics, motivations and behaviours of people who seek to sexually abuse children.
Keywords: child sexual abuse, foster carers, placement breakdown, runaway adolescents
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

2017 – Warrington – Child 1
Child 1 witnessed mother’s death in the family home in 2014 from multiple stab wounds caused by father. Child 1 sustained stab wounds including the partial amputation of finger during the incident.
Key issues: Child 1 was the eldest of 3 siblings, one of whom was also present in the home at the time of the incident. The children were not known to child protection agencies. They attended school and had no additional health needs. Father and mother were married for 16 years prior to the incident but were experiencing marriage difficulties and attending marriage counselling. Mother experienced domestic abuse and disclosed that she thought father bugged the house, her phone and computer and that she was frightened for her safety and that of her children. Both parents had been in contact with police with issues around domestic difficulties. The criminal investigation revealed that the family home was dominated by father’s controlling behaviour.
Learning: a point of separation represents increased risk of harm to a victim of domestic abuse as well as children within the relationship; stalking behaviour in the context of domestic abuse is an indicator of high risk and is significantly associate with dangerous acts; the sharing of information between professional agencies is critical.
Recommendations: development of early help initiatives to help children talk about domestic abuse; publicising and promoting the role for independent domestic violence advocates; the use of public information notices to maximise the impact of warnings in cases of stalking.
Keywords: partner violence, emotional abuse, family conflict, murder
Read the overview report

2017 - Warwickshire - Child J
Non-accidental leg fracture of a 7-month-old baby who had been on a child protection plan since birth and had been living in a mother and baby foster placement with her mother until aged 5-and-a-half-months.
Key issues: Family were known to agencies for about 6 years due to concerns about the care of 2 older children where a number of probable non-accidental injuries occurred and family violence and substance misuse were present in the household. These children were subsequently taken into care and adopted. After the placement in foster care ended, the mother was housed in her home town some distance from the foster carer.
Learning: importance of assessing the accuracy of current or historical concerns reported by others; the need to respond flexibly to requests to house families in other local authority areas; to consider what formalised support is required following a move out of a baby and mother foster placement.
Recommendations: to make arrangements for appropriate medical and health advice to be available at strategy meetings; to consider how new professionals working with a family are made aware of the case history and reasons for decision making.
Keywords: adverse childhood experiences, family violence, housing, parenting capacity, unknown men
Read the overview report

2017 - Warwickshire – Child T
Death of a 23-month-old infant due to non-accidental injuries whilst in foster care in June 2013.
Key issues: Child T was a looked after child who was placed with foster carers in March 2013 as a result of injuries sustained whilst in his mother's care. In June 2013 Child T died following admission to hospital with non-accidental injuries.
Learning: fostering social workers should consider the needs and wellbeing of the children in foster care from a safeguarding perspective, regular and consistent supervision of foster placements is crucial, unrealistic expectations and views of foster carers due to lack of knowledge of child development must be challenged and addressed through training.
Recommendations: social workers should be made aware of the need to formally register any concerns about the care offered by foster carers as complaints to be investigated.
Keywords: child death, physical abuse, foster care
Read the overview report

This list was last updated 26 March 2018.

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