Case reviews Case reviews published in 2018

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 2018. To find other case reviews search the national repository.

2018 - Anonymous - Charlie and Sam
Sexual abuse and sexual exploitation of a 12-year-old girl and her 11-year-old sister. 
Learning: the importance of assessment to ensure that the needs of minority ethnic children are considered; there was a delay in moving the initial joint investigations forward which resulted in a delay to direct work; the importance of accurate assessment; and the use of professional interpreters within safeguarding practice.
Recommendations: are made around around management of CSE concerns, assessment and information sharing.
Keywords: child sexual exploitation, assessment, ethnic groups
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2018 - Anonymous- Children F, G and H
Concerns about serious harm to three siblings due to suspected fabricated or induced illness (FII). 
Learning: GPs should take a coordinating role when a child is attending a variety of clinics and hospitals for treatment; practitioners should be wary of relying solely on information provided by parents and ensure that the child's views are sought and listened to; practitioners should be alert to signs of disguised compliance by parents; practitioners need to maintain professional curiosity in cases where concerns emerge over a period of time.
Recommendations: request a review of the national Child Protection Procedures regarding FII; share learning from this review with NHS England; request that the Department for Education updates guidance on safeguarding and FII.
Keywords: fabricated or induced illness, discguised compliance, general practitioners, professional curiosity
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2018 - Anonymous - Child H1
Sexual abuse of a 15-year-old adolescent by her older brother in 2015. 
Learning: when Early Help is delivered without holistic access to information and there is no plan with agreed outcomes, it is a challenge to monitor the impact of the intervention; it is important that efforts are made to understand why young people are engaged in behaviour described as “risk taking” and “challenging”.
Recommendations: to audit and monitor how the voices of children and young people inform assessments and interventions.
Keywords: sibling abuse, harmful sexual behaviour, listening 
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2018 – Anonymous – Child Z
Death of a 10-year-old boy from complications arising from his medical condition. 
Learning: keeping the focus on the child whilst dealing with challenging parents; dealing with child protection concerns with professionals who are also colleagues; the need for decision making panels to have a safeguarding focus.
Recommendations: to oversee an audit of cases of children with complex needs to ensure each child has a multi-agency plan in place; ensure all children with plans have regular reviews; identify the lead professional for children with complex needs; provide training for staff where parents present a challenge to engage; conduct a review of home educated children; provide appropriate support available for parents of disabled children to help them come to terms with their child's condition or disability.
Keywords: children with physical disabilities, home education, medical care neglect
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2018 – Anonymous - Emily
Death of a 3-month-old girl in March 2015 as the result of Sudden Unexpected Death in Infancy (SUDI). 
Learning: the risks associated with twins and prematurity are not routinely articulated across multi-agency partners; there may be a tolerance of sibling violence that would not be accepted for intimate partners, which does not acknowledge the risk for children; professionals overreliance on diagnosis fails to recognise the continuum of needs of parents who have learning or mental health difficulties; the lack of a multi-agency neglect framework and toolkit inhibits a shared professional understanding of neglect.
Recommendations: a number of recommendations in the form of questions to the LSCB around the additional needs of premature and twin babies; sibling domestic abuse; and professionals' understanding of neglect.
Keywords: infant deaths, child neglect, domestic abuse
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2018 – Greenwich Safeguarding Children Board – W family
Deaths of a 9-year-old mixed heritage girl and her 3-year-old brother in January 2017 at the hands of their mother who used over the counter sleeping tablets, painkillers and methadone. The mother took her own life.
Learning: the need to understand the impact of a parent’s mental health on the children and how professionals should understand the possible wider impact and risk within the family.
Recommendations: The LSCB should implement a multi-agency ‘Think Family’ approach; to review arrangements in GP practices to ensure the welfare of children in assessing mental health of parents and carers.
Model: uses a hybrid systemic model.
Keywords: child deaths, maternal depression, post-natal depression, housing
Read the overview report

This list was last updated 18 April 2018.

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