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 13-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 – Blackburn with Darwen – Child Y  
Death of a 14-year-old girl (Child Y) by suicide at her home in February 2017.
Learning: single and multi-agency responses could have been improved in order to enhance suicide prevention efforts; the work to support Child Y after the sexual assault was characterised by incomplete multi-agency working, and a general lack of awareness of the potential impact of child sexual assault on the victim and their families.
Recommendations: children or young people who are victims of sexual assault should be offered a referral to a Child Independent Sexual Violence Advisor; to ensure the voice of the child is central to any contact; GP practices should review the service they provide to victims of child sexual abuse; widely disseminate learning from this case to enhance practitioner awareness of potential suicide risk factors.
Keywords: child sexual abuse, drug misuse, psychological effects, victim support
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2018 – City of London and Hackney 
Non-accidental injuries to a 13-month-old child of African-Caribbean ethnicity (Child M), including bruising to the face and transverse fractures to both femurs in June 2016. Father found not guilty of grievous bodily harm but both parents were found guilty of child cruelty.
Learning: examples of parental avoidant behaviour or disguised compliance which exacerbate risks to children; occasions where more robust professional curiosity or challenge would have been justified; professional responses appeared more positive than the available evidence would suggest particularly concerning the child’s injuries.
Recommendations: to enhance confidence within professional networks in the context of respectful certainty/cognitive dissonance to develop plans and interventions to respond to the possibility of deliberate harm even in the absence of conclusive evidence; support practitioners working with avoidant families, frequently fluctuating circumstance and disguised compliance.
Keywords: disguised compliance, emotional abuse, fractures, immigrant families, non-accidental head injuries, non attendance
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2018 – Croydon – Joe 
Serious injury of a 2-year-11-month-old boy in June 2016 from third-degree burns.
Learning: protection of children will be compromised if a child protection plan is not working and there is insufficient insight into safeguarding processes; lack of robust inter- and intra-agency decision making jeopardises children’s safety; family and Kinship are critical members of the safeguarding network and should be regarded as such.
Recommendations: to ensure a robust, timely multi-agency process that scrutinises child protection plans for children who are the subject of a child protection plan for 18+ months and evaluate impact; professionals to be supported in gathering evidence and triangulating evidence to improve risk assessments.
Model: methodology based on the Welsh Child Practice Reviews Guidance, taking a multi-agency approach, focussing on systemic strengths and weaknesses.
Keywords: burns, decision-making, drug misuse, neglect-identification, professional curiosity
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2018 - Dorset - Child M  
Death of a 2 1/2–year-old child in 2016 following an assault by the mother’s partner, who was later found guilty of murder.
Learning: the importance for all agencies to notice patterns of behaviour, in particular considering the parenting capacity of a young parent with a complex history; effective safeguarding practice requires all professionals to consider their knowledge of domestic abuse, the predisposing factors and the impact on children; background checks on adults involved in domestic incidents are a vital part of safeguarding practice; when assessing an injury it is important that all professionals are thoughtful about the possibility of being misled by parents; asking the question “what is life like for a child in this family?” will help practitioners retain a child focus; the importance of involving non-resident fathers.
Recommendations: that agencies should be aware of the need to consider the parenting capacity of young people who have been known to services during their childhood and how this might impact on their care of children with whom they have significant relationships.
Keywords: child death, physical abuse, unknown men
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2017 – Edinburgh – The Sexual abuse of children in care
The sexual abuse of children in two residential care homes over a number of years.
Learning: vulnerable victims’ needs were not acknowledged and victims did not trust adults in authority to protect them; child protection systems contributed to the harm that the victims experienced and agency practice was too dependent on procedures.
Recommendations: Makes no recommendations but agencies should consider the distance between the findings of the report, current practice and their own aspirations and take steps to bridge the gap.
Keywords: child sexual abuse, residential care, professional curiosity
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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
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2018 – Sunderland – Baby A
Death of a 20-day-old baby following an assault by the family dog.
Learning: professionals need to help families think about risks that may be posed by family pets to children and the need to educate both parents about the risks of alcohol to the safe care of their children.
Recommendations: delivering a public awareness campaign around the risk to babies and children as a result of parental use of alcohol and unsupervised dogs.
Keywords: infant deaths, alcohol, substance misuse, unknown men
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2018 – Sunderland – Young Person Mark
Circumstances leading to a 15-year-old boy being placed in a secure setting in September 2015.
Learning: the need to improve understanding of adolescent choice and risk, especially in terms of substance misuse; the importance of shared assessment processes to pull out indicators of need or vulnerability; a lack of professional curiosity to investigate what the underlying reasons were for Mark’s behaviour and drug misuse; the need for a clear chronology of events to show where risks lie.
Recommendations: to the LSCB, develop a multi-agency framework to support the development of resilience and improve outcomes for vulnerable adolescents; support staff to engage effectively with young people and better understand issues of risk such as child sexual exploitation and substance misuse.
Keywords: behaviour disorders, drug misuse, listening, optimistic behaviour, professional behaviour
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2018 – Wolverhampton- Child G
Death of a 2-year-9-month-old boy of Caribbean and African heritage (Child G) on 22 November 2016 from cardiac arrest. After his death Child G was found to have peritonitis and a complex fracture of the skull along with other injuries. His mother's partner was convicted of murder and sentenced to life imprisonment; his mother was convicted of allowing the death of a child.
Learning: ways in which professionals assess the risk of domestic violence, and the implications that having no right to remain and no recourse to public funds have on the lives of the families they work with; professionals need to understand what parents' faith means to them during the assessment process and find out about other individuals who may be involved with them. 
Recommendations: to consider how the LSCB can draw to national attention the inconsistent application of duties for authorities to safeguard and promote the welfare of children of families with no recourse to public funds.
Keywords: immigrant families, non accidental head injuries, non-arttendance, single mothers, religion, unknown men
Read the overview report

This list was last updated 9 July 2018.

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