Child Protection Board Report

1
Review of Chapter 8 Serious Case Reviews Sue
Lewis Trust Named Nurse for Child
Protection Malcolm Wiseman Named Doctor for
Child Protection
2
What is a Serious Case Review ?

• Section 8 of Working Together to Safeguard
  Children DoH, HO, DfEE. 1999
• What Circumstances?
• When a child dies (including suicide), where
  abuse or neglect is known to be a factor
• When a child sustains a potentially life
  threatening injury
• Where the health and development of a child has
  been seriously and permanently impaired
• When a child has been seriously sexually abused
• Additionally
• The case gives rise to concerns about inter
  agency working to protect children

3
Purpose of Serious Case Reviews

• To establish if there are lessons to be learned
  about how professionals and agencies work
  together to safeguard children
• To identify those lessons, how we will act on
  them and what is expected to change as a result
• To improve interagency working to better
  safeguard children
• Case reviews are not enquiries into how a child
  died or who is culpable. Coroners and Criminal
  Courts do this

4
17 Ch. 8 Reviews involved SLaM 2001 - 2004

• Data confidence high
• Small but 100 sample
• Do figures reflect
• Thresholds for review
• Demographic change, greater more complex needs ?
• Quality of child protection practice

5
What happened?

• 2001
• Boy 10 hanged himself
• Boy 14 lost control of stolen car and died
• Boy 15 hanged himself in secure unit for young
  offenders
• Murdered girl 15 found in cement works in
  tarpaulin
• Serious sexual abuse of boy 14 and girl 9
• 2002
• Girl 14 weeks subdural haematoma and fractures
• Children 5 8 with serious fractures and bruises
• Boy 18 months dead on ground outside home

6
What happened?

• 2003
• Subdural haematoma of daughter 5, by mother
• Father drowned 13 yo daughter
• Mother attempted to drown baby
• 14 yo killed 16 yo brother with knife
• Father fractured babys skill - multiple injuries
• 2004
• Mother killed 5 yo son then self with overdose
• Boy 12, serious sexual assault of boy, 10
• Mother put baby on fire, baby died
• 14 month boy with multiple fractures

7
By Borough 2001 -2004

• Differences
• Do figures reflect
• Thresholds for review
• Demographic change, greater more complex needs ?
• Quality of local child protection practice
• (Lewisham - 5 reviews 2001-2002)

8
Ages by ( all 19 children)

• All ages at risk
• Could help us focus help
• Perinatal under 18 months - important group

9
Gender profile ( all 19 children )

• Perpetrators
• Child - all male
• 1 suicide
• 1 fatal car crash
• killed other child with knife
• serious sexual assault of child
• 1 adult - not known

10
Ethnicity profile of 19 victims

• Ethnicity poorly described in reports
• 79 black or mixed race
• Implications for service development, policy and
  practice

11
SLaM services involved - of reviews

• National Review of Serious Case Reviews 2002
• 45 of primary carers have MH problems
• 23 of secondary carers have MH problems
• All SLaM services involved
• CAMHS involvement may include contact with
  sibling
• All 5 addictions cases also involved either MH
  (2), CAMHS (2), MHCAMHS (1)

12
Family themes by

• Domestic violence most significant
• TRAUMA identified separately to domestic violence
  e.g. child soldier/war, prior sexual abuse,
  extreme violence, bullying
• 44 families with children over 5 were out of
  school

13
Calculating risk

• The whole is greater than the sum of the parts -
• A combination of any of the factors which taken
  individually would require only an initial
  assessment, when combined with violence, parental
  mental illness, excessive drinking, or drug use
  may justify considering an immediate s. 47
  enquiry
• London child protection procedures risk assessment

14
Service themes - 17 reviews

• 10 out of 17 cases need was identified but not
  acted on
• 7 of 17 cases revealed discontinuity due to
  moving home (2), service (4), and between teams
  (5)
• 5 involved one or more teams - responsibility

15
Themes of recommendations
16
Finally

• Thinking about children and parents is often kept
  artificially separate because services are
  organised to deal with individuals and not
  families
• Keeping families in mind helps parents recover,
  protects the welfare of children, and enhances
  the quality of life for the family unit

17
Questions Discussion

• How do themes relate to recommendations?
• Do recommendations address issues?
• Will effects of implementing recommendations
  improve safeguarding for the majority

18
Detail of themes of recommendations

• Some of the recommendations were made several
  times over indicating strength of importance e.g.
  (x2,3)

19
Managing child protection risk

• Trust mechanism for recognising need and risk
  (x2)
• Child Protection risk assessment to be triggered
  in serious parental mental illness (2)
• All emergency phone referrals must be followed up
  in writing within 24 hours
• Assessment and intervention should not be made
  without reference to previous history and
  recording
• Child protection conference invitees must send
  typed reports covering parental, child
  development and environmental domains
• Clarity of roles and participation in conferences
  and core groups, cases not closed without
  reference to core group (x4)

20
Managing child protection risk - 2

• Explicit clearly documented multi agency
  protection plan with identified co ordinator and
  roles, shared with families and written summaries
  to involved agencies and GP (x2)
• Cases not closed without reference to core group
  where there is a registered child or closed or
  declined without the referrer and other key
  agencies advised so that they can take
  responsibility for support and monitoring where
  required (2)
• Interagency plan facilitated by core groups
• Staff to, escalate concerns about increased risk
  or communication, involve senior staff in
  decision making and make CP referrals
  irrespective of low levels of concern from other
  agencies / team colleagues and seniors (3)
• Implementation and recording of child visiting
  plans (X2)

21
Supervision

• Implementing supervision guidelines
• Discuss concerns with appropriate supervisor or
  advisor and record out come on file
• Supervisors ensure needs of all family members
  are considered and
• Peri natal psychiatry practice supervision
• Child protection concerns addressed and
  documented
• Familiarise all staff with London, ACPC and local
  CP procedures, policy and training requirements
  (x3)

22
Training

• Common interagency induction programme
• Child protection procedures (3)
• Multi agency training
• asessment skills
• effects of parental alcohol abuse on children
• SLAM and interagency
• Parental mental health (2)
• Peri natal mental health (2)
• Learning from serious case reviews, individual
  review and cumulative

23
Systems Service Development

• Develop interagency protocol (3) for
• screening under 5s with mentally ill parent /
  pregnant mothers
• Pre birth referral and assessment including
  collation and analysis of historical information
• Contingency and crisis plans for inpatient care
  (in accord with pre birth plans)
• DNA protocols (4) - review vis a vis
• significance of DNA as potential risk indicator
• interfaces with outreach and engagement services
• child risk - alerts if children and families
  involved
• reference to core group
• communicate repeated DNA s to other agencies /
  referrer
• Reduce waiting times for vulnerable families /
  children
• Review engagement strategies for vulnerable
  families / children

24
Systems Service Development - 2

• Review interface between peri natal and other
  Trust services to achieve effective protocols for
  co ordination and clear accountability
• Independent systems (3) to review
• cases reaching threshold of risk where court
  action not appropriate
• serious complex cases
• Review and implementation of recommendations (3)
• Service for children who sexually abuse other
  children
• Electronic records across CAMHS and peri natal
  services for contemporaneous recording and
  sharing information

25
Communicating across interfaces

• Written outcome of referral assessment,
  formulations and plans to referrer and or GP,
  involved professionals - including medication
  (x5)
• Explicit protocol for transfer of care between
  teams including updated information, history,
  child need risk, visiting frequency (x2)
• Complete risk assessment prior to each move,
  including within the service, including frequency
  of visiting
• Communicate across services involved in the same
  family, within the trust and externally e.g.
  Adult mental health, CAMHS school nurse, HV and
  not just child and families in cases of suspected
  risk (3)
• CAMHS reconsider practice of obtaining parental
  consent before accessing Trust parent records in
  situations of child risk

26
Working across interfaces

• Culture shift for staff caring for parents with
  mental health problems / children to talk to the
  childs / parents professionals e.g. CAMHS,
  mental health, HV, school and not just child and
  families (3)
• Pre birth referral and interagency planning
• Refer discussions about case closure to core
  groups
• Clarification of roles and responsibilities of
  specialist teams in relation to generic services

27
Parental mental health

• Recognise parental mental ill health and make
  appropriate child protection and mental health
  referrals (1)
• Screening of under 5s with mentally ill parent
• Pre birth, assessment, referral and interagency
  planning for all parents (including fathers) with
  mental health problems (2)
• Explore psychological and emotional meaning /
  significance of pregnancy for mother with mental
  health problems (2)
• Training - Multi agency and SLAM training (X3)

28
Peri natal

• Explore psychological and emotional meaning /
  significance of pregnancy for mother with mental
  health problems (2)
• Training and practice supervision in peri natal
  psychiatry, pre birth assessment and planning
• Screen pregnant mothers including adult mental
  health
• MBU should (Operational Policy review)
• Review Mother Baby assessments and
• How they are communicated to referrer and other
  agencies
• Participate in Core Groups where a baby is
  registered
• Clarify aim of admission and expectations of
  referrer and agencies in writing
• Share aims of admission agency expectations
  with mother
• Develop Multi agency plan for conveying the plan
  to the client including support needed on hearing
  about the plan

29
Work with Carers and Families

• Provide useful information for carers
• Provide information on counselling support for
  relatives following serious incidents - local
  fact sheet of resources
• Consider effects of past trauma in work with
  families
• Trigger PTSD assessment where families have
  experienced trauma
• Explicit child protection plans

30
Domestic violence (DV)

• Disseminate Follow ACPC DV policy (x2)
• Develop SLAM DV Policy
• DV training and staff to access ACPC training

31
Black and Ethnic Minority clients

• Take race, language, culture and religion into
  account and document how they have been addressed