Lessons learned from national and local experience.

1
Central Bedfordshire Local Safeguarding Children
Board

• Lessons learned from national and local
  experience.
• For all practitioners and managers working with
  children and the adults who care for them.

2
Purpose of discussion

• To consider the lessons learned from local case
  audits and from serious case reviews carried out
  by other LSCBs.
• To discuss the issues raised
• To consider current practice and improvements
  needed

Central Bedfordshire Local Safeguarding Children
Board
3
National cases

• Daniel Assaulted, starved, neglected
• Keanu Major injuries
  received over a period of days
• Hamzah Neglected lay dead
  for over 2 years.

4
Local Case Audits

• 8 cases reviewed from Bedford Borough, Luton, and
  Central Bedfordshire
• External consultant facilitated meetings and
  produced the reports with the lessons learned
• There was a high level of practitioner engagement
  and multi-agency analysis
• Final approval of lessons learned agreed by LSCBs
  in February.

5
Lessons learned Neglect

• Cumulative nature you get used to it,
  professionals tolerate low standards of care, it
  is multi-faceted, rarely an incident or critical
  event. Need to be alert to danger of drift and
  losing child focus in long term neglect cases.
• Thinking the unthinkable - Always work with
  'healthy scepticism' when dealing with families
  where children might be at risk.
• Working with vulnerable adults those with
  mental health problems, substance misuse issues
  and families where domestic violence is present
  can involve mounting risks for children and young
  people. Where all 3 are present this is very
  high risk (commonly referred to as the toxic
  trio)

6
Lessons learned Core Group Working

• Fundamental to co-ordinating the protection plan
  and sharing information, good attendance at these
  meetings is essential.
• Information sharing relies on a shared chronology
  and other information on which to base core group
  activity.
• Need contingency plans if the chair or minute
  taker is not available
• Progress on the plan and outcomes achieved should
  be recorded reference to impact and change
  should always be recorded
• Views of children, young people, parents and
  carers should be sought and included in the
  minutes
• Professionals at core groups should consider
  whether the professional network could be
  colluding with or mirroring family dynamics.
• Professionals should be cautious about over
  optimism is there evidence of sustained
  progress?

7
Lessons learned False and non-compliance

• Parents can be highly persuasive, domineering or
  apathetic.
• Some will agree to comply.
• Some will just never comply at all.
• Explanations for injuries can be accepted as
  parents present them with strong conviction
  sometimes linking them to a real illness.
• Parental non-engagement should always be
  questioned and challenged and the reasons for it
  requested compliance does not minimise the risk
  of grooming of professionals.
• Compliance does not always mean engagement.
• Think the unthinkable.

8
Lessons learned False and non-compliance

• Are interventions taking place?
• Are they making a difference?
• Measure interventions in terms of outcomes
• What improvements do you expect to see in the
  child?

9
Lessons learned Thresholds
10
Lessons learned Thresholds

• Do you know the thresholds between early help and
  social care?
• You dont know what you dont know
• You may not have the full picture
• Having doubts? check it out!
• Thresholds criteria online make sure you have
  read and understood the thresholds.
• Forms are slightly different in each local
  authority area but referrals will not be turned
  away!

11
Lessons learned key practice points

• What is a day in the life of the child like?
• Have we listened to the child?
• Are parents needs drowning out the needs of the
  child?
• Can you see improvements?
• Is progress impaired by parents non compliance?
• Should you accept the explanations for injuries?

12
Practitioners next steps

• Check out the threshold criteria
• Sign up for training especially core group
  training
• Talk to your manager about any concerns however
  slight they may seem
• Seek peer review

13
Thank you!

• Any feedback for the LSCB?
• What can we do to support multi-agency
  safeguarding work and practice?
• Please contact the team on 0300 300 6455 or
  e-mail the LSCB team at LSCB_at_centralbedfordshire.g
  ov.uk