Introduction

A Serious Case Review (SCR) is held when abuse or neglect is known or suspected, and either a child has died, or a child has been seriously harmed and there are questions about the way that agencies worked together to safeguard the child.

The purpose of an SCR is to explore whether there are changes that can be made to the safeguarding ‘system’ (e.g. service delivery arrangements, procedures, staff skills) to reduce the likelihood of a similar event in the future.

The government provides guidance to all the agencies that work with children about how to conduct a SCR.  These are contained in ‘Working Together to Safeguard Children 2015’, click here for further details.   As well as SCRs, the LSCB should carry out other reviews when it believes there is valuable learning to be gained.  Warwickshire Safeguarding Children Board (WSCB) calls these ‘local case reviews’.

SCRs and other case reviews should be conducted in a way which:

  • Recognises the complex circumstances in which professionals work together to safeguard children
  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did
  • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight
  • Is transparent about the way data is collected and analysed
  • Makes use of relevant research and case evidence to inform the findings.

Warwickshire SCRs

Serious Case Review – August 1st 2017 – Child “J”

A serious case review has been undertaken in relation to the case of child J, a seven month old baby who suffered a serious injury while in the care of her mother. 

The Serious Case Review identified that child J was a healthy, thriving infant whose lived experience ‘was one of safe and nurturing care and a positive relationship with her primary caregiver’; she experienced both love and commitment from her mother, and the nurturing support of an experienced foster carer. The professionals who were working with child J and her mother demonstrated a high level of support and diligence in the care they provided.

Nevertheless, in spite of all these positives, child J suffered a serious injury while in the care of her mother and that injury occurred while she was the subject of a child protection plan designed to keep her safe from harm.

It is from that perspective and in the context of a long-standing involvement of a range of professionals with the family, that Warwickshire Safeguarding Children’s Board commissioned this Serious Case Review and welcomes its findings.

The process of undertaking this SCR and the learning arising from it has been an invaluable experience for all involved. The model of ‘Pathways to harm; pathways to protection’ set forth in the recent Triennial Review of Serious Case Reviews and used as the analytic framework for this review, has lent itself to a depth of learning that is clearly rooted in the case and has been able to identify pertinent learning for the Board and its partners.

As a Board we are extremely grateful to Nicki Pettitt, the lead reviewer, to the members of the review team, to Child J’s mother, and to all those practitioners who contributed to the review.

Download Serious Case Review Child J PDF

Serious Case Review – March 2017 – “T”

Warwickshire Safeguarding Children’s Board (WSCB) has today (1 March) published a serious case review (SCR) following the death of “T” a 23 month old infant.

A Serious Case Review (SCR) is held when abuse or neglect is known or suspected, and either a child has died, or a child has been seriously harmed.

The purpose of serious case reviews is to explore whether there are changes that can be made to the safeguarding “system” so all involved are able to work better together and to reduce the likelihood of a similar event in the future.

“T” was a looked after child who was placed with foster carers registered with Warwickshire County Council. Three months later, ‘T’ tragically died, following admission to hospital with non-accidental injuries.

The foster mother pleaded guilty to the manslaughter of “T” and was sentenced to a term of imprisonment.
The WCSB appointed two independent safeguarding consultants to lead the review.

The review cites their findings which board partners have used to make a number of practice recommendations, and these are already being implemented by the agencies involved. The board will continue to monitor the progress of this work.

Measures brought into place as a result of the review include:

  • Scrutiny of carers and professionals working to safeguard looked after children has been enhanced through approval panels, sharing of performance reports and regular review
  • Improvements arising from a review of fostering services, commissioned by the county council, have been implemented and will be tested through an imminent peer review. Arrangements for seeking medical information from GPs as part of the statutory process for the approval of foster carers have been strengthened
  • A Placement Hub has been developed to support improved practice in making and taking of placement referrals, and to improve matching of children with suitable carers
  • LADO (Local Authority Designated Officer) arrangements in Warwickshire have been enhanced, and the WCSB has sought assurance from agencies and staff that the role of the LADO is understood
  • The designated nurse and doctor are working to create guidance to assist clinicians providing child care protection advice to social workers and police officers in relation to suspected non accidental injuries.

Download Serious Case Review Child T PDF

Serious Case Review – October  2015 – “John”

Warwickshire Safeguarding Childrens Board (WSCB) has undertaken a Serious Case Review following the death of ‘John’ a ten-week-old baby in September 2013.

John, a premature infant, died unexpectedly on the first night his family were staying with extended family after being evicted from their social housing tenancy.

John died after he was brought downstairs for a feed and then slept on the sofa with a parent. When the parent woke John had died. The coroner recorded an open verdict on the death.

Although John did not die as a result of maltreatment, WSCB carried out a review because his circumstances and contact with agencies as a ‘child in need’ met the criteria for a Serious Case Review.

WSCB commissioned two independent safeguarding experts to carry out the review, and speak to all the agencies involved with the case to identify areas of learning. The review, which used Social Care Institute for Excellence (SCIE) ‘Learning Together’ methodology, makes five findings and identifies action to be taken on a single and multi-agency basis.

The review found that agencies working with this family had not fully understood the issues at the heart of the case, and could have done more to mitigate the impact of the family’s eviction. It also found that that there was confusion about the extent of the lead professional’s role during the child’s assessment period.

Measures brought into place as a result of the review include:

  • The housing association now holds an internal case conference including those involved with a family before eviction to ensure all information is considered and if eviction is progressed that a referral is made to children’s social care
  • Training has been developed to ensure professionals making referrals and duty social workers share a better understanding and jointly make decisions so that people receive the right level of help for their needs
  • The Safeguarding Board will clarify the role of the lead professional during an assessment
  • Additional police officers have been trained in responding to unexpected child deaths
  • New paediatricians appointed in Warwickshire are now contracted to be trained to respond to unexpected child deaths
  • The multi-agency safeguarding hub (MASH), which is being developed, will support comprehensive information sharing at the point of referral.

David Peplow, Chair of WSCB, concluded: “We want agencies both in Warwickshire and nationally to learn from this case and improve practice.”

Download the Serious Case Review PDF

Download WSCB Response to John SCR PDF

Other Case Reviews

Learning from a review of Fostering and Adoption Services -  January 2018

A recent independent review was completed of the Adoption and Fostering Services in Warwickshire, which considered the importance of how the sharing of information between teams contributes towards robust and accurate assessment of carers.  Adopting a child is different from fostering; both carry an imperative on the carer to provide for and respond to the child's needs, but in very different circumstances.  

The learning that the review identified has now been published for sharing and wider dissemination.  To access, click here.  

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