case study social work child maltreatment

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Case studies and real-life stories can be a powerful tool for teaching and learning about child welfare issues and practice applications. This guide provides access to a variety of sources of social work case studies and scenarios, with a specific focus on child welfare and child welfare organizations.

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Please note you do not have access to teaching notes, working together to identify child maltreatment: social work and acute healthcare.

Journal of Integrated Care

ISSN : 1476-9018

Article publication date: 19 October 2015

The wider research literature indicates that health professionals’ ability to identify possible child maltreatment varies, and that this can lead to under-reporting of possible maltreatment to local authority (LA) statutory child protection agencies. The purpose of this paper is to understand how acute trust paediatric and LA services work together in suspected cases of child maltreatment, and what is viewed locally as good practice.

Design/methodology/approach

A mixed-method approach, consisting of an online survey, qualitative case studies and good practice examples, was used to describe key features of current practice in joint working between acute trusts and LA services, and to generate insights that could help improve practice.

Holistic assessment and information gathering, supported by training and expert input, were identified as being critical to a comprehensive approach to identifying maltreatment. Both in-hospital and community-based social work arrangements can be effective bases for joint working in respect of child maltreatment. Effective joint working relies on shared vision and values, and investment in, and commitment to, collaborative working.

Research limitations/implications

This study covered arrangements in emergency departments (EDs) and maternity departments only, so future research could usefully look more broadly within acute care settings. Study respondents were also limited to safeguarding leads so, in future, there would be real value in exploring the experiences, practices and views of frontline practitioners.

Practical implications

The study includes practical implications for hospital and social work teams working to safeguard children.

Originality/value

The study highlights the characteristics of effective liaison between acute trust maternity and EDS and social work teams.

• Partnership working
• Healthcare management
• Interagency working
• Social work
• Child maltreatment

Acknowledgements

The authors are very grateful to the hospital and social work service staff who gave their time to the research, in both the online surveys and the case study interviews. The authors would also like to thank the project Advisory Group for their advice, insights and support throughout the study. The study was funded and conducted as part of the work of the Policy Research Unit in the Health of Children, Young People and Families (CPRU). CPRU is funded by the Department of Health Policy Research Programme, and the authors gratefully acknowledge the Department’s financial support for the study. This is an independent report and the views expressed are not necessarily those of the funders. The authors’ work was independent of the funders who did not play any part in the design, data analysis and interpretation of this study, the writing of the manuscript or the decision to submit the paper for publication. The authors would like to thank members of the Policy Research Unit for the Health of Children, Young People and Families: Terence Stephenson, Catherine Law, Amanda Edwards, Ruth Gilbert, Steve Morris, Helen Roberts, Catherine Shaw, Russell Viner and Miranda Wolpert.

Lewis, J. , Greenstock, J. , Caldwell, K. and Anderson, B. (2015), "Working together to identify child maltreatment: social work and acute healthcare", Journal of Integrated Care , Vol. 23 No. 5, pp. 302-312. https://doi.org/10.1108/JICA-08-2015-0032

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Child Maltreatment and Long-Term Physical and Mental Health Outcomes: An Exploration of Biopsychosocial Determinants and Implications for Prevention

Divya mehta.

1 Centre for Genomics and Personalised Health, Queensland University of Technology (QUT), Brisbane, Australia

2 Present Address: Child Adversity, Mental Health and Resilience Theme, Centre for Child Health and Well-being, Queensland University of Technology (QUT), Brisbane, Australia

3 School of Biomedical Sciences, Queensland University of Technology, Brisbane, Australia

Adrian B. Kelly

4 Centre for Inclusive Education, Queensland University of Technology (QUT), Brisbane, Australia

5 School of Psychology and Counselling, Queensland University of Technology (QUT), Brisbane, Australia

Kristin R. Laurens

Divna haslam.

6 Parenting and Family Support Centre, The University of Queensland, Brisbane, Australia

Kate E. Williams

7 School of Early Childhood and Inclusive Education, Queensland University of Technology (QUT), Brisbane, Australia

8 Centre for Child & Family Studies, Queensland University of Technology (QUT), Brisbane, Australia

Kerryann Walsh

Philip r. a. baker.

9 School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Australia

Hannah E. Carter

Nigar g. khawaja, oksana zelenko, ben mathews.

10 School of Law, Queensland University of Technology (QUT), Brisbane, Australia

11 Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA

Child maltreatment rates remain unacceptably high and rates are likely to escalate as COVID-related economic problems continue. A comprehensive and evidence-building approach is needed to prevent, detect and intervene where child maltreatment occurs. This review identifies key challenges in definitions, overviews the latest data on prevalence rates, reviews risk and protective factors, and examines common long-term mental health outcomes for children who experience maltreatment. The review takes a systems approach to child maltreatment outcomes through its focus on the overall burden of disease, gene-environment interactions, neurobiological mechanisms and social ecologies linking maltreatment to mental ill-health. Five recommendations relating to the accurate measurement of trends, research on brain structures and processes, improving the reach and impact of teleservices for detecting, preventing and treating child maladjustment, community-based approaches, and building population-focused multidisciplinary alliances and think tanks are presented.

Introduction

There is a major expansion in awareness of the prevalence and impact of adverse childhood experiences (ACEs) and child maltreatment in particular. The devastating impact of sexual, physical and emotional abuse on survivor well-being, the trusted institutions that failed to protect children, and the need for improving complaints mechanisms and institutional regulation/oversight has often been discussed [ 1 ]. The paper is organised into four parts: (1) Epidemiology, (2) systematic factors, (3) prevention, and (4) recommendations (Fig.  1 ). In this paper we overview definitions, heuristics for categorisation, prevalence rates, health and economic consequences of child maltreatment and school and family-oriented prevention and intervention approaches. We highlight the ongoing challenges of conducting high quality research into the development and prevention of child maltreatment, particularly in the age of COVID, when social isolation is high, and economic recession is uncovering structural inequalities, many of which are perpetuated by unequal distribution of resources, rights, and opportunities and are also known, in turn, to perpetuate child maltreatment. We argue that there are unique opportunities for the provision of evidence-based programs via recent e-health technology investments, but we will need reliable ways of measuring trends and investment in government and nongovernment coalitions to reach those most in need.

Heuristic framework for this review of literature on child maltreatment

Epidemiology of Childhood Maltreatment

Definitions.

Child maltreatment is universally understood to include four main types: sexual abuse, physical abuse, emotional or psychological abuse, and neglect [ 2 ]. Increasingly, epidemiological and other studies include exposure to intimate partner violence as a fifth form [ 3 ]. Child maltreatment are forms of adverse childhood experiences (ACEs), a broad term that also includes exposure to family mental health problems, incarceration, substance use, parental separation/divorce, as well as poverty, bullying, racial discrimination, and separation from immigrant parents [ 4 ]. Defining the nature of each form of child maltreatment is complex, but robust conceptual models have developed over time to establish growing consensus. Physical abuse is generally understood to involve intentional acts of physical force by a parent or caregiver [ 5 ]; it is normally seen as excluding lawful corporal punishment. Sexual abuse involves contact and non-contact sexual acts, inflicted by any adult or child in a position of power over the victim, to seek or obtain physical or mental sexual gratification, when the child does not have capacity to provide consent, or has capacity but does not provide consent [ 6 ]. Emotional or psychological abuse is inflicted by a parent or caregiver, and includes hostile interactions (such as belittling, degrading, shaming, denigrating or ridiculing a child, and rejection of the child), emotional unavailability (ignoring a child), developmentally inappropriate interactions, failure to acknowledge the child’s individuality, and failure to integrate the child into the social world [ 7 , 8 ]. Neglect involves parental or caregiver omissions to provide the necessities of life, as suited to the child’s developmental stage, and as recognised by the child’s cultural context. Neglect includes multiple dimensions, including physical, emotional, medical, environmental, supervisory, and educational neglect [ 9 ]. Exposure to domestic violence involves witnessing a family member being subjected to physical assaults, threats or property damage by another adult or teenager normally resident in the household. It extends to witnessing other forms of non-physical behaviour that is sexually, financially, or verbally coercive, or which isolates someone from their family or friends [ 10 , 11 ].

As of 2015, some 244 publications from across the globe were available on the prevalence of child maltreatment and 551 prevalence points were available across four forms of child maltreatment (excluding domestic violence) [ 12 ], but comparatively few of these are national prevalence studies that report on all or most domains of child maltreatment [ 13 ]. The challenges of estimating child maltreatment are well established and widely recognised [ 13 ].

A key challenge is reconciling the disparities between official child protection agency data, informant studies (where data relies on sentinel reports, for example reports from police and educational and welfare workers), and self-report studies. The available evidence is that only 5% of child physical abuse and 8% of child sexual abuse is reported to child protection authorities [ 14 ]. The core reason for low child abuse estimates in official child protection agency data is that most cases are not reported. Even for reported cases, abuse may not be officially confirmed despite being present, and therefore not included in child abuse estimates [ 15 ]. Nondisclosure rates are high for multiple reasons: maltreatment occurs in private; many cases involve infants who are not in regular contact with protective adults outside the home; parents do not self-report; children themselves do not report; maltreatment is difficult to detect; and even when detected by others, it is frequently not reported. For some types of abuse in particular, non-disclosure is typical. With sexual abuse, for example, the child may be preverbal, deceived into believing the abuse is normal, reticent to report because of shame and guilt, or fear reprisals [ 15 ]. Accordingly, prevalence rates drawn from agency data lead to underestimates of prevalence because the majority of childhood maltreatment does not come to the attention of such agencies. Combined (male and female) lifetime prevalence rates from informant studies range from 0.3% for physical abuse and emotional abuse to 0.4% for sexual abuse. Furthermore, agencies typically are under-resourced and therefore prioritise responses to children suspected of experiencing more severe maltreatment; many reported cases are screened out, or not investigated, or are investigated but do not lead to officially recorded maltreatment for technical reasons. Also, informant studies are typically based on one-year temporal windows, whereas self-report studies tend to cover longer temporal windows, such as lifetime prevalence [ 12 ].

These data from informant studies stand in stark contrast to lifetime prevalence rates from self-report studies. Systematic reviews and meta-analyses of self-report studies indicate rates of 12.7% for sexual abuse; 22.6% for physical abuse; 36.3% for emotional abuse; 16.3% for physical neglect; and 18.4% for emotional neglect [ 12 ]. Based on international studies up to 2014, more recent systematic reviews of some 337 studies found higher prevalence rates for sexual abuse [ 16 ]. Median lifetime prevalence of sexual abuse was found to be 28.8% for Australian females and 20.4% for North American girls, and for males, these indices were 6.1% and 14.1% for Australians and North Americans respectively. Moody et al. (2018) also found that combined rates (females and males) for lifetime prevalence of physical abuse were 6.7% and 18.1% for Australia versus North America [ 17 ]. For child emotional/psychological abuse, combined rates for lifetime prevalence were 9.2% and 23.9% for Australia versus North America. For child neglect, combined rates (females and males) for lifetime prevalence were 14.4% and 30.1% for Australia versus North America. In a recent analysis of U.S. national survey data on exposure to violence (2011–2014) [ 18 ], it was found that 6.1% of children reported some form of neglect in the past year, and 15.1% reported neglect at some point in their lives. In the European Region, it has been estimated that 18 million children suffer from sexual abuse, 44 million from physical abuse and 55 million from mental abuse, with child maltreatment leading to the premature death of 852 children under 15 years old each year [ 17 ].

The above median prevalence rates bely great variability across studies, leading researchers in the field to recommend improvements in measurement of childhood maltreatment [ 13 ]. Due to the specific questions asked, it is likely that some studies underestimate the prevalence of maltreatment. Based on a systematic review of some 30 national prevalence studies crossing all or most forms of child abuse and neglect [ 13 ], Mathews et al. recommend “behaviourally specific questions grounded in sound constructs of maltreatment with representative samples of the population (p. 14)”. Many studies use measures for which psychometric data are unavailable or not reported or are based on vague operational categories.

Health and Economic Burden

While child maltreatment has historically been perceived as a child protection matter, a criminal justice issue, and a broader social concern, there is increasing recognition of its status as a major public health concern with substantial economic impact [ 19 ]. Maltreated children may experience long term impacts on mental, physical and reproductive health, with economic implications for health, welfare and justice systems as well as productivity losses from reduced labour force participation rates [ 20 ]. A comprehensive understanding of the health and economic burden associated with child maltreatment is essential in determining the potential benefits of preventive measures. However, there is limited evidence for this internationally. Childhood sexual abuse was the only form of maltreatment that was included in the Global Burden of Disease 2010 study. A paucity of literature on the burden of other forms of maltreatment has been noted [ 2 , 21 ].

Childhood maltreatment is a known precursor to a range of mental health and high-risk behaviours that compound the risk of ill health [ 22 ]. Child sexual abuse frequently causes immediate and intractable negative physical, psychological, and social problems [ 23 ] and when sexual abuse co-occurs with other ACEs (as it often does), the risks of adverse medical and mental health problems are higher than for other combinations of ACEs [ 24 ]. Consequences commonly include post-traumatic stress disorder (PTSD) [ 25 ], obesity and eating disorders [ 26 – 28 ], alcohol and drug problems [ 29 – 33 ], poor school achievement [ 34 ], depression [ 35 , 36 ], dissociation [ 37 ], social impairment [ 38 ], antisocial behaviour, anxiety [ 39 ], self-harm and suicide [ 40 , 41 ], and increased chance of revictimization [ 42 , 43 ]. In students from high-achieving schools, ACEs were associated with between two and five-fold increases in adult psychiatric diagnoses, depending on the extent of exposure to ACEs [ 44 ]. Reviews have highlighted the high rates of insecure disorganised and dissociative attachment styles in situations of severe and ongoing maltreatment [ 45 ]. Vanderminden et al. [ 18 ] found evidence that neglect has been associated with increased trauma, suicidality, and underage alcohol and drug use.

The economic burden of child maltreatment can be considered in the context of direct costs incurred by society for health service use, child welfare, criminal justice and education systems. Additionally, monetary costs may be assigned to the impacts on morbidity and mortality using measures such as DALYs or quality adjusted life years (QALYs). The types of costs assigned, and the valuation method adopted, mean that findings of different studies cannot be directly compared. Nonetheless, published evidence indicates the economic costs are substantial at both an individual and societal level.

In the USA, the total estimated per-victim cost of nonfatal child maltreatment was $830,928 in 2018. This included direct costs of approximately $70,000 for health, welfare, justice and education costs, and $760,000 in monetised costs of QALYs lost due to child maltreatment. Fatal child maltreatment was valued at $16.6 million per victim [ 46 ]. Together these estimates translated to a total US population burden of approximately $2 trillion. The total annual cost of child sexual abuse has been estimated at £3.2 billion in the United Kingdom in 2013 [ 47 ]. This included criminal justice system costs (£149 million), services for children (£124 million), child depression (£1.6 million), child suicide and self-harm (£1.9 million), adult mental and physical health care (£178 million), and loss of productivity (£2.7 million).

In China, Fang et al. estimated an economic burden of child maltreatment by converting DALY losses to a monetary value, assuming that one DALY was equivalent to the per capita Gross Domestic Product [ 21 ]. The burden of physical abuse of children was equivalent to 0.84% of China’s Gross Domestic Product (GDP), or $US 50 billion in 2010. Losses for emotional and sexual abuse in children were 0.47% and 0.39% of GDP respectively. Similar assumptions were applied in the Fang et al. analysis of the economic burden of child maltreatment in East Asia and Pacific regions [ 48 ]. This study estimated economic value of DALYs lost to child maltreatment accounted for 1.88% of the region's GDP, with higher proportions observed in low-income regions. This translated to an economic burden of $194 billion in 2012 US dollars. In their recent systematic review and meta-analysis, Bellis et al. [ 49 ] found that the total annual costs attributable to adverse childhood experiences (ACEs) were estimated to be US$581 billion in Europe and $748 billion in North America, and that even a 10% reduction in the prevalence of ACEs could result in annual savings of 3 million DALYs or $105 billion.

Systemic Factors Associated with Child Maltreatment

Emphasising the pivotal roles of communities, families and schools in protecting children from maltreatment, we discuss systemic determinants of child maltreatment within Bronfenbrenner’s social ecological framework [ 50 , 51 ]. In this framework, child risk and protective factors are viewed as multi-systemic and often nested (e.g., risk and protective factors at the child, family, community level). We use this framework as a heuristic mechanism, rather than a theoretically driven mechanism, because empirical research favours a cumulative risk model of child abuse potential over a social ecological framework (i.e., risks significantly predict child abuse potential regardless of which level of social system they arise from) [ 52 ]. We begin with an overview of micro and mesosystems linked to trauma, including neurobiological and epigenetic mechanisms linked to trauma, then draw on attachment and trauma theories to highlight exosystemic influences, including coverage of the longstanding damage that arises from threats to safety and broken trust [ 45 ], and the importance of well-functioning, evidence-based and well-resourced support structures for maltreated children in their recovery journey [ 53 ].

Neurobiological Mechanisms

Childhood maltreatment elicits a cascade of neurodevelopmental alterations that increase vulnerability to poor health in adulthood [ 54 , 55 ]. Core changes include sustained stress-related alterations in the neuroendocrine system and related brain structures, including the hypothalamic–pituitary–adrenal (HPA) axis and locus coeruleus/autonomic nervous system. Other neurobiological changes associated with early life stress are discussed in recent reviews of neuroimmune and inflammation pathways [ 56 , 57 ], microbiome, oxidative stress, metabolic, and sleep/circadian system changes [ 56 ].

Influential recent proposals have reconceptualised the brain changes that follow early maltreatment exposure from non-specific stress-related damage to an adaptive response that may help the child cope in the maladaptive context, albeit potentially incurring increased risk of psychopathology or other poor health outcomes [ 54 , 58 ]. Stress-induced changes elicited by abusive experiences commence with alterations of glucocorticoid, noradrenergic, and vasopressin-oxytocin stress systems and neurotransmitters. These affect basic neurodevelopmental processes (neurogenesis, synaptic pruning, and myelination) during sensitive periods in individuals with genetic vulnerability, inducing downstream effects on the structure and/or function of brain regions that have a high density of glucocorticoid receptors and undergo protracted postnatal development [ 54 , 55 ]. The limbic structures of the hippocampus and amygdala, which support memory formation/organisation and emotional reactions, respectively, have been a particular focus of child maltreatment research. Volume reduction of the adult, but not child, hippocampus is a consistent finding, including in non-clinical samples unconfounded by the stress of experiencing mental health difficulties and the effect of receiving treatment [ 59 ]. These effects may be more pronounced in hippocampi of men relative to women [ 54 ], with age and gender constituting important moderators of brain changes following maltreatment. Structural alterations in the amygdala are inconsistent, with both reductions and increases in volume reported, perhaps relating to different psychopathologies across study samples [ 59 , 60 ].

Other structural brain changes are reported in the prefrontal cortex (PFC) structures supporting higher-order executive functioning [anterior cingulate gyrus (ACC), orbitofrontal cortex, and dorsolateral PFC], the cerebellum and caudate, and in the corpus callosum and other white matter tracts supporting network connectivity [ 54 , 56 , 60 ]. The type of maltreatment may engender specific alternations in regions and pathways related to that aversive experience, such as genito-sensory cortex thinning in adult women exposed to childhood sexual abuse [ 61 ], though few studies have directly compared brain changes across maltreatment subtypes [ 62 ].

Functional neuroimaging in maltreated individuals has identified changes in regions and pathways associated with four neurocognitive systems: threat and reward processing, emotion regulation, and executive control [ 58 , 63 ]. The amygdala is hyperactive during threat processing and hypoactive during avoidance, and there is decreased activity in the striatum during anticipation and receipt of rewards [ 54 , 58 ]. Whole-brain meta-analyses indicate hyperactivity of the amygdala and ACC during processing of socio-affective cues (e.g., facial emotions), with variable evidence for hyperresponsivity in dorsomedial PFC, superior/middle temporal gyri, parahippocampal gyrus and insula [ 64 , 65 ]. ACC hyperactivity is also present in maltreated individuals during self-regulation and performance monitoring (executive control) tasks [ 58 ]. Many of these changes are evident even in the absence of overt psychopathology, but also confer vulnerability to future psychiatric disorder [ 58 ]. The degree to which these structural and functional brain alterations, as well as broader neurobiological consequences of childhood maltreatment, may be reversed is yet to be determined [ 54 ].

Epigenetic Processes

It is become increasingly clear that child maltreatment interacts with genetic factors to drive the risk for chronic psychiatric and physical disorders [ 20 , 66 ]. The first paper reporting a gene-environment interaction (GxE) [ 67 ] demonstrated an interaction of the monoamine oxidase. A gene with child maltreatment in the development of antisocial behaviours. Since then, many studies have replicated the GxE successfully while other researchers were unable to replicate these findings, questioning the robustness of GxE studies [ 68 ]. Two common biological explanations of how child maltreatment can influence health include the biological embedding theory [ 57 ] and the toxic stress theory [ 69 ]. Both theories suggest that child maltreatment triggers a cascade of biological events, resulting in abnormal brain functioning and psychopathology [ 70 ].

One way in which child maltreatment could influence the genome is via epigenetic mechanisms. In contrast to inherited genetic variants, epigenetic mechanisms reflect the effect of environmental factors that alter gene activity via chemical modifications. Among the epigenetic mechanisms, the major focus has been on DNA methylation given its high prevalence and measurement ease. DNA methylation involves the addition of methyl groups to the DNA cytosine base [ 71 ] often resulting in altered gene expression [ 71 ].

Amongst DNA methylation studies of child maltreatment, the most commonly studied genes have been those that regulate glucocorticoid signalling [ 72 – 74 ]. Genetic variants in the glucocorticoid receptor (NR3C1/GR) co-chaperone gene FK506 binding protein 51 (FKBP5) interact with child maltreatment via DNA methylation changes, altering the risk of developing post-traumatic stress disorder (PTSD) in adulthood [ 75 , 76 ]. Binding of the FKBP5 to the GR complex reduces the affinity for cortisol, resulting in a less active GR. Individuals carrying the FKBP5 risk allele with a history of child maltreatment show demethylation of glucocorticoid response elements within the FKBP5, resulting in enhanced FKBP5 transcription and consequently GR resistance and HPA-axis dysregulation [ 74 , 77 , 78 ].

Genome-wide studies have further demonstrated the influence of child maltreatment on epigenetic changes. Labonté et al. [ 79 ] compared post-mortem hippocampal brain tissues of individuals with and without a history of child maltreatment and found global, orchestrated DNA methylation differences and alteration of biological pathways. We and others demonstrated that depending on the history of child abuse, there were distinct gene expression and biological pathways associated with PTSD [ 75 ]. Interestingly, DNA methylation drove a greater proportion of observed gene expression changes in PTSD with child abuse, suggesting that early maltreatment has long-lasting biological effects.

Recent research involves using DNA methylation marks as a measure of molecular or epigenetic age [ 80 ]. Few studies have looked at the role of child maltreatment in accelerated epigenetic aging and shown that childhood sexual abuse was associated with DNA methylation age acceleration [ 81 , 82 ] in some studies but others have failed to find an association between child adversity and DNA methylation age acceleration [ 83 ].

Taken together, DNA methylation changes caused by child maltreatment affect the stress response and result in adverse health outcomes. With regards to the effects of child maltreatment on DNA methylation and other biological mechanisms, the timing, type and duration of adversity is important. Additionally, studies have demonstrated that psychosocial interventions such as service utilisation [ 84 ] and treatment for PTSD [ 85 ] can alter child maltreatment-associated DNA methylation patterns. Future longitudinal studies will provide a deeper understanding of the dynamicity and endurance of child maltreatment on the genome.

Exosystemic Risk Factors

A large body of literature now identifies individual risk factors for child maltreatment. Social ecological frameworks typically focus on family and macro-level risks in children. We summarise research by grouping studies according to the type of child maltreatment and by social ecological level (parent/family, macro-systems).

Parent/Family Risk Profiles

Sociodemographic predictors of child maltreatment include low education and socioeconomic disadvantage [ 52 , 86 – 88 ], although some mixed findings make the association unclear [ 89 ]. Consistent findings of child emotional neglect are more difficult to establish, in part because the definition of neglect is time-oriented, and varies across developmental stages [ 90 ]. Emotional neglect is associated with parental stress relating to the child’s temperament, reconciling work and family, depression, alcohol and other drug use, poverty and low social support (the latter for older children) [ 90 ]. Children referred to child protection agencies report having fathers who were 21 years of age or less at their birth and have little involvement with extended families [ 91 ]. Using general population survey data from the Netherlands, Bussemakers et al. [ 92 ] examined clustered problems in child adversity (eight domains covering maltreatment but also broader problems including family dysfunction, financial and health problems). They found that about 11.6% of the sample reported collateral physical and emotional maltreatment and financial problems, and 4% of the sample also reported high levels of depression, alcohol problems, divorce, and health problems. Higher child maltreatment potential has been associated with low self-efficacy for managing difficult child behaviour, and negative internal attributions about one’s own parenting [ 93 ]. Consistent with Clément et al. [ 90 ], other nationally representative research (United States) found that the likelihood of physical abuse increased for parents with depression, maternal alcohol consumption, and history of family violence [ 87 ].

Victims of child sexual abuse frequently report poor parent child relationships [ 94 ], parental substance use, and domestic violence [ 95 ]. Children living with one biological parent rather than two are at double the risk of sexual victimisation [ 96 ] and parents of sexually abused children have a higher likelihood of psychiatric symptomatology [ 97 ]. Mothers of maltreated children and children at risk of maltreatment report ongoing stressful life events and low emotional support [ 98 , 99 ]. Perpetrator characteristics include a history of being victims of child maltreatment themselves—approximately 30% of caregivers with a history of being a victim of maltreatment go on to engage in child maltreatment [ 100 ]. Studies of perpetrators of child sexual abuse have identified modest elevations in psychological distress, loneliness, rigidity and unhappiness compared to control groups, and higher levels of emotional neediness [ 88 ].

Community Risk Profiles

It has long been established that children from dangerous and economically disadvantaged communities are at elevated risk of sexual abuse [ 96 , 101 , 102 ], and the risk of child maltreatment increases for communities where housing stress, child care burden, and drug and alcohol availability are high [ 103 – 105 ]. Families coming to countries as refugees and asylum seekers have pre-migration and transit trauma [ 106 ]. These families are first displaced in their homeland, subsequently many must stay in overcrowded, impoverished and unsafe camps during transit [ 107 ]. These families frequently experience ongoing economic hardship, unemployment, social isolation, problems accessing health and educational services, prejudice, and racism. As a result of relocating to a new county, they must acquire a new language, social values, customs, and traditions to thrive in the new environment [ 108 , 109 ]. Children in these families are susceptible to physical and emotional abuse and neglect as parents and carers are overwhelmed by their own acculturative stress [ 110 ].

Children, who enter countries as an asylum seeker spend a substantial amount of time in detention centres [ 111 ]. Unstable living arrangement or stay in the camp exposes the children to sexual abuse [ 112 ]. Along with mental health issues, such as severe depression and anxiety, these children are at risk of abuse and maltreatment as their parents/carers are unable to provide emotional support and care due to their own mental health issues [ 113 ]. These incapacitated parents can also abuse these children emotionally and physically. Further, the circumstances of an unaccompanied child refugee/asylum seekers are severe as they might complete the migratory journey without adult supervision or guidance [ 114 ]. These children encounter neglect and are at risk of experiencing physical, emotional, and sexual abuse because of their interaction with a range of perpetrators during their journey to safety [ 115 ].

In sum, family and community risks often co-occur and profiles are rarely simple. Family risk factors include stress, early parenthood, mental health, substance use and financial problems, low emotional support, family breakdown and parenting skills deficits. For asylum seeking children and families, the risks of exposure to child maltreatment in detention centre settings are further elevated.

Evidence-Informed Approaches to the Prevention of Child Maltreatment

School-based approaches.

Experience of childhood maltreatment has the potential to significantly and detrimentally impact on educational attainment trajectories [ 116 ]. Mediating pathways include attentional problems, lower engagement in extracurricular activities, and disciplinary absences [ 117 ]. Childhood maltreatment is also associated with poorer emotional regulation, social difficulties [ 118 ], mental health problems [ 119 ], internalizing and externalizing behaviour problems [ 120 ], bullying and cyberbullying [ 121 ], and developmental delay [ 122 ], all likely to impact on educational engagement and achievement.

There has been a particular focus on preschool education settings and their critical role in prevention, identification, and effect remediation for children prior to school [ 123 ]. Regardless of type, timing, and chronicity, maltreatment has a detrimental effect on both the cognitive and non-cognitive aspects of school readiness [ 124 – 127 ]. School readiness is a high priority because competencies at school entry are highly predictive of ongoing educational trajectories [ 128 ] and competency gaps are likely to widen, rather than close, across the school years [ 129 ]. For children who have experienced childhood adversity, the key school readiness skillset of social-emotional competence (self-regulation, prosocial skills, relational abilities) is both detrimentally affected [ 118 , 130 ] and, when strengthened, can serve as a buffer against poorer long-term outcomes [ 131 ]. For these reasons a focus on social-emotional and behavioural outcomes in the early years of education is imperative with a number of key strategies identified [ 132 ].

Teacher-student relationships are a key context within which support for social-emotional development can be provided. However, in an additional double-burden for children who have been maltreated, their challenging behaviour and poorer self-regulation skills may make it more difficult for positive teacher-student relationships to develop [ 133 ]. Given that teacher–child closeness predicts growth in children’s social–emotional competence, at least in the preschool years [ 134 ], this is a real challenge for early education settings. Education of teachers in relation to trauma is a key contemporary approach to addressing the impact of childhood maltreatment in education settings and in a small qualitative study was successful in improving teacher–child relationship quality [ 135 ].

Trauma-informed practice and its educational counterpart, trauma-aware education, has developed from the recognised need to increase educators’ understanding of trauma effects on children’s behaviour and development, and appropriate responses. The premise is that educators need to understand and be sensitive to the effects of child maltreatment rather than relying on disciplinary practices that further compound these effects [ 117 ]. While enthusiasm for trauma-informed practice within some educational jurisdictions is high [ 136 ] evidence for its effectiveness is scarce [ 137 ], though several small evaluations have delivered promising results. This growing movement has seen policies, strategies, and frameworks for supporting children with trauma published for early childhood [ 138 , 139 ] and school settings [ 140 ]. However, the extent to which these are successfully enacted and go on to have the intended positive outcomes for students is largely unknown and a key challenge for future research and practice.

Along with acting to address the educational impacts of child maltreatment, educators are mandatory reporters in many jurisdictions. Given the amount of time children and young people spend in education settings, educators have a key role to play in detection. However, studies have documented the complexities of this role with levels of self-efficacy, attitudes, knowledge, and experience of educators in this area influencing reporting behaviour [ 141 ]. Effective education and training to build the requisite professional capabilities for child maltreatment reporting have been documented [ 142 – 144 ] but it is not yet known how these translate to actual reporting outcomes, and these initiatives are yet to be widely disseminated [ 137 , 145 ].

School-based programs that aim to develop students’ understanding of abuse as part of prevention and intervention efforts have also been documented as successful for children from early childhood [ 146 – 148 ]. While Walsh et al. [ 148 ] provide strong evidence that children’s knowledge and self-protective skills are increased by school-based sexual abuse prevention programs, these programs are not implemented early or frequently enough [ 147 ]. Yet to be the focus of longitudinal research are the life course effects of family violence prevention programs delivered in childhood and adolescence with a view to influencing the next generation of parents. Further, with an increasing number of program options available to early education and school settings, a key challenge for the education sector is to choose the most appropriate, rigorous, and effective approaches and to implement these with fidelity [ 149 ]. Adding further complexity, educational settings themselves have been sites for child maltreatment [ 150 , 151 ] but prevention and intervention efforts have been few in terms of addressing this with educators [ 143 ].

The challenging behaviour often presented by children who have experienced trauma has been shown to impact on teachers’ mental health and well-being [ 152 ]. Given teacher retention in the profession is a key concern for the field [ 153 , 154 ] addressing teacher stress is an important consideration. Schools and parents working together for consistent messaging and skill building is critical [ 147 ]. However, few school-based programs for the prevention of child maltreatment simultaneously address parents and students [ 155 ]. How child protection authorities collaborate with education settings is also an important consideration [ 117 ] and addressing health and education silos remains an ongoing challenge. Finally, there have been recent calls for system-wide embedding of trauma-informed practice to best support children and educators [ 136 ], with the complexity of the system presenting a challenge to this ideal.

Family-Oriented Prevention Approaches

Family interventions typically target physical and emotional abuse but also reduce family dysfunction risk factors that impact other categories of abuse and neglect. Interventions for child maltreatment can be broadly categorised into preventative and treatment interventions. Prevention programs target known and modifiable risk factors outlined in section 1.5 (e.g., harsh or coercive parenting practices), with the goal halting a potential trajectory towards potential abuse and neglect [ 156 ]. Treatment interventions reduce the incidence of maltreatment in target parents and families where maltreatment is already occurring. Treatment interventions often target similar risk factors, but they are typically more intensive and focus on changing unhelpful or dysfunctional patterns of behaviour.

High-quality reviews, assessed as strong by Health Evidence , show that parenting programs for reducing child maltreatment are effective [ 156 – 158 ]. Metanalytic studies comparing effect sizes of different maltreatment interventions of various types show small but significant effect sizes with treatment interventions showing larger effects than prevention focus programs ( d  = 0.36 versus d  = 0.26 respectively) although prevention interventions tend to have ongoing effects which further improve at follow up [ 159 ]. Overall, these effect sizes are small to moderate but when considered as a whole of population they offer a significant contribution to the reduction of maltreatment [ 160 ]. Implementation factors such as training, fidelity monitoring and supervision have been shown to have substantial impacts on intervention outcome particularly in the area of child maltreatment [ 161 , 162 ].

General parent training programs have been shown to reduce both substantiated and self-reported child maltreatment as well as to reduce risk factors and enhance protective factors [ 156 ]. For a detailed review of parenting training programs see [ 163 ]. Importantly, parenting programs, most of which have been developed in the West, have also been demonstrated to be efficacious across a range of cultural groups [ 156 , 164 ] including in Indigenous Australians [ 165 ] and low resource settings where the majority of the world’s children live [ 166 , 167 ] . In fact, metanalytic studies have shown the Western parenting programs implemented in the developing world have similar or stronger effects than in their country of origin [ 168 ]. Given that violence towards children is particularly high in such contexts parenting programs have a significant role to play.

In addition to prevention and treatment programs are a small number of programs that purport to be universal (e.g., The Triple P Positive Parenting Program, and SOS! Help for Parents [ 169 , 170 ]). These differ in an important way from other interventions in that they do not specifically target individual families; instead, they aim to increase parent knowledge and skills, and reduce maltreatment, at a whole of population level using a public health approach and a blending of prevention and treatment programs [ 160 ]. Truly universal programs aim to reduce the population level prevalence of maltreatment, not the incidence in intervention families, and are evaluated at a population level rather than individual client or case level. As such they are well placed to inform broad policy and are more likely to be cost-effective.

Only one parent training program has been evaluated at a whole of population level—the Triple P System [ 171 ] and this study only examined the impact of parenting on a single measure of maltreatment—physical abuse. The trial randomly assigned 18 United States counties to the Triple P System or care-as-usual and compared 3 independently derived measures of maltreatments from state records. After controlling for baseline large effect sizes were found on substantiated cases of child maltreatment, out of home placements, and child maltreatment related injuries (hospital admissions and ER visits). These objective measures of maltreatment are likely to under-represent real change given much maltreatment fails to meet thresholds required for health or child protective services involvement and that assessment was limited to physical abuse [ 172 ]. A similar study showed population level effects of the Triple P System on child maltreatment risk factors including the prevalence of coercive parenting, parental stress and parental depression and on child internalising and externalising disorders [ 173 ]. The reduction of child internalizing and externalising problems is especially important given the impact of these in educational outcomes. Such populations studies suggest there is promise in universal public-health interventions, particularly Triple P, for reducing child maltreatment (i.e. physical abuse) at the population level. However, replication is needed, and more work is needed to examine the impact of such intervention on other forms of maltreatment. Ideally parenting interventions would form one part of a multifaceted approach where families received tailored support and children received similar messages (e.g. about body integrity to prevent sexual abuse) from both critical settings may be especially beneficial and are consistent with Bronfenbrenner’s ecological model.

Recommendations

We make five key recommendations for rebuilding and maintaining an evidence-based approach to reducing the prevalence of child maltreatment and improving recovery and outcomes for children who experience maltreatment.

Recommendation 1

Establishing reliable and valid survey tools to capture trends in prevalence over time. Data from agencies underestimate the prevalence of child maltreatment and evidence indicates that self-reported prevalence is more likely to be a false negative than a false positive. Reliable and valid measures will enable clear conclusions about the impact of policies and programs oriented toward the prevention of and interventions for child maltreatment.

Recommendation 2

Further research on how brain structure and functional abnormalities (chronic stress and epigenetics) that are the sequelae of maltreatment may be recalibrated to more normative patterns. Longitudinal and detailed surveying of brain circuitry and gene activity will reveal the acute and chronic neurobiological effects of child maltreatment and help understand how early experiences affect biological systems governing our response to stress. The dynamic nature of neurobiological markers will also allow assessment of intervention and treatment strategies for child maltreatment and its consequences on long-term mental and physical health.

Recommendation 3: Teleservices

Technology provides a way of transcending social isolation and reaching children, families and communities that have historically been too difficult to reach. In some countries, governments are finally investing in telehealth services to address mental health problems. For example, in Australia, people with identified mental health conditions receive support for a range of services, but it is unclear how much funding is available for evidence-based prevention approaches to child abuse and neglect. In the COVID-19 context, e-health technologies have evolved at great pace, and offer unique and safe opportunities to reach isolated and vulnerable communities and individuals.

Recommendation 4: Community-based approaches

A key conclusion of this paper is that determinants of child maltreatment are multi-systemic. It therefore makes sense that interventions be multi-systemic in their approach through a mix of individual, family and social systems focused interventions (school/community) and a weighted approach to detection, prevention, early intervention and treatment. Community coalition approaches to children’s mental health problems show great promise for ACEs prevention [ 174 ] and have solid efficacy for prevention of adolescent substance use and crime [ 175 – 177 ]. These approaches have utility for preventing child maltreatment through mixes of individual, school and family-oriented programs. Another strength is that coalition approaches build sustainable and locally focused skills and resources that are co-created with community stakeholders [ 178 ]. These approaches typically involve the building of local coalitions (consisting of existing individuals and organisations focussing on children, mental health, education, social work, and justice) under the auspices of a lead agency and local champions. Local coalitions identify community priorities through evidence collection using reliable and valid tools, and skills building in the delivery of cost-effective programs and policies to address the problems.

Recommendation 5: Investment in evidence-based policy, practice, and research-oriented think tanks

Multi-systemic approaches to child maltreatment prevention are clearly under-resourced and will need substantial investment from government and nongovernment sectors. Silo-ed approaches to service provision hamper reliable measurement, high quality and synchronised delivery of services, dovetailing of services to maximise effects, and cross-disciplinary collaboration. There is a substantive risk that the spotlight on child abuse and neglect may dim as a consequence of the global focus on vaccine development/distribution and COVID-related economic recovery. COVID has increased rates of family distress, domestic violence and heavy alcohol and other drug use, which are known determinants of adverse child outcomes. Subsequent waves of COVID, including those occurring through its variants, will place further pressure on families and communities. As government budgets shift to economic recovery, there is a risk that early detection policies and programs for child maltreatment will receive lower prioritisation.

This review has highlighted the high and most likely underestimated prevalence of child maltreatment, the ongoing challenges of measurement, the profound and long-lasting impacts of child maltreatment on mental and physical health, and the substantial economic costs associated with these impacts. Mapping trends in child maltreatment using valid and reliable measures is needed to evaluate the impact of prevention and early intervention programs. We summarised structural and functional brain alterations that result from child maltreatment, and the impact of chronic stress and trauma on gene activity via DNA methylation mechanisms. Detailed surveys tracking the longitudinal associations between child maltreatment, brain circuitry and gene activity are needed. We summarised the familial and macro-system risk factors centre around economic disadvantage, mental health problems, social isolation and domestic violence. Finally, we reviewed prevention and early intervention programs for child maltreatment, concluding that there is good evidence that school and family-focused programs have significant positive effects on child outcomes. A key challenge in promoting a paradigm shift from treatment to prevention is in justifying the upfront costs of preventive measures, given the longer-term nature of positive health and economic outcomes. There is a paucity of evidence on the cost-effectiveness of preventive approaches for child maltreatment, and further studies are needed. Current evidence suggests that while the cost-effectiveness of specific programs may vary, preventive approaches are likely to be highly cost-effective and have the potential to produce net cost-savings to society when lifetime health and social benefits are accounted for [ 179 , 180 ].

Funding was provided by National Health and Medical Research Council and Australian Research Council (FT170100294).

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Divya Mehta, Adrian B. Kelly, Kristin R. Laurens, Divna Haslam, Kate E. Williams, Kerryann Walsh, Philip Baker, Hannah E. Carter, Nigar Khawaja and Ben Mathews have contributed equally to this work.

Divya Mehta and Adrian B. Kelly are joint first authors.

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Article Contents

Introduction, procedure of safe home, need for structured risk assessment, spj instrument for child abuse risk assessment: care-nl, the present study, supplementary material.

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Research-based Risk Factors for Child Maltreatment: Do Child Protection Workers Use them in their Case Investigations?

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Brenda Erens, Corine de Ruiter, Henry Otgaar, Joke Humblet, Research-based Risk Factors for Child Maltreatment: Do Child Protection Workers Use them in their Case Investigations?, The British Journal of Social Work , Volume 52, Issue 7, October 2022, Pages 3945–3963, https://doi.org/10.1093/bjsw/bcac042

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Risk assessment is an essential aspect of child abuse investigations in order to estimate the risk of future abuse and to develop a risk management and intervention plan. According to the risk–need–responsivity model, intervention and risk monitoring needs to target dynamic risk factors to prevent future child maltreatment. In the current study, we examined whether child protection workers in the Netherlands focus on evidence-based risk factors for child maltreatment. We investigated 192 case files retrospectively for risk factors included in the Child Abuse Risk Evaluation-NL, a structured risk assessment instrument. We expected to find limited information concerning parental risk factors and risk factors related to parent–child interaction, but more information on family and child factors. These hypotheses were confirmed. Because parental and parent–child interaction factors are the most important and proximal risk factors for child abuse, our findings point to a large gap between science and child protection practice. We recommend the use of a structured risk assessment instrument and a risk-focused approach to intervention planning.

As is the case for many other countries in Europe (e.g. McElvaney and Lalor, 2014 ), the exact prevalence of child abuse in the Netherlands is difficult to establish. A recent national epidemiological study in the Netherlands showed prevalence rates of 3 per cent (based on reports by professionals) and 12 per cent (based on self-reports by children aged eleven to seventeen years; ten Boom et al ., 2019 ).

The definition of child abuse under Dutch Law is ‘Any form of threat or violent interaction of a physical, psychological, or sexual nature towards a minor that the parents, or other individuals with whom the minor is dependent upon, actively or passively force upon the minor, which leads to the threat of or actual severe injury to the minor in the form of physical or psychological harm’ (Dutch Youth Act, Article 1.1). Safe Home (in Dutch: Veilig Thuis ) is the agency where citizens and professionals can file reports on alleged child abuse and domestic violence. Safe Home employs social workers, behavioural scientists and forensic-medical doctors. Currently, there are twenty-six regional Safe Home organisations in the Netherlands. These centres provide advice on child abuse to professionals (such as schoolteachers, general practitioners, sports coaches) and citizens, and investigate reports of allegations of child abuse and domestic violence. In the first six months of 2019, Safe Home received 64,960 reports of possible child abuse and domestic violence ( Central Bureau of Statistics, 2019 ).

According to the protocol Safe Home’s operational guidelines ( Baeten et al ., 2019 ), the main tasks of the organisation entail initial safety assessments, investigation of cases of possible child abuse and domestic violence and provision of advice for intervention or treatment, if needed. To execute these tasks, Safe Home collaborates with different partner organisations, such as public prosecutors, police, probation services, mental health institutions and local municipalities. Together, these organisations have a shared responsibility to intervene in unsafe family situations and prevent future child abuse. Each report of possible child abuse or domestic violence is first subjected to a so-called ‘safety assessment’. That is, the report is screened for immediate danger, structural risk and multi-problem factors (e.g. problems with (mental) health, work and finances). Safe Home also receives relevant collateral information from its partners, such as police reports. During this initial safety assessment, risk factors for child abuse are not (yet) considered.

After the initial safety assessment, Safe Home can decide to start an investigation into the reported child abuse, or to transfer the case to a professional that is already involved (e.g. a social worker or psychologist) to continue treatment. An investigation consists of interviews with parents/caretakers, an interview with the child and consultations with professionals that serve as collateral informants, such as schoolteachers, general practitioner or mental health professional. The outcomes of these interviews are summarised in an investigative report, together with the information from the initial safety assessment. During the investigation, professionals of Safe Home are encouraged to investigate relevant risk factors, also described in the operational guidelines of the protocol. However, the protocol does not prescribe how these risk factors should be analysed or reported. Therefore, evidence-based risk assessment is not a standardised or default practice at Safe Home. As the protocol describes, risk factors are documented in the case file and this information will be transferred to relevant partners for the implementation of risk-focused care (e.g. mental health care in the case of parental mental health problems). The local municipality usually gives the order for initiating intervention or treatment and appoints a case manager. Ideally, Safe Home will formulate recommendations for the type of treatment that is needed, and formulate safety agreements together with parents and professionals involved in the case. After transferring the case, there is a so-called monitoring phase in which Safe Home monitors the safety of the child by checking in with parents and professionals on the safety agreements and treatment progress. A case file can be closed after one year of monitoring when the safety in the family is maintained. In case the family does not comply with treatment and the situation is deemed unsafe by Safe Home, the case is transferred to the Child Protection Board for further investigation and a possible supervision order by the court (see Figure 1 for a summary of the work processes of Safe Home).

The work processes of Safe Home.

The decision-making process of child protection professionals in actual cases is a complex process and largely ‘a black box’ (Munroe, 2019). Research has shown that certain risk factors are important predictors of future (recurrent) child maltreatment (e.g. Brown et al ., 1998 ; Barth, 2009 ). Conducting structured risk assessment can be considered crucial in child protective investigations to establish and maintain a safe environment.

Risk factors can be divided into different domains, such as parental factors, child factors, parent–child interaction factors and environmental factors ( Assink et al ., 2016 ). Research has shown that parental factors, such as mental health problems (including substance abuse) and domestic violence are the most important factors in predicting recurrent child abuse ( Assink et al ., 2016 ). In terms of type of maltreatment, neglect has higher rates of recurrence than physical abuse, which in turn has higher recurrence rates than sexual abuse ( White et al ., 2015 ). Also, cases involving multiple types of maltreatment are associated with increased rates of recurrence ( Hindley et al ., 2006 ). Next to parental factors, environmental factors, such as lack of social support, stress (such as socio-economic stress) and child factors (such as a child less than four years of age, a child with a disability) are predictive of future child maltreatment.

Given that unstructured clinical judgements tend to be unreliable and inaccurate ( Monahan, 1981 ; de Ruiter and Pollmann, 2003 ; Viljoen et al ., 2021 ), structured, research-based risk assessment is preferable practice. Traditionally, two types of structured risk assessment tools can be distinguished ( Heilbrun et al ., 2021 ). Actuarial tools include static risk factors (i.e. historical risk factors not amenable to change, such as previous history of child abuse) that are weighed according to a fixed algorithm to determine the risk of future child abuse. Although actuarial risk assessment tools have been used in several public service fields for almost a century, they emerged approximately twenty-five years ago in the field of child protective services to estimate recurrent child maltreatment ( Coohey et al ., 2013 ). Professionals working in Child Protective Services (CPS) oftentimes deal with complex cases and have been criticised for making inaccurate and inconsistent decisions (e.g. Dorsey et al ., 2008 ). Clinical decision making is subject to several cognitive biases (e.g. confirmation bias) and decision-making errors, making them fallible for predicting future harmful behaviour (e.g. Grove and Meehl, 1996 ). Actuarial risk assessment tools can facilitate CPS professionals in making the right decisions. Studies have consistently shown that actuarial predictions are mostly superior in terms of accuracy compared to unstructured clinical judgements (e.g. van der Put et al ., 2017 ). However, research has shown that actuarial tools are no substitute for clinical judgement altogether since contextual information is important for the development of client treatment programmes ( Shlonsky and Wagner, 2005 ).

In the USA, child protective services in approximately half of the states use actuarial risk assessment tools to estimate the risk of future child maltreatment ( Johnson, 2011 ). For example, the California Family Risk Assessment (CFRA) is an actuarial tool widely used among child protective services in the state of California. The CFRA, as used in practice, allows child welfare workers to ensure that higher risk children not requiring out-of-home placement receive in-home services before lower risk children ( Johnson, 2011 ). In the Netherlands, the Actuarial Risk Assessment Instrument for Child Protection (ARIJ; van der Put et al ., 2016) has been widely implemented in Dutch child welfare services to assess the risk of future child maltreatment ( Vial et al ., 2021 ). The newest version of the ARIJ (3.0) contains thirty items scored by either ‘yes’, ‘no’ or ‘unknown’ to assess the risk for future child maltreatment. The predictive validity of the ARIJ has been studied in several Dutch welfare organisations (including Safe Home) and a moderate predictive validity has been found for different outcomes; Area Under the Curve (AUC) = 0.68 for child protection orders, AUC = 0.62 for residential care and 0.58 for hotline reports of child abuse or domestic violence ( Vial et al ., 2021 ). The predictive accuracy of the ARIJ is comparable to the predictive accuracy of other actuarial risk assessment instruments for child maltreatment (AUC = 0.70; van der Put et al ., 2017 ).

Structured Professional Judgement (SPJ) tools (e.g. the Child Abuse Risk Evaluation-NL (CARE-NL; de Ruiter and de Jong, 2006 ), see below) do not provide a sum of individual risk factors, but consist of the weighing and integrating of both static and dynamic risk factors, as well as protective factors ( de Ruiter et al ., 2020 ). Both actuarial and SPJ tools have their own strengths and weaknesses, which have been a topic of research and debate (e.g. Mills, 2017 ). Whilst actuarial risk assessment aims to gain insight into children at high risk of re-abuse (based on static risk factors), SPJ tools focus on changeable (dynamic) factors that are targets for risk management and treatment. A meta-analysis by Singh and Fazel (2010) found mixed evidence regarding the comparative accuracy of actuarial and clinically based tools in a forensic context. In their analysis, they looked at studies comparing actual risk assessment with clinical risk assessment. Two of the five reviews concluded that actuarial instruments were more accurate compared to SPJ tools ( Hanson and Morton-Bourgon, 2007 ). Two studies ( Grove et al ., 2000 ; Ægisdóttir et al., 2006 ) found that actuarial measures were superior to clinical judgement, but did not divide them into unstructured and structured clinical judgement. The fifth review ( Guy, 2008 ) found no advantage for actuarial tools compared with measures that employed SPJ. A meta-analysis by van der Put et al. (2017) investigated the predictive validity of twenty-seven different risk assessment instruments for child maltreatment. In this analysis, they investigated thirty independent studies ( N  =   87,329) and found an overall significant, but moderate predictive validity (AUC = 0.68). Furthermore, actuarial instruments outperformed both clinical judgement and SPJ instruments by making a better distinction between higher and lower risk cases. The authors argue for further development of actuarial instruments, specifically to integrate risk assessment with case management by distinguishing static from dynamic risk factors, as described by the risk–need–responsivity (RNR) model ( van der Put et al ., 2017 ). Research suggests that choosing a risk assessment tool should be guided by the goal of the risk assessment. If the goal is to identify children whose situation should be further investigated, actuarial risk assessment tools are mostly better predictors compared with SPJ tools (e.g. Ægisdóttir et al., 2006 ). The statistical modelling of risk factors enables professionals to make evidence-based decisions on which children are at high risk for recurrent abuse and should therefore be referred to child protection. However, if the goal is to gain a more comprehensive picture of the child or family to receive treatment and/or supervision, an SPJ tool might be more effective, as these tools are more flexible and incorporate more items, leading to more information ( de Bortoli et al ., 2017 ).

With SPJ tools, dynamic risk factors or ‘needs’ can be used to deploy (preventive) interventions that respond to these factors and thereby meet the care needs of the child and his or her family ( Assink et al ., 2016 ). Needs assessment is an important aspect of the RNR model ( Andrews and Bonta, 2016 ) in which the role of risk and need factors in the prediction of harmful outcomes (e.g. abusive behaviour) is described. Briefly, the RNR model explains that (1) the intensity of risk management or treatment should match the level of risk for abuse (‘risk principle’); (2) treatment should be aligned with the needs of the perpetrator (dynamic risk factors linked to risk of recidivism; ‘need principle’); and (3) treatment should be offered in a way that corresponds with the motivation, learning strategies and intellectual capacities of the perpetrator (‘responsivity principle’) ( Assink et al ., 2016 ). Different meta-analytic studies have demonstrated the effectiveness of the RNR model in reducing the risk of recidivism among young and adult offenders (e.g. Hanson et al ., 2009 ; Koehler et al ., 2012 ). The RNR model was initially developed for preventing recidivism in criminal offenses. The RNR principles can be applied to perpetrators of different types of offenses, including sexual abuse ( Hanson and Yates, 2013 ). Child abuse is prohibited by the Dutch law and is oftentimes considered as a criminal offense. For example, child abuse can be prosecuted in cases of physical injuries after physical abuse or neglect, sexual assault and deprivation of basic needs. Therefore, it can be hypothesised that the principles of the RNR model would be equally applicable to child protection work to reduce future child abuse ( Assink et al ., 2019 ). After all, just as in risk assessment for criminal offending, the RNR principles can be used in child protection work to explain the balance between multiple risk and protective factors present in children lives ( Mulder et al ., 2018 ). As described above, the principles of the RNR model are incorporated in the operational guidelines of Safe Home by the principle of implementing risk-based care after the investigation.

One of the SPJ tools for risk assessment that can be used in line with the RNR model is the CARE-NL ( de Ruiter and de Jong, 2006 ). This instrument was developed as a structured risk assessment tool for all types of child abuse. The CARE-NL can be used in cases where child abuse has occurred in the past or when there are strong suspicions of current child abuse ( de Ruiter et al ., 2012 ). The CARE-NL contains eighteen risk factors: eight parental risk factors, three parent–child relationship factors, five family factors and one factor regarding vulnerabilities of the child. One extra risk factor about sexual abuse is included, although all CARE-NL factors are important in assessing the risk for child sexual abuse. The risk factors of the CARE-NL are summarised in Table 1 . A more detailed description of the individual risk factors has been included in Supplementary Appendix S1 .

CARE-NL risk factors

From de Ruiter and de Jong (2006) .

The reliability and predictive validity of the CARE-NL have been investigated in a retrospective file study ( de Ruiter et al ., 2020 ) at the predecessor of the Safe Home organisations, the Advice and Reporting Centres for Child Abuse (ARCCA). The CARE-NL was coded on the basis of files from four ARCCAs ( N  =   240) and its predictive validity was tested at two years follow-up. This study found satisfactory to good results for the instrument’s interrater reliability. The predictive validity of the final risk judgement (low–moderate–high) for the family as a whole, was good for out-of-home placement (AUC = 0.78) and moderate for placement of the child under supervision of the court (AUC = 0.73). In addition, one of the main findings was that in the 240 ARCCA files, information about parental factors was limited. This is especially relevant because, as mentioned earlier, parental factors such as mental health problems, are strong predictors of recurrent child abuse ( Hindley et al ., 2006 ; Assink et al ., 2016 ). Most files did contain information about parenting skills, family factors (with the exception of socio-economic stress), and child vulnerability factors. The latter finding is in line with the results of a Danish study by Sørensen (2018) for which social workers were asked to choose the twenty most frequently used risk factors among thirty-eight risk factors that were presented to them. For this study, risk factors were divided into child factors, family (including parental) factors and society factors. Results showed that three of the five most frequently mentioned risk factors were related to the child (externalising problem behaviour, school problems and problems with leisure time or friends). Furthermore, some family risk factors were also mentioned frequently; namely insufficient care (62 per cent of the cases) and severe disharmony at home (56 per cent of the cases).

The aim of the current study was to investigate whether Safe Home operates according to the RNR model for preventing future child abuse. We therefore investigated which risk factors of the CARE-NL were documented in Safe Home case files. In line with past research investigating the use of risk factors in child protective work ( de Ruiter et al ., 2020 ), we expected to find limited information on parental risk factors as well as parent–child risk factors. We expected to find more information on risk factors relating to the child and family factors. This would indicate that the RNR model is not fully implemented in the work process of Safe Home. Furthermore, we measured safety level in the families, approximately three and nine months after Safe Home had closed the investigation. It was expected that when the RNR model is not fully adhered to, these safety levels will often decrease, resulting in new incidents (reports at Safe Home).

Ethical approval for the current study was granted by the Ethics Review Committee Psychology and Neuroscience from Maastricht University, under the code ‘Master_205_11_03_2019’.

Case files ( N  =   289) were selected from the database of Safe Home South-Limburg for the period between January 2017 and December 2018. Of the 289 cases, 198 concerned (suspicions of) child abuse, the other ninety-one case files concerned reports without any children involved, such as domestic violence. We used the 192 files regarding possible child abuse for our study (six files were excluded from our analysis because they did not contain any information on risk factors). If there were multiple reports for the same family, this was counted as one case file. A case file was selected when: (1) a child abuse investigation had been conducted in response to the report and (2) there was a completed monitoring phase (with at least one monitoring moment). We also gathered information from the monitoring phase of all 192 case files. That is, for each case, registrations on the safety level in the families after three (and if present, after nine months) were gathered. At these moments, Safe Home usually checks whether the safety agreements have been met, and if these agreements have resulted in short- and long-term safety improvement. We also looked at the presence of a new report (that is, possible new incidents of child abuse) at these moments.

Instruments

The case files were coded using the CARE-NL item descriptions. Cases were scored by a Master student and a PhD student, both specialised in forensic psychology and trained in using the CARE-NL. Each risk factor was scored 0 (‘not present or not enough information’), 1 (‘possibly present’) or 2 (‘definitely present’) according to the CARE-NL manual. A list of additional (risk) factors not mentioned in the CARE-NL was also made. Interrater reliability was calculated for 22 per cent ( n  =   40) of the cases. We calculated single and average measure intraclass correlation coefficients (ICCs) to measure the interrater reliability for each of the seventeen items of the CARE-NL (item S18 was excluded because it could be scored in only two of the cases). While the single measure ICC is an index for the reliability of the ratings for one, typical, single rater, the average ICC is an index for the reliability of different raters averaged ( Fleiss, 1986 ). Critical values for ICCs are >0.90 = excellent; 0.75 ≤ ICC ≥ 0.90 = good; 0.50 ≤ ICC ≥ 0.75 = moderate; ICC ≤ 0.50 = poor ( Koo and Li, 2016 ). ICCs could not be calculated for item PC10 and item F17, because of the large number of missing values on these items. We observed a high degree of agreement between the two raters, quantified by an average ICC of 0.87, 95% Confidence Interval (CI) (−0.11 to 0.99) and a single ICC of 0.78, 95% CI (−0.05 to 0.97). Only for item F15, agreement was poor, with an average ICC of 0.41, 95% CI (−0.11 to 0.69) and a single ICC of 0.26, 95% CI (−0.05 to 0.52).

Table 2 presents an overview of the frequency distribution of the CARE-NL risk factors in the 192 cases.

Overview of the presence of CARE-NL factors in case files ( N  = 192)

Parental factors

Information on three parental factors was largely absent in the case files. First, P2, ‘The parent/caretaker was a victim of child abuse’, was available in four (2 per cent) of the 192 cases (all scored ‘definitely present’). Furthermore, factor P4, ‘Suicidal or homicidal ideation/intent’, was found in six (3 per cent) cases (five times ‘definitely present’) and factor P7, ‘Extreme minimisation or denial of child abuse’, was found in twelve (6 per cent) cases (eight times ‘definitely present’). Also, P5, ‘Substance abuse problems’, was found in thirty-two (17 per cent) of the files. The parental risk factor with the highest prevalence ( n  =   90, 47 per cent) was P3, ‘Serious mental disorder’ ( n  =   43 (22 per cent) as ‘definitely present’ and n  =   47 (25 per cent) as ‘probably present’).

Parent–child and child vulnerability factors

In terms of the parent–child factors, risk factor P10, ‘Negative attitude or distorted views of the child’, could not be coded based on the information available in any of the case files. Factor PC11, ‘Parent–child interaction problems’, was found in 23 (12 per cent) of the case files. The child risk factor C12, ‘Vulnerability-increasing child characteristics’, was found in 69 (36 per cent) of the case files, forty times as ‘definitely present’.

Family factors

F13, ‘Family stressors in the past year’, could be coded most frequently, in 100 (52 per cent) cases, followed by factor F16, ‘Relational violence’, which was present in sixty (31 per cent) cases. Factors F17, ‘Cultural influences’, and F15, ‘Insufficient social support in the past year’, were found the least, that is, in two (1%) and fifteen (8%) cases, respectively.

Many of the case files included factors that were mentioned problems, but these are not included in the CARE-NL as risk factor. Examples were: parents that do not speak the Dutch language, living in a polluted environment, and young parents. These factors or problems were not always mentioned as risk factors per se, but accounted as problems that should be taken into account in the investigation.

Monitoring outcomes: Level of safety

For all 192 cases, the level of safety at the first monitoring moment was extracted from the case file. The first monitoring moment normally takes place after three months, but can take place earlier if needed (e.g. if the case includes a lot of risk factors for future child abuse). The investigator of Safe Home checks whether the safety agreements have been adhered to (e.g. treatment compliance) and if there have been any new incidents of child abuse. This information is then used to rate the safety level as increased, decreased or the same as at the end of the Safe Home investigation. It is noteworthy that at the end of an investigation, the level of safety is always estimated as sufficient, since the first task of Safe Home is to conduct a safety assessment and decide which steps are needed to repair any immediate danger. Further guidance and/or treatment is needed to increase the safety level (with risk-focused care) and maintain a safe family environment long term. The average duration until the first monitoring moment was 4.3 months (Standard deviation (SD)   =   1.9). In 59.4 per cent ( n  =   114) of the cases, the level of safety improved between the end of the Safe Home investigation and the first monitoring moment. In 37 per cent ( n  =   71) of the cases, the safety level did not change in this time period. In 3.6 per cent ( n  =   7) cases the level of safety decreased. In eighty-one cases, a second monitoring moment took place ( M  =   8.9 months, SD =   3.3). We compared level of safety between the second and the first monitoring moment. After this time, the level of safety increased in 66.7 per cent ( n  =   54) of cases. In 29.6 per cent ( n  =   24) of the cases the level of safety remained the same and in 1.5 per cent ( n  =   3) cases safety decreased.

Monitoring outcomes: Number of new reports

For all 192 cases, we examined whether Safe Home received any new reports during the time of the investigation or during the monitoring phase on the same family. At least one new report regarding possible child abuse or domestic violence was received in thirty-seven (19 per cent) cases (see Table 3 ). Thirty (16 per cent) of these reports were received during the monitoring phase (the other seven were received when the investigation was still ongoing).

Frequency of new reports per case ( N  = 192)

The current study aimed to investigate whether Safe Home, the Dutch reporting agency for child abuse and domestic violence, operates according to the RNR model for preventing recurrence in child abuse investigation cases.

Our findings showed that although the domain of parental risk factors is the most important empirical predictor of recurrent child abuse ( Hindley et al ., 2006 ; White et al ., 2015 ), these factors were often not mentioned in the case files at Safe Home. Our findings resemble some of the findings of de Ruiter et al . (2020) where information on parental risk factors was often limited in the case files of the predecessor of Safe Home.

In the files we investigated at Safe Home, the three parental risk factors that were found least frequently were: ‘The parent/caretaker was a victim of child abuse’, ‘Suicidal or homicidal ideation/intent’ and ‘Extreme minimisation or denial of child abuse’. However, a few of the other parental factors were found more frequently. The factor ‘Serious mental disorder’, could be found in 47 per cent of the cases. A possible explanation for this is that sometimes a mental disorder is already mentioned in the report received by Safe Home or is mentioned by the general practitioner, who is often consulted as a collateral informant during the investigation. This is in contrast with other risk factors such as ‘The parent/caretaker was a victim of child abuse’ that often require specific inquiries by the investigator. Another important finding is that the factor ‘Substance use problems’ was found in a mere 17 per cent of the investigated files. This finding is comparable with the study by de Ruiter et al . (2020) , where this factor was present in 26.5 per cent of the investigated files. This finding is particularly worrisome, because substance abuse is a strong predictor of recurrent child abuse ( Brown et al ., 1998 ; Hindley et al ., 2006 ). Concerning the parent–child factors, the risk factor ‘Negative attitude or distorted views of the child’ could not be coded on the basis of the case files, while ‘Parent–child interaction problems’ could be coded for only 12 per cent of the case files. These findings are worse compared to the study by de Ruiter et al . (2020) , where this information was found in 20 per cent and 40 per cent of the investigated case files. This finding was also in line with our hypothesis, that besides parental factors, there would also be limited information on parent–child factors. Given that research has shown that abusive parents often have distorted attitudes about their child ( Chilamkurti and Milner, 1993 ; Daggett et al ., 2000 ), it seems rather unlikely that this risk factor was not present in any of the 192 cases, and it is thus more probable that the Safe Home investigators did not investigate this risk factor. The factor ‘Vulnerability-increasing child characteristics’ was found in 36 per cent of the case files. Although we expected more information on this child factor compared to the parental and parental–child factors, this factor was found in less than half of the case files. This finding is surprising, given that, in line with previous studies, we expected child protection workers to be more focused on child factors ( de Ruiter et al ., 2020 ). Furthermore, because Safe Home often consults the schoolteacher of the child as an informant, information on child characteristics would be expected.

Also, as expected, family factors were mentioned most frequently in the case files. We observed ‘Family stressors in the past year’ in 52 per cent and ‘Relational violence’ in 31 per cent of the cases. These factors are often mentioned in the first report to Safe Home (relational violence is often reported as a cause for concern) or by the family itself during the first home visit. Less frequently mentioned risk factors were ‘Cultural influences’ and ‘Insufficient social support in the past year’. The fact that ‘Cultural influences’ was found in only 1 per cent of the case files is quite remarkable, because this information should not be difficult to access. This begs the question whether professionals at Safe Home are aware of this risk factor.

We also found risk factors mentioned in the case files that are not included in the CARE-NL, such as parents that do not speak the Dutch language, living in a polluted environment and young parents. The CARE-NL offers the option to code case-specific risk factors that do not fit within the item descriptions of the eighteen risk factors. In any given CARE, there may be case-specific risk factors that are crucial to professional judgements concerning risk, even if there is perhaps only limited scientific evidence for these factors at the time. However, there is also a possibility that professionals might view certain factors as a risk for further abuse when they are not, or, alternatively, focus on factors that are not the most important factors for preventing future child abuse. Risk assessment training can prevent professionals from focusing on the wrong factors for tackling child abuse and developing treatment programmes.

According to the RNR model, interventions or treatment should be aimed at the key risk factors in a specific case in order to prevent recurrence of harmful outcomes ( Andrew and Bonta, 2010 ; Andrews, 2012 ). Factors that are important for risk management can vary from case to case and should be targeted accordingly. Research has shown that better adherence to these RNR principles by risk management and intervention programmes leads to larger reduction in (violent) recidivism ( Andrews, 2012 ). After the investigation of Safe Home has been completed, the case usually is transferred to the municipality where the family resides, which offers intervention. The intervention is provided by a local (mental health) organisation. If a structured risk assessment, with an analysis of key risk factors, in the individual case is lacking, the likelihood that the intervention plan will not be risk-focused (in line with the RNR model) is high. Our study highlights a wide gap between the scientific knowledge on child abuse risk assessment and management, and current practices at Safe Home in the Netherlands.

Limitations

Some limitations of the current study should be mentioned. First of all, this file study was conducted at one of the twenty-six Safe Home organisations in the Netherlands. Because Safe Home works according to operational guidelines, the same work procedures across these organisations should be expected. However, the protocol of Safe Home allows for (large) differences between the Safe Home organisations. This also appears in differences in the way children are being interviewed at Safe Home ( Erens et al ., 2020 ). Although it is stated that risk factors should be mentioned in the case files, it is not specified how. Still, we do not think this had a major impact on our results or their generalisability, because previous studies ( de Ruiter et al ., 2020 ) conducted in the Netherlands revealed similar findings.

Another limitation concerns the fact that although many risk factors were absent in the case files, we do not know for certain that professionals did not give attention to these risk factors. This could be explained by various reasons that should be investigated in future studies. By talking to the professionals of Safe Home, a deeper understanding can be reached on how the risk assessments were performed and what considerations have been taken.

Implications

Our findings have implications for the work executed by Safe Home, and the Dutch child protective system in general. The quality of fact-finding in Dutch child protective services is a long-standing problem (e.g. Huijer, 2004 ). One of the major issues has been the lack of structure in investigations and the clinical judgement that dominates decision-making processes ( van Gastel et al ., 2010 ).

It seems that the protocol of Safe Home is not used by the professionals of Safe Home as intended by the authors of the protocol. The principles of risk-based care for child abuse cases cannot be applied when structured risk assessment is absent. Inadequate risk assessment in Dutch youth care organisations has been a point of discussion for years ( de Ruiter and Pollmann, 2003 ; Bartelink, 2014 ). The majority of risk factors that have been proven to predict future child abuse could not be scored on the basis of information in the case files. The lack of evidence-based risk assessment at Safe Home suggests that professionals use their own clinical judgement to assess the level of safety in a given case. Although the use of intuitive knowledge in child protective services is valuable, it is insufficient to assess the risk of future violence ( Munro, 2019 ). Intuition enables professionals to understand behaviour at a basic level, but remains vulnerable to a diversity of cognitive biases among different professionals with a variety of backgrounds and experiences ( Munro, 2019 ). To establish a proper risk assessment in child abuse investigations, SPJ instruments need to be implemented: They make use of scientifically supported risk factors, allow for the inclusion of case-specific risk and protective factors and they provide essential input for risk management plans ( de Ruiter et al ., 2020 ).

In order to conduct evidence-based investigations in child maltreatment and to deploy scientifically based interventions and treatment, the use of structured risk assessment tools, such as the CARE-NL, should be implemented at Safe Home. If the CARE-NL is used in every case, risk factors can be systematically evaluated and mentioned in the advisory report of Safe Home to the municipalities, as well as included in the risk management plan. The offered treatment and interventions can then conform to the RNR model, and consequently the risk of recurrent child abuse will likely be diminished. It is noteworthy that training in itself is no guarantee for success; organisations should provide supervision for professionals and managers should be actively involved in this process to facilitate implementation ( Gillingham and Humphreys, 2011 ; Munro, 2019 ). To deploy evidence-based interventions, it is important that current practices in child protection are adjusted to the latest scientific insights. Future studies are needed to evaluate the effectiveness of structured risk assessment and adherence to the RNR model on child abuse prevention.

Supplementary material is available at British Journal of Social Work Journal online.

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Book Title: Child Maltreatment: An Introductory Guide With Case Studies

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Book Description: This guide provides an overview of the different types of abuse, including signs to look for when a child is being abused or neglected. Legal responsibilities to identify and report suspected child abuse are also presented. This resource also contains case studies with interactive questions that allow for theory to be applied to practice.

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This guide provides an overview of the different types of abuse, including signs to look for when a child is being abused or neglected. Legal responsibilities to identify and report suspected child abuse are also presented. This resource also contains case studies with interactive questions that allow for theory to be applied to practice.

Child Maltreatment: An Introductory Guide With Case Studies Copyright © 2023 by Susan Loosley and Jen Johnson is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

Child abuse

Understanding Child Abuse and Neglect (1993)

Chapter: 9 ethical and legal issues in child maltreatment research, 9 ethical and legal issues in child maltreatment research.

Child maltreatment research requires a host of ethical and legal considerations in formulating a research agenda for this field. Although research in this field typically focuses on children who have been identified through case reports of child abuse or neglect, studies on prevention and intervention strategies as well as those on the etiology or consequences of child maltreatment may uncover previously undetected incidents of prior, current, or imminent abuse. The ethical and legal obligations of research investigators to their research subjects 1 can be problematic, especially when research topics involve embarrassing, violent, and illegal actions (Myers, 1992; Sieber, 1992a,b).

The panel reviewed the state of knowledge about ethical issues in child maltreatment research, both to identify gaps in that knowledge base and to highlight areas in which studies are needed to examine basic assumptions and guidelines that influence research behavior and project outcomes. Such studies can help clarify the needs and values of the research community, research subjects, and other parts of society; strengthen the integrity of research on child maltreatment, especially in the development of large data sets; and offer guidance when conflicts develop among competing interests.

Certain key ethical questions deserve explicit attention in the field of child maltreatment studies:

The panel also selected several legal issues for review, although the scope of effort in this area was limited by the composition of the panel and the mandate of the study. As a result, the issue of children's rights in the context of adult relationships is not thoroughly explored in this study, even though this issue can be an integral aspect of research efforts. Comprehensive reviews of legal issues in the field of child maltreatment have recently been published (see, for example, Myers, 1992), but such reviews focus primarily on legal issues associated with the treatment of child abuse cases within administrative agencies and the courts rather than research studies.

The questions noted above are not completely resolved in the following discussion, but the panel has identified areas in which further research may assist in their resolution.

Framework Of Analysis

Ethical and legal issues that require consideration in formulating a research agenda for studies of child maltreatment fall within the following three categories:

This discussion identifies significant ethical and legal issues from each of these categories that should be considered in developing a research agenda for child maltreatment studies. Such issues should be raised explicitly now to strengthen this area of empirical study and to inform the development of policies, regulations, and legislation that may affect subject rights and researcher obligations.

The panel anticipates that ethical and legal issues will gain increasing prominence with the growth of research activities on child maltreatment, especially as researchers acquire the ability and resources to conduct long-term prospective studies of nonclinical samples involving large numbers of children and families. Appropriate consideration of such issues can strengthen the integrity of research on child maltreatment. Disregard for these issues can disrupt research investigations and can stimulate additional legislative or bureaucratic requirements that could diminish the scope or creativity of future efforts. Consequently, the panel's research agenda includes topics that can foster greater understanding and possible resolution of difficult ethical or legal issues in child maltreatment research.

Issues In Research On Human Subjects

Three fundamental principles have guided the ethical framework for research on human subjects: (1) respect for persons—the obligation to treat individuals as autonomous agents and the need to protect those with diminished autonomy; (2) beneficence—the principle commonly interpreted as "doing no harm" as well as maximizing possible benefits and minimizing possible harm; and (3) justice—the principle of fairness, including a fair sharing of burdens and benefits (Levine, 1986).

In most cases, these principles are mutually reinforcing and potential conflicts can be resolved by appropriate research designs and informed consent procedures (Levine, 1986). But at times, value conflicts and ethical dilemmas can arise. For example, a scientist might be uncertain whether to emphasize the principle of beneficence or respect for persons in determining whether or not to disclose to a parent information revealed by a child, especially if the child is an adolescent.

Research on both victims and offenders in child maltreatment studies is subject to the same federal regulations that govern all human subjects research (45 CFR 46). In addition, federal regulations require additional protections for children involved in research (Subpart D). Some studies of child maltreatment may also be governed by Section 46.407, "Research not otherwise approvable which presents an opportunity to understand, prevent, or alleviate a serious problem affecting the health or welfare of children." Technically, federal regulations apply to federally funded research, although most institutions that receive federal funds apply the same regulations to

nonfederally funded studies. In addition to federal regulations, several professional associations (such as the American Psychological Association) have adopted guidelines that apply to human subjects research.

Federal regulations and professional guidelines generally address the following substantive norms: There should be (1) a good research design, (2) competent investigators, (3) a favorable balance of harm and benefit, (4) informed consent, and (5) equitable selection of research subjects.

Federal regulations require that the scientist prepare a protocol that seeks to achieve scientifically valid results. The interest of the scientist in validity affects all phases of the research project, including the development of the research design, recruitment and selection of the project sample, assignment of research subjects to control and experimental groups, choice of research instrumentation, and evaluation of research outcomes. In addition, the research protocol discusses the need for human subjects, associated risks and benefits, and the use of appropriate safeguards for risks associated with the research. The research protocol is reviewed by an appropriately constituted institutional review board to assess the impact of the proposed research on human subjects and to ensure that the safeguards are adequate.

In the research protocol, the research investigator must develop an appropriate informed consent procedure that includes an explanation of potential risks of the research project to each research subject. 2 Parents or authorized guardians (who may be court-appointed) are asked to provide permission for the child's research participation. The assent of the child (who is too young to give legal consent) must also be obtained. Both the child and the parent or guardian have the right to veto participation in the study at any point during the procedure. A waiver of requirements of some aspects of informed consent can be obtained as long as certain limits are observed (Levine, 1986). For example, consent might be waived if the procedure presents no greater burden than mere inconvenience and appropriate safeguards for confidentiality are in place, such as in the use of records without identifiers. Also, a waiver of parental permission may be obtained when parents are not likely to act in the child's best interests.

Research that involves deception or unusual psychological stress often includes provision for a session to debrief or desensitize research subjects following any period of experimental manipulation to ensure that they have not been harmed as a result of the research procedure.

All human subjects research should be voluntary and noncoercive. This condition is particularly important when the research involves persons of dependent status, such as children, prisoners, and the mentally disabled. Special protections for dependent persons have evolved in federal regulations and professional guidelines, and these conditions are particularly relevant to child maltreatment research (Levine, 1991; Stanley and Sieber, 1992).

The National Institutes of Health has established the Office for Protection from Research Risks (OPRR) which provides legal and ethical guidance to research scientists, administrators, and institutional research boards. The office is authorized to suspend research with human subjects that involves violations of Department of Health and Human Services regulations for the protection of human subjects. Where necessary, it can withdraw an institution's departmental assurance of compliance with the regulations.

Each research institution that receives federal funds for human subjects research is required to organize an Institutional Review Board (IRB); the IRB reviews research protocols to determine whether they comply with federal regulations governing human research. Although IRBs are not the primary arbiters of scientific matters, frequently they discuss aspects of research design and procedures, both in terms of their impact on research subjects and on the likelihood of achieving the stated objective. If risks are involved in the research project, IRB members may request modifications in research design features to improve the validity of the study or to provide safeguards for human subjects in the proposed research project. Many funders require evidence of IRB approval prior to a funding decision and some scientific journals require evidence of IRB approval prior to acceptance of research manuscripts.

A properly constituted IRB may have as few as 5 members, drawn from a variety of disciplines and affiliations, including research scientists, administrative officials, health professionals—such as physicians, nurses, and other specialists involved in selected aspects of clinical care—and ethicists. Regulations require that IRBs include at least one nonscientist and a community representative, such as a ministers, social worker, or other individual who provides community services. Child maltreatment research protocols are often reviewed by IRBs that examine numerous other clinical or scientific studies unrelated to issues of child abuse and neglect. Because of the small number of research scientists associated with child maltreatment research, IRB members (or research investigators) who are not familiar with the literature or methodology of studies of child abuse and neglect may call on expert consultants to examine protocols in this area for relevant risks and safeguards.

Child victimization can be controversial or sensational in nature, especially when sexual abuse is involved. The potential legal liability of the research institution should emotional harm occur to children or their families during the course of the research can lead to rigorous requirements on the research investigators to demonstrate the need for the research, the validity of the research design, appropriate selection of research subjects and methodologies, and careful treatment of research data and interpretations including safeguards for privacy and confidentiality.

The wide variation in child maltreatment research projects needs to be

considered in reviewing the significance of ethical and legal issues. Some projects involve only limited contact with research subjects, such as reviews of report records. Survey projects may be done in an anonymous fashion or with identifying information provided for follow-up interviews and evaluations. Some projects require more extensive interactions, and possible interventions, with parents and children. Some studies may raise only one or another ethical or legal issue; some may raise all of them. Projects that involve large numbers of research subjects, whose behavior is studied in the home over extensive periods of time, are more likely to contain a wider range of difficult ethical and legal issues than those that involve small study samples requiring only minimal interactions between the investigator and subject in an institutional setting.

Ethical Issues In Child Maltreatment Research

Many ethical issues arise in the course of human subjects research, some of which have special relevance for studies of child maltreatment. Five issues that deserve special attention include: (1) the recruitment of research subjects; (2) informed consent and deception; (3) assignment of subjects to experimental or control programs; (4) issues of privacy, confidentiality, and autonomy; and (5) debriefing or desensitizing of research subjects following research procedures that involve deception or significant stress.

Recruitment of Subjects

Investigators often have difficulty identifying and recruiting large and representative groups of subjects, especially when investigating controversial or low-base-rate phenomena. Scientists are thus dependent on various institutions and personnel for the assessment and recruitment of appropriate subjects. Potential subjects for child maltreatment research may be referred by family service programs prior to or following a report of child abuse and neglect, or they may be selected from case reports by child protective service or child welfare officials. Since case workers often identify and recruit potential subjects, the nature of the relationships among the scientific investigator, the case worker, and the research subject in child maltreatment studies deserves special consideration.

Researchers generally are familiar with the requirements of voluntarism in human subjects research, but they are often not present when potential subjects are recruited for their project. Many child welfare agencies have a less than ideal clinical relationship with the parents of abused or neglected children (Bradley and Lindsay, 1987). The status of these research subjects, many of whom may be under investigation or involved in legal pro-

ceedings, is comparable to that of other ''captive populations" in human subjects research. Potential subjects may be told, or may incorrectly believe, that participation in the research will be beneficial to their family or may mitigate severe penalties (such as the removal of their children). As a result, elements of real or perceived coercion may exist in a subject's initial agreement to volunteer for the research.

A second issue to consider in subject recruitment is the offering of monetary payments or desired goods in return for research participation. A modest financial stipend is generally appropriate to cover the inconvenience and transportation costs incurred by a participant in a research study (Bradley and Lindsay, 1987). However, large sums may be coercive, especially for low-income participants (Keith-Spiegel and Koocher, 1985; Koocher and Keith-Spiegel, 1990). The American Psychological Association guidelines for research indicate that subjects must be informed of their right to terminate their participation without forfeiting their honoraria (American Psychological Association, 1987; Bradley and Lindsay, 1987). Instead of monetary stipends, some investigators offer such items as videotapes of the subjects' children, small household appliances, and toys for the children as incentives for participation, a practice that has not been discussed in professional research guidelines.

Informed Consent and Deception

One of the most difficult ethical issues to resolve in child maltreatment studies is the extent to which the true purpose of the research project is disclosed to and discussed with the subject or parent. As noted by Bradley and Lindsay (1987), in all areas of human research scientists must walk a fine line between protection of their subjects and procedures designed to enhance the validity and merit of scientific results. The social stigma and legal consequences of child abuse and neglect, as well as the possible ramifications for individuals and their families, require a careful review of fundamental principles that should guide responsible research practice in this area.

Researchers typically believe that full disclosure of the purpose of a child maltreatment study would limit participation to admitted abusers, a procedure that would severely curtail the strength and scope of their research. Subjects therefore might be told that they are participating in a study of "families or children with problems" or "ways that families punish children who misbehave." One study of research procedures in child maltreatment studies has recommended that researchers be encouraged in their publications to include details about what was told to the subjects regarding the purpose of the study (Bradley and Lindsay, 1987).

Accurate but incomplete descriptions of the purpose of the research

study are common, and good clinical judgment is often the primary source of guidance in developing such descriptions. In some cases, prospective subjects may be told that some information is being withheld deliberately (Levine, 1986). The withheld information may involve the purpose of the entire study or the nature of some methods used in the study. Many scientists believe that subjects should never be deliberately deceived about the nature of the study, but the deliberate withholding of information may be necessary to maintain the validity of the study. In cases in which information is deliberately withheld, professional guidelines have urged that disclosure should be given (dehoaxing) at the conclusion of the subject's participation and the subject should be returned to a good state of mind about the experience (desensitizing) (American Psychological Association, 1987; Holmes, 1976a,b; Sieber, 1992b). However, dehoaxing is sometimes harmful, and desensitizing is sometimes impossible.

Deception research has profound implications, since it may carry over into relationships of the subjects with their own family members as well as with clinicians, social workers, law enforcement personnel, and so forth. For example, parents who are presented with photos in which their child appears to be misbehaving (such as destroying a toy or scribbling on a wall) may conclude that their child is "bad" or may feel that prior negative perceptions of their child have been confirmed (Bradley and Lindsay, 1987). Such research practices may be uncommon, but they can affect other areas of deceptive research if inadequate safeguards are in place.

The methods of obtaining consent and parental permission are also important to consider. The process of obtaining consent involves more than the completion of a written form—it requires a discussion, in lay terms, of the purpose of the study and potential risks that may accompany the research. The consent form itself is the legal record documenting that such a discussion has occurred. Studies of college students often rely on written consent forms, but such instruments may be poorly suited to studies of populations that are younger, undereducated, underserved, or have learning disabilities. When subjects have literacy problems, or when English is not their primary language, face-to-face methods with orally presented information about the research can facilitate the consent process.

Similar problems can arise in the course of asking questions in the research process, particularly if written self-report measures are employed. In some cases, the researcher presents the entire procedure in the subjects' native language(s), sometimes assisted by translators. Studies that focus on particular ethnic groups must adapt their instruments to the traditional practices of that group. Appropriate comparative groups should be employed to distinguish maltreatment from cultural practice as well as to identify cultural practices that may contribute to maltreatment.

Some research investigators have developed strategies that use proxies

or analogous behaviors to study physical abuse (Bauer and Twentyman, 1985; Frodi and Lamb, 1980; Pruitt and Erickson, 1985; Wolfe et al., 1983). Although such approaches may successfully resolve many ethical problems in experimental design, they present particular responsibilities for the investigator to fully debrief the research subjects.

The issue of mandatory reporting is important to consider in the process of identifying informed consent (see the section on mandatory reporting requirements in Chapter 3). When issues of privacy and confidentiality are discussed in the informed consent procedure, a statement such as the following might be included and explained carefully: 3

What is discussed during our session will be kept confidential with two exceptions: I am compelled by law to inform an appropriate other person if I hear and believe that you are in danger of hurting yourself or someone else, or if there is reasonable suspicion that a child, elder, or dependent adult has been abused.

Assignment of Research Subjects

An important ethical issue that arises in many human subject studies is the ethical acceptability of randomly assigning research participants to experimental and control treatment groups. Although random assignment is essential to scientific validity, it may be ethically impermissible if it means that a potentially life-saving or therapeutic intervention is withheld from the research subject. This issue is particularly complex when a given intervention is thought to be sufficiently effective that withholding it may constitute inhumane treatment (Kaufman and Zigler, 1992:279).

Indeed, it may be unethical to select any group of abused children for a control sample in which children would not have access to possibly therapeutic services. But modifications of experimental designs can resolve dilemmas between beneficence and requirements for scientific validity (Kaufman and Zigler, 1992:279). Such modifications include treatment partitioning, in which control subjects are randomly assigned to alternative treatment programs; "waiting list" controls, which make use of the often significant time lag in gaining access to a treatment program or after its discontinuance; or selecting control subjects from nearby or comparable communities that do not have access to service programs (Cook and Campbell, 1979; Seitz, 1987).

The National Institutes of Health has issued policy statements for inclusion of minorities and women in research, which should be considered in the development of child maltreatment studies (National Institutes of Health, 1991).

Ethnic and social class representation should also be considered in the assignment of research subjects to experimental and control groups. Race has often been used as a grouping variable but it has less value than charac-

teristics linked more directly to ethnicity and culture. These latter variables often are stronger influences on attitudes and practices that are transmitted intergenerationally. The terms black or Hispanic are more political concepts than terms that accurately reflect the heritage or nationality of groups that vary by culture, national origin, and other factors (Wyatt, 1991). Sociocultural studies of child maltreatment often need to consider the immigration status of research subjects, their generational status, the extent of their acculturation, and household density. A more flexible typology is needed to identify or "unpack" critical group variables that influence behaviors and relationships. Important differences within and between ethnic groups that reflect their sociocultural experience cannot be ignored in their assignments to control or comparison groups in scientific studies.

Privacy, Confidentiality, and Autonomy

Throughout the research project, issues of privacy, confidentiality, and autonomy may arise. Guidelines should be prepared prior to interviews or observational studies regarding the conditions under which a researcher will divulge to parents or guardians details about the child's behavior. Parents may wish to know details about the sexual behavior of their child. Parents may also have attitudes about certain child behaviors (such as thumb-sucking, bedwetting, and masturbation) that differ significantly from those of the research investigator. Parental perceptions of risks and benefits may also differ from those of the researcher. Researchers may be reluctant to disclose information revealed by the child in any case, but particularly when the parent appears to be hostile, punitive, or acting not in the best interests of the child.

The AIDS epidemic has given new force to many of these dilemmas. The growing number of cases of HIV transmission as a result of child sexual abuse, for example, raises special issues of reporting, criminal proceedings, and the possibility of discrimination based on HIV status.

Another issue that affects privacy and confidentiality is data sharing, particularly when large sets of social behavior data collected for one study (such as alcoholism) are subsequently used by other researchers for studies on child maltreatment. The issues of data sharing in the use of public records are sufficiently complex that they are the focus of a separate National Research Council study (Duncan et al., 1993).

As in the area of recruitment of research subjects, research reports of child maltreatment studies rarely describe procedures used at the end of the project; either debriefings do not occur, or they are not considered impor-

tant enough to warrant discussion in journal articles (Bradley and Lindsay, 1987). Holmes (1976a,b) has provided a useful, though dated, outline of the depth of debriefing required in deceptive research, an approach that has substantial application in the field of maltreatment studies even if deception is not present. Debriefing subjects in a post-project interview may strengthen the research study by identifying misclassified subjects (Adair et al., 1985), increase the sophistication of the research participants, and revise misunderstandings by the subjects regarding the nature of the experiment or negative characteristics of their own or their child's performance (Bradley and Lindsay, 1987).

Post-project discussions and follow-up meetings also provide opportunities for the researcher to convey useful information and insight to parents and children about practices, such as discipline, that might improve their lives.

Research On Children And Families

The importance of validity.

The validity of scientific research takes on special relevance in studies of children and other vulnerable populations, when research results are likely to influence social policy and public perceptions of the problem under study (Sieber, 1992a). Information that scientists disseminate about child victimization is often socially and politically sensitive and can affect both parental and professional behavior as well as public policy. Scientific information, communicated through the popular media, can influence the manner in which abusive parents view abuse, and the ways in which victims view themselves. High-quality research is needed to provide information that has a factual, scientific basis, rather than information based on conjecture or opinion.

Because validity is important but hard to achieve in research on children and families, factors that affect validity are receiving increased attention. These factors include the definitions of child maltreatment, instrumentation and research methods, selection of subject samples, collection of data, interpretation of findings, and safeguards for ensuring privacy, confidentiality, and reliability in the research study.

Child maltreatment research often involves retrospective study of reported cases, an approach that provides a convenient, but often limited, assessment of basic psychological and ecological factors that influence the development of child victimization. In contrast, multivariate longitudinal studies of large populations that include abused as well as nonabused children are presumed to provide more valid and generalizable conclusions, as long as appropriate methods are employed (Weis, 1989; Widom, 1988). Such studies require greater resources, time, and effort not only from investigators and participants but also from institutions and service personnel

who are expected to identify, treat, and prevent child abuse and neglect. Large prospective studies also expose greater numbers of children, families, and researchers to risks and uncertainties associated with observations of sensitive family behavior over extensive periods of time.

A related issue of validity is associated with the reliability of child reports and testimony. As noted in previous chapters, the accuracy and veracity of child reports and the validity of psychological measures purporting to reveal incidents of abuse or neglect remain unresolved issues. The issue of the reliability of adult memories of childhood abuse, in particular, remains controversial.

One major methodological problem associated with studies of child abuse and neglect is how to get a sample of young children to talk candidly about abuse and attempted abuse, especially abuse involving sexual behavior (Finkelhor and Strapko, 1992:161). Depending on the children's social context, their level of maturity and quality of interactions with peers and other families, and so forth, many children may not be able to identify certain forms of abusive behavior or to perceive it as such. Adult survivors may not recall incidents of abuse that occurred during their childhood, even if the investigator has obtained records that document such experiences. Children, or their parents, may be unwilling to discuss incidents that are personally embarrassing, violent, or stressful, especially if they believe that they were responsible for these incidents or that discussion of the incidents will cause harm to family members, not change their interactions with the offender, and not prevent future such incidents. Exaggeration, manipulation, and distortion of the circumstances of the abuse experience, expecially in retrospective studies, are also possibilities.

Interviews in which researchers or therapists have been viewed as manipulating children into disclosing incidents of abuse that did not actually occur has generated much discussion about the roles and responsibilities of professionals in this field. Such concern has resulted in symposia and articles about the boundaries of appropriate professional behavior in conducting interviews with children about incidents of abuse and neglect, especially in cases in which no report of abuse has been filed.

Many investigators seem to be able to conduct intensive interviews with children about these matters successfully, but several ethical issues require consideration in this research. As identified by Finkelhor and Strapko (1992), these issues include: (1) whether and how to get parental permission to conduct such interviews; (2) how to handle state reporting requirements, especially when research interviews reveal abusive or neglectful practices that do not appear to harm the children and that the children do not wish to disclose; and (3) how to reduce the trauma of the interview itself.

Such issues are particularly important to address and resolve in developing prevention efforts so that unintended consequences may be avoided.

Research evaluations, especially in the area of child sexual abuse, have suggested that some prevention programs (such as the "good touch, bad touch" educational programs) may not diminish child maltreatment, often stimulate greater disclosure of abuse reports among the child participants, and may have unintended long-term consequences on adult sexual behavior (such as distrust of physical or sexual intimacy) that have not been carefully considered in the development of the program (Conte, 1987).

In addition to these ethical issues, legal considerations may affect the validity of child maltreatment research. For example, who is authorized to give permission for a child to participate in a study of child abuse and neglect if the parent is the alleged perpetrator or cooperated with the abusing parent? Do individual parties have a right of access to information disclosed in the course of a research study if the information is pertinent to a case that is in litigation or that may be appealed?

Dissemination of Research Results

Research on child maltreatment receives much public attention because it affects children and adults directly and shapes norms and perceptions that can influence policy directives much more rapidly than research in fields of study more distant from everyday human activity (Sieber, 1992a). Research on human behavior often involves unique subject populations that cannot be replicated. As such it is far more politically and socially sensitive than research in the physical sciences, in which controversial or uncertain research findings can often be tested by replication. Thus, breakthroughs in the physical sciences are far easier to verify, but also far more difficult to discuss or interpret without specialized training. They are more likely to be discussed in the media only when significant scientific generalizations (or exorbitant research costs) have been achieved that are understandable to the public. Public misinterpretation or misunderstanding of physical sciences research findings, even if it occurs, rarely has immediate social consequences.

Problems can arise when misinformation about child abuse and neglect is disseminated to the general public. Such problems are particularly significant when members of the research community are the initial sources of reports of invalid research results on child maltreatment. Unconfirmed or inaccurate research findings may also be publicized by the press against the advice or wishes of the researchers. Such incidents can result in vigorous, often sensational, discussions in media and social policy circles.

Research On Socially Sensitive Topics

Scientific studies of child maltreatment require extraordinary care and confidentiality in eliciting, safeguarding, and disclosing information from

respondents because of the socially sensitive nature of the research subject. Family disciplinary practices, the use of violence between family members, and expressions of anger or rage are difficult to detect, observe, and record. Research on children's sexual development is one of the most unexamined areas in all of social science and is impeded by a variety of social taboos (Finkelhor and Strapko, 1992; Furstenberg et al., 1989; Wyatt et al., in press). Political sensitivities have impeded governmental support for studies of sexual behavior in general and discussions of sexual behavior with children in particular. Ethical ambiguities surround this topic.

Unlike priests, physicians, and lawyers, social scientists are not traditionally entitled to testimonial privilege. Scientists do not have an unrestricted right to determine whether to reveal to a law enforcement officer or a court official the identity of their research subjects or the nature or sources of their information. Field researchers who conduct studies of criminal behavior or socially sensitive behavior may be subject to legal interventions when data are thought to be relevant to cases that are in litigation or are under judicial or legislative review (Myers, 1992). Conflicts between the interests of law enforcement officials and the goals of the research community have resulted in the development of specific legislative exemptions—called certificates of confidentiality—that protect some scientists from subpoenas of their research data.

The certificate of confidentiality is the most effective, yet underutilized, protection against subpoena. Researchers involved in socially sensitive studies also have sometimes relied on anonymous data collection, the use of aliases, transmission of data to colleagues in foreign countries, and statistical strategies as ways of guarding the confidentiality of their data (Sieber, 1992b).

The U.S. Department of Health and Human Services may authorize certificates of confidentiality for research investigators conducting socially sensitive research to protect the identities of their research subjects (Levine, 1986; 42 CFR Part 2a). The certificates provide immunity from subpoena, and are most commonly requested in the conduct of research sponsored by the National Institute of Mental Health, the National Institute of Alcoholism and Alcoholic Abuse, and the National Institute of Drug Abuse, although the research need not be funded by or connected with any federal agency (Sieber, 1992b). Certificates of confidentiality are available on application to the NIH Office for Protection from Research Risk for any funded or unfunded research if there is concern that confidentiality is necessary to achieve the research objectives. Certificates of confidentiality are also available for research funded by the Department of Justice. Legal protections have established that information developed through research supported by the National Institute of Justice, for example, "shall be immune from the legal process" (42 U.S.C. 3789).

Although the federal certificate of confidentiality may preempt state reporting requirements, legal opinions on this matter differ (Sieber, 1992a). Few researchers have obtained certificates of confidentiality (Melton, 1990), and none have tested the relevance of such waivers to the mandatory reporting requirements of state child welfare laws. Hence, the prevailing practice is for researchers to assume that certificates of confidentiality or waivers do not preempt state reporting laws, and the informed consent procedure serves as the mechanism by which scientists warn research subjects of their reporting obligations. There appears to be no penalty for the researcher who testifies after obtaining a certificate of confidentiality, but criminal penalties do exist for those who deliberately withhold evidence of suspected child maltreatment.

Conclusions

Researchers who seek to foster valid and creative research projects must address fundamental ethical issues in the recruitment of research subjects; the process of obtaining informed consent; the assignment of subjects; debriefing, dehoaxing, and desensitizing subjects when deception or stressful research is involved; and in providing referrals for children and family members in distress. The ethical and legal issues in child maltreatment research discussed here have been derived from legal and ethical literature regarding the use of human subjects in research, the use of children as research subjects, and the conduct of research on socially sensitive topics.

If larger prospective, longitudinal studies of child maltreatment are developed, as recommended in this report, the ethical and legal issues discussed in this chapter will acquire greater importance and emphasis. The need to ensure the validity of large cohort studies and to develop rigorous evaluations of interventions that might serve as models for other communities will require increased emphasis on issues of scientific validity, data sharing, conflicts between principles of confidentiality and disclosure, and the need for legal protections. Finally, the nature of professional and legal rights and obligations in areas such as mandated reporting, confidentiality for research subjects, and informed consent require more detailed review and analysis.

Research Recommendations

The panel believes that a research agenda for child maltreatment studies should include attention to fundamental ethical and legal issues that pervade this field of inquiry. In particular, the panel recommends the following topics as research priorities:

Recommendation 9-1: The disclosure of unreported incidents of abuse by research subjects requires greater analysis to clarify the circumstances that foster such disclosures, the methods by which researchers respond to subject disclosures, and the outcomes for research subjects who disclose incidents of maltreatment.

Public awareness of the traumatic consequences of child abuse and neglect may begin to affect research participation. Children and adult survivors who disclose unreported incidents of maltreatment to researchers will require professional guidance and support in dealing with the consequences of their maltreatment. Furthermore, the ethical and legal role of researchers in responding to such disclosures requires methodological considerations in formulating appropriate guidance for the research community.

Recommendation 9-2: Methodological research is needed to develop design procedures and resources that can resolve ethical problems associated with recruitment, informed consent, privacy and confidentiality, and assignment of experimental and control groups.

In particular, the use of masked data strategies may acquire additional importance in the development of large data sets that will be used in secondary analyses by researchers who were not associated with the primary collection of the data. These issues would benefit from clarification of the nature of conflicting interests in the course of research, development of clinical advice and experience that can resolve such conflicts, and identification of methods by which such guidance could be communicated to researchers, institutional research boards, research administrators, research subjects, and others.

Ethical issues likely to arise in longitudinal prospective studies need to be identified, to clarify principles of responsible conduct regarding the treatment of risk factors, suspected abuse scenarios, and the rights of research subjects to privacy and confidentiality. Issues related to the sharing of research data, particularly in studies that were not designed as child maltreatment research projects, will need to be addressed in research that focuses on antecedents and consequences of various forms of abuse and neglect. The selection of appropriate models for long-term studies also requires consideration.

Recommendation 9-3: Research is needed to determine the impact of debriefings both on subjects' post-project perceptions as well as on research results. This research will have ethical implications for the inclusion or omission of such interviews in research designs.

Recommendation 9-4: Research on the institutional research board process should be done to improve the quality of the process by which studies of child abuse and neglect are initiated and approved.

The research community could benefit from studies that determine factors that influence approval and disapproval decisions by institutional research boards, the use of waivers and certificates of confidentiality, and other aspects of ethical decision making connected with research on child maltreatment.

1. The term research subject has sometimes been replaced by the term research participant to convey more respect for those who participate in research studies. As noted by Sieber (1992b:13), however, the term subject ''continually reminds the reader that the person being studied typically has less power than the researcher and must be accorded the protections that render this inequality morally acceptable." In the case of research on children, it is highly likely that they will more often be "subjects" than "participants."

2. Informed consent involves several basic components, including a description of the purpose of the research project, an explanation of the procedures in which the subject will participate, and a discussion of potential risks of the project. Following this presentation, the research subject is asked to sign a written form indicating that he or she understands the purpose of the study and agrees to participate. When children are involved as research subjects in the study, the parent or guardian is requested to sign an "assent" form as a proxy for the child. The documentation for informed consent may be waived in some instances.

3. Adapted from a statement developed by David H. Ruja, discussed in E. Gil, The California Child Abuse Reporting Law: Issues and Answers for Professionals . Publication 132(10/86). Sacramento, CA: California Department of Social Services, Office of Child Abuse Prevention.

Adair, J.G., T.W. Dushenko, and R.C. Lindsay 1985 Ethical regulations and their impact on research practice. American Psychologist 40:59-72.

American Psychological Association 1987 Casebook on Ethical Principles of Psychologists . Washington, DC: American Psychological Association.

Bauer, W.D., and C.T. Twentyman 1985 Abusing, neglectful and comparison mother's responses to child-related and non-child-related stressors. Journal of Consulting Clinical Psychology 53:335-343.

Bradley, E.J., and R.C. Lindsay 1987 Methodological and ethical issues in child abuse research. Journal of Family Violence 2(3):239-255.

Conte, J. 1987 Ethical issues in evaluation of prevention programs. Child Abuse and Neglect. 11(2):171-172.

Cook, T., and D. Campbell 1979 Quasi-Experimental Design and Analysis Issues for Field Settings . Chicago: Rand McNally.

Duncan, G.T., T.B. Jabine, and V.A. deWolf, eds. 1993 Private Lives and Public Policies: Confidentiality and Accessibility of Government Statistics . Washington, DC: National Academy Press.

Finkelhor, D., and N. Strapko 1992 Sexual abuse and prevention education: A review of evaluation studies. Chapter 7 in D.J. Willis, E.W. Holden, and M. Rosenberg, eds., Prevention of Child Maltreatment . New York: John Wiley and Sons.

Frodi, A.M., and M.E. Lamb 1980 Child abusers' responses to infant smiles and cries. Child Development 51:238-241.

Furstenberg, F.F., J. Brooks-Gunn, and L. Chase-Landsdale 1989 Adolescent fertility and public policy. American Psychologist 44(2):313-320.

Gil, E. 1982 The California child abuse reporting law: Issues and answers for professionals. Publication 132 (10/86). This booklet is printed and distributed by the State of California Department for Social Services, Office of Child Abuse Prevention, 744 P Street, M.S. 9-100, Sacramento, CA, 95815.

Holmes, D.S. 1976a Debriefing after psychological experiment: I. Effectiveness of postdeception dehoaxing. American Psychologist 31:858-867. 1976b Debriefing after psychological experiment: II. Effectiveness of experimental desensitizing. American Psychologist 31:868-875.

Kaufman, J., and E. Zigler 1992 The prevention of child maltreatment: Programming, research, and policy. Chapter 12 in D.J. Willis, E.W. Holden, and M. Rosenberg, eds., Prevention of Child Maltreatment . New York: John Wiley and Sons.

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Levine, R.J. 1986 Ethics and Regulation of Clinical Research . Second edition. New Haven: Yale University Press. 1991 Respect for children as research subjects. Chapter 117 in M. Lewis, ed., Child and Adolescent Psychiatry; A Comprehensive Textbook . Baltimore: Williams and Wilkins.

Melton, G. 1982 Children's rights: Where are the children? American Journal of Orthopsychiatry 52(3):530-538. 1983 Child Advocacy: Psychological Issues and Interventions . New York: Plenum Press. 1990 Certificates of confidentiality under the Public Health Service Act: Strong protection but not enough. Violence and Victims 12:369-386.

Myers, J.E.B. 1992 Legal Issues in Child Abuse and Neglect . Newbury Park, CA: Sage Publications.

National Institutes of Health 1991 NIH Guide to Grants and Contracts. 20(32):1-3. August 23.

Pruitt, D.L., and M.T. Erickson 1985 The Child Abuse Potential Inventory: A study of concurrent validity. Journal of Clinical Psychology 41:104-111.

Seitz, V. 1987 Outcome evaluation of family support programs: Research design alternatives to true experiments. In S.L. Kagan, D. Powell, B. Weissbound, and E. Zigler, eds., America's Family Support Programs: Perspectives and Prospects . New Haven: Yale University Press.

Sieber, J. 1992a Issues Presented by Mandatory Reporting Requirements. Background paper prepared for the National Research Council's Panel on Research on Child Abuse and Neglect. 1992b Planning Ethically Responsible Research . Newbury Park, CA: Sage Publications.

Stanley, B., and J.E. Sieber, eds. 1992 Social Research on Children and Adolescents: Ethical Issues . Newbury Park, CA: Sage Publications.

Thompson, R.A. 1992 Developmental changes in research risk and benefit: A changing calculus of concerns. Chapter in B. Stanley and J.E. Sieber, eds., Social Research on Children and Adolescents: Ethical Issues . Newbury Park, CA: Sage Publications.

Weis, J.G. 1989 Family violence research methodology and design. In L. Ohlin and M. Tonry, eds., Family Violence . Chicago: University of Chicago Press.

Widom, C. 1988 Sampling biases and implications for child abuse research. American Orthopsychiatric Association 58(2):260-270.

Wolfe, D.A., J.A. Fairbank, J.A. Kelly, and A.S. Bradlyn 1983 Child abusive parents' physiological responses to stressful and non-stressful behavior in children. Behavior Assessment 5:363-371.

Wyatt, G.E. 1991 Examining ethnicity versus race in AIDS related research. Social Science and Medicine 33(1):37-45.

Wyatt, G.E., M. Newcombe, M. Riederlee, and C. Notgrass in press The Effects of Child Sexual Abuse on Women's Sexual and Psychological Functioning . Newbury Park, CA: Sage Publications.

The tragedy of child abuse and neglect is in the forefront of public attention. Yet, without a conceptual framework, research in this area has been highly fragmented. Understanding the broad dimensions of this crisis has suffered as a result.

This new volume provides a comprehensive, integrated, child-oriented research agenda for the nation. The committee presents an overview of three major areas:

• Definitions and scope —exploring standardized classifications, analysis of incidence and prevalence trends, and more.
• Etiology, consequences, treatment, and prevention —analyzing relationships between cause and effect, reviewing prevention research with a unique systems approach, looking at short- and long-term consequences of abuse, and evaluating interventions.
• Infrastructure and ethics —including a review of current research efforts, ways to strengthen human resources and research tools, and guidance on sensitive ethical and legal issues.

This volume will be useful to organizations involved in research, social service agencies, child advocacy groups, and researchers.

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Recently published case reviews

Case reviews published in 2024.

A list of the full overview reports and executive summaries added to the National case review repository. To find all published case reviews search the national collection .

Case reviews describe children and young people's experiences of abuse and neglect. If you have any concerns about children or need support, please contact the NSPCC Helpline on 0808 800 5000 or emailing [email protected] .

2024 - Anonymous - DHR

Murder of a female adult victim by her former partner. A child born to the victim and perpetrator was placed with the perpetrator and his then partner under a Child Arrangement Order (CAO). It was alleged the perpetrator exploited the placement of the child with him to manipulate and control the victim. Learning includes: the need for enhanced professional awareness of the potential for CAOs to be exploited or subverted to coerce or control individuals who are a party to the CAO; the impact of loss of custody or restrictions on contact with children on the mental health of females who have experienced domestic abuse; the need for professionals to consider both the victim and the perpetrator’s prior domestic abuse history when assessing risk and making referrals; raising awareness of the Domestic Violence Disclosure Scheme (DVDS); where there are concurrent safeguarding children and domestic abuse concerns, the importance of not overlooking the needs of parents who are suffering domestic violence and abuse. Recommendations include: the relevant children’s services to review arrangements for the grant of CAOs in which children’s social care are involved, to consider the response to indications that the CAO may be breaking down, and the notification of the CAOs to partners, particularly primary care; and for children’s services to ensure appropriate emotional support is offered to parents whose children are removed from their care. Keywords : residence orders, child protection, children in violent families, separation [mother-child], partner violence, children’s services > Read the overview report

2024 – Barking and Dagenham – Child F

Death of a 9-month-old baby in Autumn 2018. Child F had a head injury consistent with shaking. The child’s mother was 18-years-old, separated from the father and had a history of adverse childhood experiences. Learning themes include: responding to risk to babies both before and after their birth; assessing parenting capacity of a vulnerable young parent; unseen men; and coordination of effort between services and information sharing. Recommendations to the partnership include: all training should include clear guidance about the importance of gathering social history information from parents, checking agency records and making an assessment of all adults involved in the care of young babies, especially new partners; review and revise the existing multi-agency guidance about supporting and assessing the parenting capacity of young vulnerable parents to clarify what factors would heighten risks and which would serve as protective factors for their child; and undertake a multiagency review of the effectiveness of partnership working with parents with high needs, particularly those families of vulnerable children under two years to ensure that there are more effective joint responses, information sharing and systems to support parents and to safeguard children. Keywords : adolescent mothers, adverse childhood experiences, infant deaths, non-accidental head injuries, parenting capacity, shaking > Read the overview report

2024 - Berkshire West - Alex

Serious accidental injuries to a 7-year-old boy whilst in the care of his mother in February 2021. Alex’s mother failed to seek medical treatment and the consequences could have been life threatening. She has since been prosecuted for neglect. Learning themes include: how agencies work together; making and responding to referrals; response to neglect and substance misuse; consideration of the role of the stepfather; risks and protective factors; consideration of child’s identity; and the impact of Covid and other organisational issues. Recommendations to the partnership include: arrange a multi-agency audit that considers the effectiveness of the service provided to children who are referred to Children Single Point of Contact (CSPoA) late in the day where there are potential concerns about significant harm; arrange a multi-agency audit regarding whether fathers’ names and dates of birth are being recorded by practitioners, including mother’s presenting for antenatal care and all referrals to CSPoA; seek evidence from social housing providers that they will contact CSPoA if they become aware that any utilities for a household containing children may or have been disconnected; address any challenges that frontline practitioners experience in identifying whether a child protection medical is required and then offering and/or securing one; seek assurance from the police that they will ensure increased oversight of the use of police powers of protection, and that they will continue their ongoing partnership intelligence sharing pilot, and arrange for a multi-agency appraisal of the pilot at the conclusion, whose findings will be shared with the MASH board partnership. Keywords : addicted parents, child neglect, drug misuse, injuries, interagency cooperation, step-parents > Read the overview report

2024 – Bexley – Baby Y

Serious non-accidental injuries to a 9-month-old baby in July 2022. Adult A, the partner of Baby Y’s mother, was arrested on suspicion of causing the injuries. Learning considers: assessment of neglect; physical and mental ill health in the family; parents’/carers’ background and history; issues of domestic abuse; ethnicity and issues arising from intersectionality and diversity; working with uncertainty and gut feeling; working with fathers and other significant males; and assessing risk to children from men who join vulnerable families. Recommendations include: to oversee the completion of an evaluation of the use of the multi-agency neglect toolkit; to develop a seven minute briefing and tips for practitioners about how to act on gut feelings and professional curiosity; to seek assurances from all member agencies that their training strategy includes awareness raising about the importance of including fathers and other male family members in assessments and ongoing work; and to ensure that professionals have the knowledge and understanding of intersectionality to identify and consider issues around families who experience multiple oppressions and disadvantage, when assessing and managing the risk to children. Keywords: neglect identification, injuries, infants, family violence, unknown men, professional curiosity > Read the overview report

2024 – Birmingham - BSCB2018-19/01

Life changing injuries to a 3-year-old child in November 2017 whilst in the care of their parents. Evidence was found of old fractures and bleeding on the brain. After two years in hospital the child was discharged to parents. Mother was found guilty of child neglect in July 2020. Learning points include: assessments of parenting capacity to fully consider the impact of the experiences of asylum seekers in their countries of origin and the potential for post-traumatic stress disorder and potential isolation in the UK; the need for professionals to understand national and local asylum seeking systems and processes, the role of the Home Office and contracted services, and local arrangements for support; the importance of early help to support first-time parents facing complex challenges and the need for comprehensive and holistic assessments; health professionals should consistently follow the ‘was not brought’ policy and inform social workers involved with the child concerned; the need for robust discharge planning for premature babies and children with complex needs; when children present with unexplained or suspicious injuries, professionals to exercise professional curiosity, healthy scepticism, respectful uncertainty, and work to avoid assumptions and the rule of optimism; following child protection procedures when a child is in hospital with a non-accidental injury; timely progress of plans to initiate care proceedings; and the importance of effective multi-agency communication between children’s social care and hospital providers, including the appropriate level of supervised contact for parents with their child in hospital. Recommendations are embedded in the learning points. Keywords : child neglect, injuries, non-attendance, asylum seekers, parenting capacity > Read the overview report

2024 – Bristol - Quality of child protection investigations

Death of a 4-month-old child in December 2022 which was determined not to be the result of abuse or neglect. The family had previous periods of agency contact including early help, child in need and child protection involvement with the older siblings. Explores key barriers and system pressures that impact on achieving consistently good quality child protection investigations. Learning includes: professionals involved in the initial stages of child protection investigations want to work together more efficiently and more effectively; chairing of strategy discussions is seen as critical to the initial stages of achieving consistently good quality child protection investigations; a call for greater knowledge and skills about how to conduct multi-agency child protection investigations; a need for mapping and explaining the different agency roles and responsibilities; and the development of quality standards, or descriptors relating to the child protection process could be helpful to the multi-agency network. Recommendations include: seek assurance that there is information and data available which supports the regular review of the quality and standard of child protection investigations; the development of a three to five year workforce strategy specifically for those professionals involved in child protection work; compile a selection of analysis tools to support practitioners and managers achieve stronger analysis for use from the point of strategy discussions onwards; and develop a resource, which easily explains the different agency roles, responsibilities and expectations. Keywords : infant deaths, interagency cooperation, staff development, information sharing, organisational behaviour, training > Read the overview report

2024 - Calderdale - Child P

Significant injuries to a 3-month-old infant boy in April 2018 whilst in the care of his parents. Child P’s mother had longstanding mental health problems, with the family receiving support from a range of agencies since her first pregnancy. Learning considers: the impact of parental mental health; the effectiveness of early intervention co-ordination and planning; child-focussed practice; and the role of the father and other adults in the home. Recommendations include: remind partner agencies of the need to consider the potential impact of the birth of a subsequent child to a family about which there are prior concerns and to ensure that support needs are acted upon promptly; emphasise the importance of fully assessing the risks that parental mental health could present to children in the household, ensuring that single and multi-agency policy, systems and training supports the assessment of such risks, and obtain assurance that adult mental health services always give priority to the child’s needs when considering risk; obtain assurance that the provision of early help is timely, addresses all needs and is managed robustly to avoid drift; examine the issue of how the lead agency/practitioner for early help is decided upon and, where necessary, reviewed; remind agencies of ‘hidden male’ research findings with a particular focus on raising awareness in adult services; seek assurance that the perinatal mental health pathway includes sufficient focus on parenting capacity and that knowledge of the pathway is promoted by the local NHS foundation trust; and the local NHS foundation trust to update guidance to practitioners on the safety of breastfeeding whilst the mother is taking medication. Keywords: infants, injuries, maternal depression, psychoses, early intervention, postnatal care > Read the overview report

2024 – Cheshire East – Child L

Disclosure of sexual abuse of a 13-year-old girl in 2022 by a known sexual offender. At the time of the incident, Child L was subject to an interim supervision order and a child protection plan and had previously made three allegations of rape and sexual assault outside of the home. Learning themes include: appreciating the child's lived experience and the cumulative impact of adversity, harm, and trauma; listening to children and young people who make disclosures of abuse with intent to take action; ensuring systems and practice are domestic abuse aware and trauma-informed; recognising the safety that school can provide for children experiencing intra and extra-familial harm; increased awareness of the signs of child sexual exploitation and processes to access specialist guidance and support; and developing a whole family response to support understanding of risk where there are complex adult issues. Recommendations to the partnership include: consider how it can strengthen practitioner skills that enable the child’s voice and experiences to be listened to and responded to verbally or non-verbally, including child observations and understanding of behaviours that may reflect harm and distress; work undertaken with regard to the role of education in providing a key protective factor should include learning about the importance of relational practice, trusted adults, and advocacy; clear leadership and challenge should be provided about victim-blaming language; and seek assurance that when services are commissioned/decommissioned, a relational approach is taken with regard to children and families to be mindful of the importance of continuity of relationships from the child’s perspective. Keywords: extrafamilial child sexual abuse, rape, children in violent families, substance misuse, trauma informed practice, voice of the child > Read the overview report

2024 - Cheshire East - Jez and siblings

Death of a 17-year-old boy in December 2022 from a drug overdose. Jez was autistic and known to services due to experiences of domestic abuse, mental health issues, substance misuse and self-harm. There were allegations against Jez’s stepfather of domestic abuse and sexual abuse. Learning includes: response to concerns about child sexual abuse and the impact a lack of a robust response can have on children’s lives; support for children and families when they experience domestic abuse; responding to allegations of physical abuse; support to mothers with care and support needs; and professional response to deteriorating mental health, self-harm, and substance misuse in the context of a trauma informed approach. Recommendations to the partnership include: set up a task and finish group to improve the multi-agency response to child sexual abuse; consider how to strengthen practitioner skills that enable the child’s voice and experiences to be listened to whether there is a verbal or non-verbal disclosure; ensure that all partner agencies have awareness of self-harm NICE guidance and the key principles of safety planning, managing risk and suicide prevention; and implement a domestic abuse-informed response within child safeguarding responses. Keywords : suicide, substance misuse, domestic abuse, children with a mental health problem, autism spectrum disorder > Read the overview report

2024 - Cheshire West and Chester - Child suicide or death through undetermined intent

The children considered as part of this review all died as a result of a deliberate act of self-harm. Some deaths have been concluded as suicide or undetermined intent. Learning themes include: recognition of bullying; think family in blended families; child’s voice: how could a child present so differently between school and home; child to parent violence: adult issues versus the focus on the child; and multi-agency communication and consent as a barrier. Recommendations include: undertake scrutiny of how consent for information sharing is addressed by agencies to ensure that the best interests of children are maintained; when there are concerns about violence or behaviour that is challenging to the parents, professionals must be able to explore why the child is behaving in a particular way and develop an action plan based on this knowledge; policy must be able to make a difference to children across all localities to reduce inequalities of access to therapeutic support; ensure that local policy and procedures emphasise the need for assessments, including school admission, to incorporate any parent or carer, especially biological fathers, male carers, and male partners, this should include the requirement to record the status of the adult in the child’s life, parental responsibility, and how they are involved in the care of the child; and undertake an audit of cases which are at the level of early help or team around the family, and explore the views of children and young people in relation to sharing information. Keywords : suicide, child behaviour problems, voice of the child, self harm, bullying~ > Read the overview report

2024 – Croydon - Eva

Non-accidental injuries to a 4-month-old girl in June 2023. Baby Eva was taken to hospital by both parents, with a pain in her right arm. Examination revealed a spiral fracture and further examination revealed multiple fractures, including rib fractures of varying ages. Both parents were subsequently arrested and remain under investigation, with Baby Eva's mother later alleging domestic abuse by the father. Learning themes include: assessment of the impact of previous learning; the impact of systems on the quality and response to information sharing; and responding to information about fathers and other children. Recommendations include: ensure partner agencies review and enhance their systems and practices to facilitate effective information sharing, particularly concerning fathers or male partners; share the findings of this review with the out of area hospital where Eva’s mother attended antenatally and gave birth, to enable them to consider what action they need to take in response to the identified factors that impacted upon safeguarding; seek assurance that the ‘normalisation’ of parental/carer aggression is not happening routinely and there are appropriate systems in place to support professionals who may be at risk of vicarious trauma; and consider whether there is a need for the Integrated Care Board to undertake an assessment to gain assurance across the borough that GP practices are applying a system of coding that facilitates the immediate identification and sharing of safeguarding concerns for different health practitioners working within the practice, staff who may work in multiple practices, and for when patients transfer surgeries. Keywords : adverse childhood experiences, abusive men, aggressive behaviour, family violence, fathers, physically abused infants > Read the overview report

2024 - Derby and Derbyshire - Theo

Death of a 10-month-old boy while in his parents’ care. On examination, Theo was found to have multiple injuries. Evidence suggests his death was likely to have been the result of abuse. Learning themes include: the quality of ‘parenting assessments’ and ’social work assessments’; recognising the difference between ‘family arrangements’ and being looked after; the effective use of pre-proceedings; concealed pregnancy; parental cannabis misuse; increasing the level of multi-agency work in care proceedings; reunifying children with their parents during care proceedings; working with families who appear to be avoiding contact with professionals; responding to issues of domestic violence and abuse; and workforce issues. Recommendations include: undertake a multi-agency audit of recent parenting assessments to evaluate the quality of analysis and conclusions and the effectiveness of information-sharing and professional challenge; ask the local authority to provide evidence of its improved practice in distinguishing between ‘family arrangements’ and ‘placements’; ask the local authority to provide evidence of the improved effectiveness of pre-proceedings work with children and parents; revise its procedures and guidance in respect of concealed pregnancy; encourage local public health commissioners of substance misuse services and the local authority to develop a working joint protocol in line with guidance; work with the local authority’s legal service to develop and implement a practice model that will enable effective multi-agency work while children are subjects of care proceedings; complete a multi-agency audit of cases where children were reunified with parents in pre-proceedings or during care proceedings; seek a report from its domestic abuse strategy lead to verify that child safeguarding partners have arrangements in place to deliver an effective local response to domestic abuse. Keywords : assessment [social work], CAFCASS, care proceedings, child abuse, child deaths, family reunification > Read the overview report

2024 – Dudley - Child F

Assault to a teenage boy in 2022 by a group of males. This was believed to be a targeted assault, possibly linked to criminal exploitation. Child F was a looked after child and had police and youth justice involvement. Child F’s mother had involvement from services for mental health and substance misuse. Learning includes: information sharing and communication, specifically how complex decision making and rationale is explained to families; relationship building and professional curiosity around potential safeguarding concerns; recognising exploitation risks; the potential relevance of ‘adultification’ in safeguarding teenagers; Think Family approach in relation to safeguarding, contextual risk and lived experience of a child; and identifying young carers. Recommendations include: agencies working with adults and/or children to provide assurance to the partnership that they have effective joint working practices when working with members of the same family, recognise how the needs of each person in the family affect each other, and respond appropriately; the partnership to revisit the multi-agency training content to incorporate ‘adultification’ into appropriate courses to raise awareness of this concept so practitioners can understand how this can relate to practice and professional curiosity; and the partnership should strengthen communications to ensure that professionals are aware of their responsibilities in identifying and ensuring that there is assessment of young carers. Keywords : child criminal exploitation, contextual safeguarding, adolescent boys, professional curiosity, violence > Read the overview report

2024 - Enfield - Emily

Alleged rape and drugging of a 16-year-old girl in December 2022 by a perpetrator encountered whilst online gaming. Emily was in care from 4-years-old due to neglect, and experienced placement instability. She has a diagnosis of autism, global developmental delay and ADHD. Learning themes include: planning to prevent the escalation of risk; effectiveness of multi-agency practice in risk assessing a child’s changing needs and risks alongside balancing the prevention of harm against Deprivation of Liberties Safeguards (DoLS); online safety and use of social media by children with additional needs; how a child’s capacity to make decisions and give informed consent is understood and influences care planning and decisions; and assessment and planning for transition to adulthood. Recommendations include: partner agencies to develop a tool that supports more consistent and effective risk assessment and planning for children with complex needs; where there are children who are discussed at the dynamic risk register meeting, it should be considered to share relevant risks with the police; the partnership to flag the lack of suitable placements for children with complex needs to the national panel; and provide further guidance on transition planning to all children’s practitioners so they are clear what the pathways are for children approaching adulthood. Keywords : rape, online grooming, children with a learning disability, children in care, risk assessment > Read the overview report

2024 – Gloucestershire – Child X

Sexual abuse of a 15-year-old girl in care with complex emotional and behavioural needs. Child X was the subject of a Deprivation of Liberty order and was cared for in an unregistered placement. Child X became pregnant in this setting, which was thought to be the result of grooming and sexual abuse by a male carer. Learning themes include: crisis placements; the child’s voice, culture and identity; commissioning of placements and care packages for children with complex needs; quality assurance arrangements for placements and care packages including the quality and competence of professionals commissioned to look after children with complex needs; and managing allegations against staff working with children. Recommendations include: the Safeguarding Children Partnership Executive should have oversight of all children placed in unregistered settings and ensure that there is good quality governance and accountability; the children in care nursing service must be involved when a child is placed out of authority to support careful and consistent health and care planning; all agencies must develop a robust and informed approach to assessing and meeting children’s cultural, race and identity needs; all agencies must ensure that there is an understanding of racism and bias that can lead to the adultification of some children where their vulnerability and support needs are not understood; and awareness should be raised of the local authority designated officer (LADO) role and ensure that partners understand their responsibility in contacting the LADO when there are concerns that an adult may cause a child harm through abuse or professional neglect. Keywords : secure accommodation, racism, sexually abusive people, special educational needs, additional needs and disabilities, adverse childhood experiences, institutional child abuse > Read the overview report

2024 – Gloucestershire - Operation ACORNE

Operation ACORNE was a large scale and complex multi-agency investigation into child sexual abuse. It was initiated in June 2017 in response to concerns about the behaviour of multiple children. The case in question developed over several years and encompassed multiple children and adults from four families within a tightly controlled family network, including close family friends. Learning is embedded in the recommendations. Recommendations include: highlight the findings of this and other relevant reviews with regard to sexual abuse; highlight to the Department for Education (DfE) the lack of guidance for staff managing sexually harmful behaviour in primary schools, ‘peer on peer abuse’ is not appropriate for children of this age group; develop local guidance for practitioners in all agencies in managing sexually harmful behaviour; identify appropriate assessment tools for children demonstrating sexualised behaviour; ensure that working with sexual abuse and harmful sexualised behaviour are part of the inter-agency safeguarding training programme; local guidance regarding complex abuse inquiries to be clarified to explicitly state that all relevant agencies should be represented at a senior level from the outset; the constabulary and children’s services should review the numbers of achieving best evidence trained staff and commission new training programmes to train new staff and refresh those who may have undertaken the training some time ago; review how both strategy meetings and child protection medicals are carried out more rigorously and holistically; undertake a thematic review of cases where there has been concerns about sexual abuse; review how cases are managed when there are concerns about both children and vulnerable adults; and undertake a review of how cases where children are subject to child protection plans are ‘stepped down’ and reassert the rigour with which children in need plans need to be managed. Keywords : child sexual abuse, foster parents, harmful sexual behaviour, voice of the child, risk assessment > Read the overview report

2024 - Haringey - Child Jay

Removal of a child from his mother’s care after an NSPCC referral in December 2021. A paediatric medical was undertaken and concluded Jay’s injuries were non-accidental. Learning themes include: cross borough practice; antenatal care and support from mental health services; risk assessment, intervention and multi-agency decision making; and agency responses to parents who struggle to engage. Recommendations include: write to NHS England to emphasise that written communication provided for patients on GP registration should be more explicit about whole family registration; when family members are registered at different GP practices safeguarding agencies need to ensure that they have the correct details for each family member; review the multi-agency training on parental mental ill health and ensure that staff working with parents have an appropriate level of skill and expertise to assess and intervene; promote awareness for safeguarding professionals on mental health assessment and interventions for parents of young babies; a mechanism should be established between the health visitor and GP, so that following multidisciplinary discussions, there is a shared understanding of actions, by when and by whom; decisions to close children’s casefiles in safeguarding agencies should be communicated to all involved and if there is professional disagreement about that decision, agencies should use the existing escalation processes; review the use of their existing Escalation and Resolution Protocol and make sure all professionals are aware of its use; and ensure that all multi-agency safeguarding training explicitly reminds professionals of the crucial roles of birth fathers and carers in a child’s life. Keywords : abuse allegations, NSPCC, parents with a mental health problem, physically abused children, family violence > Read the overview report

2024 - Hartlepool and Stockton-on-Tees - Child Roo

Death of a 7-month-old infant boy in August 2023 whilst sleeping in his cot at home. At 5-months-old, bleeds on Roo’s brain were identified. Roo and his siblings were subjects of interim care orders and remained in the care of their mother with supervision by a family friend. Learning themes include: recording and evidencing the cumulative impact of neglect; recognising behaviour as evidence of domestic abuse without disclosure; recognition of signs of abuse and neglect in young children, particularly in those with violent behaviour or ‘adultification’; professional’s understanding of the impact of a parent’s learning disability or difficulty; clarity of explanation between medics and non-medics; adhering to procedure in the management of bruising in non-mobile babies; the impact of race, culture and ethnicity on professionals’ decision-making; abusive fathers, their parenting choices and the impact on family functioning; and the child’s lived experience. Recommendations include: children’s social care assessment of family members or friends proposed to supervise a parent’s care of their child(ren) must include thorough local authority checks and clear expectations of the level of supervision required; the partnership to collaborate with education to reduce the risk of a child being excluded as a result of childhood trauma; designated professionals to ensure child protection medical reports use laymen terms and deliver multi agency training on understanding child protection medical reports; and evaluate the child's lived experience in multi-agency assessment using the child's language, reflecting their developmental stage, and recognising all children equally. Keywords : infant deaths, interim care orders, adults with learning difficulties, culture, child neglect, domestic abuse > Read the overview report

2024 – Herefordshire - Child HN

Suspected diabetes mismanagement of an adolescent boy after he presented at hospital in a critical state in March 2023. Learning themes include: management of type 1 diabetes; cross-border working together; understanding an adolescent’s world; working effectively with families; and assessing medical neglect to inform levels of need and intervention when working with adolescents with chronic conditions. Recommendations include: ask the National Panel to consider the benefits of producing national multi-agency guidance on the management of chronic health conditions in children; ensure that the roll-out of child neglect tools and training is updated and includes guidance on understanding and identifying what constitutes medical neglect; run a series of multi-agency practice learning briefings on direct work and voice of the child; address the quality of CIN plans and communication with partner agencies, including ensuring minutes are circulated to all partner agencies and the family in a timely manner; in line with NICE guidelines a task and finish group should find a solution to ensuring that children and young people with type 1 or type 2 diabetes are able to see a mental health professional who is skilled to understand their issues, including psychological barriers that children with diabetes can have; review the guidance for both regions around protecting children and families who move across local authority borders, ensuring that they are aligned and include guidance on information sharing when a family move into a refuge and are subject to a statutory plan, as well as information about cross-border transfer of children with chronic health conditions. Keywords : children with a chronic health condition, medical care neglect, refuges, school attendance, temporary accommodation, transient families > Read the overview report

2024 – Kent - David

Death of a child in 2022 following an asthma attack. David was home educated and at the time of the incident, it was unclear what medication he was taking regularly and how his asthma was being monitored. David’s mother was arrested for neglect but later refused charge. Learning themes include: medical neglect; ‘was not brought’ policies; secondary, primary and community interface and plans in place for children with asthma or allergies; engagement of wider professionals, including pharmacies, schools and public health; and engagement with families to ensure they understand asthma or allergy plans and medication. Recommendations include: the partnership’s neglect strategy and associated training should emphasise the impact of medical neglect relating to chronic, potentially life threatening conditions on children with the wider children’s workforce; the adoption of standard templates for asthma and allergy plans; encouraging health and education professionals to discuss with parents the expectation that asthma/allergy plans are shared with other key professionals and the impact of any subsequent refusal of consent on the child is considered; public health to consider expanding the remit of the school nursing service so it is available for children with chronic medical conditions who become electively home educated; and the integrated care board to support all health providers to routinely review and audit their ‘was not brought’ policies to measure compliance and effectiveness. Keywords : medical care neglect, children with a chronic illness, non-attendance, home education, child deaths > Read the overview report

2024 - Lancashire - Baby Lily

Death of a baby in February 2021. Lily died after her mother fell asleep in bed with her at her mother and baby foster placement. Lily was a looked after child, having been made the subject of a care order shortly after her birth and placed into the care of the local authority. Learning: N/a Recommendations to the partnership include: recommendations are embedded in the learning and include: placement planning from assessment units where end dates are known should be commenced early enough to allow for smooth, trauma-informed transition; where the placement proposed is for a child to be placed with a parent in a new setting, such as a mother and baby placement, care planning must run concurrently to the placement planning; risk assessments should be completed before placement, or as soon as practicable after placement and should always be undertaken by the designated local authority; professionals should ensure that assessments are read and understood by others working with the family and that plans and risk assessments which do not reflect the underpinning assessments are challenged; the local authority should review the use of language following assessments to ensure that simplistic language such as the use of ‘pass, fail, positive’ does not impact on practice and decision making; where the local authority has accommodated a baby within a mother and baby foster placement and there have been concerns in relation to co-sleeping, these should be addressed in writing within an agreed placement plan and include specific requirements for the foster carer to check that the baby is in its cot. Keywords : domestic abuse, care orders, child deaths, parenting capacity, placement, sleeping behaviour > Read the overview report

2024 - Manchester - Child S1

Suicide of a 17-year-old girl in 2021. Child S1 was sexually exploited as a young teenager and was made subject to a care order in 2018. Child S1 spent two years in a therapeutic residence, before returning home to live with her mother. Learning considers: the visible and hidden complexities of childhood trauma; awareness of foetal alcohol spectrum disorder (FASD); trauma-informed practice; appropriate professionals in attendance at multi-agency meetings; individual and collective interventions; risk assessment and risk of death through self-harming behaviours; children’s plans; safety plans; chronology of significant impact events; and management of adolescent risk when threats to life have been identified. Recommendations include: the partnership to request an early review of the local authority’s 2020-24 suicide prevention strategy to specifically address risk in respect of adolescent children, including response to alcohol and substance misuse and emotional and mental health difficulties, and guidance around the timing and completion of risk assessments across health and social care; CAMHS to provide expert advice and guidance to multi-disciplinary teams when plans are being formulated to respond to adolescent suicide and self-harm; the partnership to seek assurance from children's health and social care services that they have systems in place to support robust managerial oversight of children's plans; and the partnership to ensure that practitioners working with a child who has a neurodevelopmental condition, have access to information describing the impact of neurodevelopmental disorders and how this may shape their approach and intervention, making sure this is reflected in their assessments and care-planning. Keywords : suicide, adolescent girls, self harm, family reunification, risk assessment > Read the overview report

2024 – Mid and West Wales – Child A

Death of a 16-year-old girl in October 2020. The condition of Child A’s body was indicative of chronic neglect, and there were significant concerns about the unhygienic condition of her immediate living environment. Child A was found to be grossly obese and immobile and consequently had extensive inflammation and infection leading to her suffering and ultimate death. Learning themes include: the importance of coordinated 'care and support' to help a child with a lifelong and potentially life-limiting chronic disability live a ‘normal’ life; the importance of monitoring weight and physical activity for children with spina bifida; the importance of monitoring skin conditions for children with limited mobility; transitioning from childhood to adulthood with spina bifida; and the context of the COVID-19 pandemic. Recommendations to agencies include: undertake a review of existing training programmes and policy guidance to ensure all practitioners speak to and communicate directly with children and their responsibility to accurately record any communications is explicitly clear; clarify or create a protocol regarding regular monitoring of the skin condition of children with complex health needs and mobility limitations, including spina bifida; and review processes and pathways in place for children with chronic disabilities to ensure that: children’s complex care needs and the services they receive are overseen and coordinated by a single agency or practitioner; there are sufficient checks and balances in place to support opportunities for reassessment of a child’s changing needs; and relevant practice guidance is available to ensure children and their families receive the right information, advice and assistance at the right time. Keywords : children with multiple disabilities, chronic illness, medical care neglect, body weight, poverty, children missing education > Read the overview report

2024 - Northumberland - Sophia

Hospitalisation of a 13-year-old girl in March 2023. Sophia was unresponsive, had very low blood sugar, bone marrow failure and malnutrition. She weighed 13.8kg. Learning themes include: the need to see a child and think about situations from their perspective in all interactions; the need to work together when a child has more than one developmental need or when a situation significantly impacts on how a child functions and develops; the need to share information and be curious; the need to have a co-ordinated multi-agency plan when there is one or more agency working with a child and their family; the need to have a discharge planning meeting following lengthy, complex or safeguarding hospital stays; and the need for everybody to use clear and simple communication. Recommendations to the partnership include: consider how it can introduce shame sensitivity and shame sensitive practice into learning and development opportunities; encourage workers to gather a detailed history with parents and carers to identify roles and responsibilities; encourage agencies to record information in a child’s record as if they are writing to children and their family; review its information sharing procedures; develop a framework that supports people to feel confident in the role as a lead professional for any type of plan; provide guidance about child developmental milestones and growth charts; support designated safeguarding leads (DSLs) to have access to regular and accessible safeguarding supervision from an experienced worker; support ongoing multi-agency opportunities to reflect as a group on a specific circumstance for a child. Keywords : child neglect, sexually abused children, eating disorders, children missing education, child development, special education needs, additional needs and disabilities > Read the overview report

2024 – Rochdale - Child E1

Death of a 3-week-old baby in January 2021. Child E1 was taken to hospital by ambulance after their mother reported that the baby was unresponsive after having difficulty breathing. Child E1 later died from a head injury typical of being violently shaken. Learning themes consider: professional understanding of maternal mental health needs, their impact upon parenting capacity and parental ability to manage the challenges of a newborn baby with a disability; professional consideration of an early help assessment when it was revealed that Child E1 had cleft lip and palate; and consistent and co-ordinated postnatal support and safe sleeping advice to help parents cope with crying and reduce the risk of abusive head trauma. Recommendations include: ensure that all relevant professionals are aware of circumstances which indicate an increased risk to an unborn child and may require a pre-birth assessment, and the requirement to make a referral to children’s social care if there is increased risk; that the safeguarding policy on pre-birth assessments is amended to identify a diagnosis of a disability in an unborn baby as a factor which may be an indicator of increased risk; when referrals are made to the cleft lip and palate team, any information held in respect of parental mental health is shared with that team; advise the National Safeguarding Children Panel of the lack of abusive head trauma prevention advice and propose that appropriate abusive head trauma advice is provided to parents across other cleft lip and palate networks. Keywords : infant deaths, cleft lip and palate, maternal depression, non-accidental head injuries, postnatal care, early intervention > Read the overview report

2024 – Solihull – Arthur

Provides evidence-based opinion on the actions of practitioners involved in the case of 6-year-old Arthur Labinjo-Hughes, who was murdered in June 2020 by his father and his then partner. Focuses on the specific period from 15 April 2020, when Arthur's paternal grandmother contacted the local emergency duty team (EDT) regarding bruising to Arthur, to when the case was closed by children's social care on 27 April 2020. Examines the actions and decisions of the local emergency duty team (EDT) following contact from Arthur's grandmother; the police in response to EDT's request for a welfare check and on receipt of photographs of bruising; MASH in response to EDT's referral and on receipt of the photographs; and the local authority social worker and family support worker during and after a home visit. Identifies three missed opportunities for sharper practice, largely centred around the photographs of the bruising to Arthur's back. Learning: N/a Recommendations: N/a Keywords : murder, child deaths, professional curiosity, bruises, physical abuse identification > Read the overview report

2024 – Solihull – Serious Youth Violence

Two separate incidents of serious youth violence in 2022. The first occurred in January, where a young person under the care of the local authority inflicted serious harm on another. In August, a fight between rival groups involving knives and machetes left three individuals with stab wounds. Learning themes include: intersectionality and adultification; exploitation strategy and the understanding of gangs; disruption activity; threshold criteria; early help and community organisations; and education. Recommendations include: consider agreeing a strategic approach to practice with the safeguarding adults board that includes ACEs and a trauma informed approach; review the existing language matters guide and disseminate across the partnership, aiming it at frontline practitioners and managers with a focus on upskilling the workforce around use of language and approaches to working with young people who are the victims of exploitation; promote effective supervision with an emphasis on diversity, reflective discussions and unconscious bias; review and re-launch the ‘Thematic Exploitation Communication Strategy’; review the multi-agency procedures with particular attention to the contextual safeguarding approaches and to ensure the pathway for receiving referrals, assessing, planning and interventions for places, spaces, and peer groups is clear; develop a greater understanding of the activity of organised crime groups both locally and cross border to identify entrenched and emerging networks and establish robust risk outside the home/extra familial harm pathways; foster flexibility in early help pathways to enable the practitioner that is most trusted by the family to remain as the lead practitioner and capture this within procedures and process documentation. Keywords : adolescent boys, adverse childhood experiences, child criminal exploitation, education, gangs, violence > Read the overview report

2024 - Telford - Alfie

Non-accidental injuries to a 4-month-old infant in 2021 whilst in the care of their parents. Bruising was identified during a routine health appointment and a later skeletal survey identified significant internal injuries. Alfie’s mother and father reported experiencing anxiety and depression at the time of the incident. Alfie’s father was subsequently convicted of grievous bodily harm and neglect. Learning includes: the impact of COVID-19 on parental mental health; the need to 'see' fathers; information sharing and consent; and responses to risk. Recommendations include: all efforts are undertaken to ensure fathers/partners are fully known and engaged in their unborn/new-born babies lives across universal and specialist services, and that father’s demographic details are checked regularly; fathers/partners are offered support and parenting intervention, particularly during the perinatal period; adult mental health services should work with children’s services to ensure consent to share information reflects the family’s situation, any support needs, and impact on parenting and children; consideration of the family’s situation and confidence in engaging in online or in-person therapies should inform the agreed intervention in a timely way; and policies on bruising in non-mobile infants should be reviewed to check for consistency with the evidence base and national guidelines. Keywords : parents with a mental health problem, infants, physical abuse, fathers, child neglect, postnatal care > Read the overview report

2024 - Telford and Wrekin - Neglect

Considers the local systems and practice where there are concerns that may indicate child neglect through learning from two cases. Following the death of a 4-week-old baby in Family 1, where there do not appear to be any suspicious circumstances, significant concerns were identified about the living conditions of the baby and their siblings. Family 2 were considered at a rapid review meeting after serious concerns emerged about the home conditions. Learning includes: sharing information about a child’s history, a parent’s vulnerabilities, and concerns is essential when considering if a child requires support, an assessment, and/or a safeguarding response; professionals need to identify when there is an impact on children when they are having difficulties in meaningfully engaging with a parent; professionals need to explore a child’s lived experience and recognise the cumulative harm to children when they experience neglect over time; and when there is a ‘concealed’ pregnancy, information sharing, and a coordinated inter-agency approach is required. Recommendations include: that the partnership implements a neglect strategy and toolkit to improve the understanding of neglect; the partnership to seek assurance that schools are aware of the need to and are accessing information available to them about a child’s history when they have concerns about the child or their family; and the partnership to ask agencies how they are ensuring the expectation that professionals making a referral in respect of a child are checking their own systems to ensure they are aware of background, previous concerns and are including that information. Keywords : child neglect, infant deaths, home environment, parent-professional relationships, siblings, pregnancy > Read the overview report

2024 - Telford and Wrekin - Neglect revisited

Considers the learning from a case where serious neglect was identified following the seemingly unrelated death of an 11-month-old girl in 2022. Learning explores: practice when a family move between local authority areas; the need to consider any cultural and language issues when working with a family with dual heritage and where one parent grew up outside of the UK; the need to identify and ‘name’ neglect when there is developmental delay; and the identification of young carers. Recommendations include: partner agencies to remind professionals of the need to be culturally aware and competent in assessments and direct practice; the need for professionals to be sensitively honest about any difficulties in understanding a parent when English is not their first language; the need to include unannounced visits in plans when working with a family where neglect and household conditions are a concern; and that the partnership considers how it can ensure improved and good practice regarding safeguarding children who move across local authority borders, including those who are children in need. Keywords : child neglect, home environment, infant deaths, culture, language, siblings > Read the overview report

2024 - West Sussex - Adult A, Child 1, Child 2, Adult B

Death of a family comprising two adults and two young children, all of whom died, by gunshot, in March 2020. Adult A, Child 1 and Child 2 were killed and Adult B, as the perpetrator, died by suicide. Learning includes: the need for greater professional curiosity by police and health professionals about dishonesty and integrity, as well as the origins, impact and risk of recreational drug use on other household members; the need to improve systems, policy expectations and processes with sharing information between the GP and the police; and the need to raise awareness, in general, about the unpredictable and negative impact of recreational drug use. Recommendations include: health professionals who are in contact with people reporting alcohol/drug use to consider the impact of substance misuse on the whole family; review the current timescale of holding a gun license for five years without any form of updating information, monitoring or refreshing of holder’s circumstances; and Home Office should revise the gun licensing guidance to state that all police licensing authorities, when seeking health/medical information about an applicant, should be sent a standard pro forma for GPs to complete. Keywords: homicide, suicide, weapons, medical records, mental health, substance misuse > Read the overview report

2024 - Worcestershire - Alfie

Murder of a boy in February 2021 by his mother’s partner, following a period of physical abuse and cruelty in the home. Learning considers: assumptions around contact when new partners join families; professional understanding of domestic abuse; adults of concern who do not meet the threshold for public protection meetings; fixed thinking or confirmatory bias; effectiveness of the core group process; responding to physical abuse; issues around professional reliance on children disclosing abuse and harm; and how the safeguarding system responds to concerns from friends and neighbours. Recommendations include: agencies should challenge their views and hypotheses in cases when there is no evidence to substantiate those views; safeguarding partners to ensure intelligence held on those involved in the lives of children on child protection plans is shared and used to reduce risk; the partnership to ensure that multi-agency staff are prepared for their role in core groups; the partnership to seek assurance that professionals know when a strategy discussion and child protection medical is required in relation to a child’s injuries, with care taken about the weighting given to the child's explanation; the partnership to provide support to professionals on distinguishing between the misplaced use of physical chastisement in responding to behavioural concerns and the use of physical abuse; the partnership to provide development for practitioners to promote an understanding of the relative weighting to be given to evidence of concern, professional judgement, and direct disclosure of harm; and the partnership to provide guidance to practitioners on how they can strengthen child protection plans by supporting family members and neighbours to formalise reports of concerns. Keywords : murder, child deaths, unknown men, physical abuse, disclosure, medical assessment > Read the overview report

Case reviews published in 2023

2023 – anonymous – child a.

Death of a 16-year-old girl. Child A may have died by suicide. Learning focuses on: interagency working when there are disclosures of historical sexual abuse; the impact of sibling-to-sibling sexual abuse; partial disclosure of sexual abuse or assaults; responsibilities of private therapists to safeguard children; peer support and influence; and school transition from secondary to sixth form. Recommendations include: a multi-agency reflective learning event to explore the application of research to improve responses to child sexual abuse; undertake a multi-agency audit of cases of sibling sexual abuse to inform the learning event; contact the British Association for Counselling and Psychotherapy (BACP) asking that members are reminded that their counselling ethical framework sets out directives to refer safeguarding concerns; encourage schools to regularly audit their child safeguarding records to ensure compliance with school transfer protocols; and consider how peer mentoring could be developed and used to support children and young people who decide not to proceed with allegations of historical abuse. Keywords : child deaths, suicide, child sexual abuse, sibling abuse, adolescent girls > Read the overview report

2023 – Anonymous - Child A

Serious injuries to a 2-year-old boy in November 2020. Child A was subject to a child protection plan at the time, having previously been subjected to other injuries. Learning includes: professionals working with a family should fully understand the parental history held across agencies, including a full understanding of any learning difficulties; living with domestic abuse as a child can have an impact when a person becomes a parent; domestic abuse in the wider family may be a risk to a child; all professionals working with children need to be aware of and use the practice guidance for responding to bruises in non-mobile babies; if a child has an injury information should be shared widely with all professionals to ensure awareness of the whole picture and any patterns of cumulative harm; when babies and children are reported to have sustained accidents, professionals should not only consider neglect through lack of supervision, but also the possibility of physical harm; professionals need to be empowered to challenge each other; and for a child’s plan to be effective, a chronology of each agency’s involvement is essential. Recommendations include: review and update the practice guidance for assessment, management and referral on bruising in non-mobile babies; review and update the professional disagreement and escalation policy; partner agencies consider introducing a requirement that individual agencies produce impact chronologies for all child protection conferences; and request that agencies work together to develop systems that allow identification (possibly via a trigger or alert) when there are repeated injuries on a child or young person. Keywords : adults with learning difficulties, child protection registers, family violence, head injuries, hostile behaviour, parents with a mental health problem > Read the overview report

2023 – Anonymous - Child E

Death of a 15-year-old-boy in July 2021. Child E was fatally stabbed by another 15-year-old-boy. Learning focuses on: the involvement of young people in exploitation and knife crime and the potential for rapid escalation of violence; the heightened risk that children who have special educational needs, or who experience a disrupted education, may become involved in serious youth violence or may be exploited; helping children involved in criminal activity or at risk of exploitation who have suffered severe adverse experiences in early childhood; responding to the needs and circumstances of Black children and their families; and the role of social media in exploitation and the response of professionals. Recommendations include: local safeguarding children partnerships (LSCPs) test whether there is effective response to the rapid escalation in violence that can occur when there is child exploitation or serious youth violence; LSCPs test the effectiveness of arrangements to promote better school attendance, and reduce rates of exclusion, among young people at risk of exploitation; LSCPs review the effectiveness of responses to families from Black and minority ethnic communities to consider how best to understand and discuss their experiences, values and perspectives; the Child Safeguarding Practice Review Panel should promote learning from the review of services provided to suspected perpetrators of serious youth violence and criminal exploitation, both through guidance issued by the panel and by seeking changes to the statutory guidance 'Working Together to Safeguard Children 2018'; consideration should be given to wording in the draft 'Police, Crime, Sentencing and Courts Act 2022' guidance on the review of offensive weapons homicides. Keywords : child deaths, adolescent boys, violence, child criminal exploitation > Read the overview report 

2023 – Anonymous – Thematic review of Infants Under 1 Year

Thematic review on infants under 1-year-old, covering seven rapid reviews from August 2019 to March 2020. Cases involve infants who suffered abusive head trauma, fractures consistent with non-accidental injury and concerns in relation to neglect, substance misuse and domestic abuse. Learning includes: children aged 0-2-years-old are not always visible to services; the totality of commissioned services for infants needs to be mapped and a gap analysis completed in order to strengthen earlier identification of need and risk; the single point of access for children's services needs to be embedded and thresholds well understood and applied consistently; improving the knowledge and skills of practitioners to observe and assess the lived experience of pre-verbal and non-verbal children; information sharing continues to create challenges for professionals, including misunderstandings of data protection legislation; the need to understand and assess the emotional and physical risk to babies and children of being present in a household where there is known domestic abuse; professionals need to robustly consider the likelihood of future risk to children, considering how parental mental health concerns, substance misuse and domestic abuse can fluctuate over time; professionals should challenge colleagues if new information is not sufficiently considered which may lead to a safeguarding risk; fathers or co-parents need to be an equal part of assessments, support and plans in order to ensure that the needs and risks to a child are known and met; professionals need to know when a formal pre-birth assessment needs to be undertaken, and provide challenge if this does not happen. Recommendations : N/A Keywords: infants; head injuries; injuries > Read the overview report

2023 – Barnsley – Child ‘T’

Death of a 9-week-old-boy in November 2018 from non-accidental injuries, including a very serious injury to his brain and fractured bones. Learning includes: there were no obvious issues that would have suggested to staff working with the family that Child 'T' was at risk of abuse or neglect; with the exception of a missed pre-birth visit by health visitors, agencies did accord with their own policies and procedures and managers within public health and the midwifery service are taking action to resolve the communication issue; there is evidence of good practice in the record keeping by both midwives and health visitors; and staff in both agencies kept comprehensive records that clearly evidenced assessments they completed and conversations they had with parents to discuss known risk factors to babies. Recommendations : makes no recommendations. Keywords : general practitioners, fractures, homicide, infant deaths, non-accidental head injuries, record keeping > Read the overview report

2023 - Berkshire West - David

Arrest of a 16-year-old boy arrested on suspicion of murder in November 2021. David was a looked after child who had been the victim of criminal exploitation. Learning includes: developing positive, strengths-based relationships with parents and carers supports safety planning; robust, child centred, and focused support plans must be in place for Special Guardians and these need to be regularly reviewed and adapted; children and young people at risk of criminal exploitation need consistent professional involvement and relationships; safeguarding agencies need to regularly review their approach to child criminal exploitation by listening to the experiences of young people and applying this learning to practice; contextual safeguarding meetings should have the same 'status' in safeguarding partnerships as child protection case conferences; practitioners need to develop their understanding of culturally sensitive practice and consider how a young person might experience oppression, discrimination, and risk. Recommendations include: test and evaluate the use of contextual safeguarding meetings; pilot a 'child safeguarding pathway' for exploited children and use the evidence to inform future practice; consider learning from other safeguarding partners and agencies who have developed effective contextual safeguarding practice, particularly implementing 'Signs of Safety' as a practice model; develop a safety planning toolkit which supports practitioners in their child criminal exploitation work; children's social care to test out having a single social work practitioner to support children experiencing exploitation; consider how to implement a trauma informed approach to practice, including how to support staff with vicarious and secondary trauma and develop arrangements for critical debriefing. Keywords : child criminal exploitation, contextual safeguarding, adolescent boys, foster care, special guardianship orders > Read the overview report

2023 - Birmingham - Adult A

Fatal stabbing of an adult in October 2020. A 14-year-old girl pleaded guilty to manslaughter on the grounds of diminished responsibility. Learning themes include: identifying, understanding, and responding to the needs of those at greatest risk from children exhibiting the most harmful behaviour; the effectiveness of systems to protect those most vulnerable, particularly within the context of intersectionality, structural racism, adultification and extra-familial harm; understanding family dynamics, needs and history in its broadest context is vital; the importance of recognising and understanding the impact of trauma and abuse on children and utilising a trauma-informed approach; the importance of the continuity of care, support and information exchange when a child moves area; recognising that children involved in offending behaviours are vulnerable too and resolving their unmet needs is critical to reducing the risk they present to others; the need of all agencies to constantly question and challenge themselves on how well they understand a family and how effectively they are working, both with the family, within their own agency and with each other; a child at risk of being permanently excluded should trigger a multi-agency safeguarding response; and housing authorities should consider risk and vulnerability when placing vulnerable individuals and families into accommodation. Recommends that: “Working Together to Safeguard Children, 2023” strengthens the importance of housing being involved routinely in multi-agency arrangements to safeguard children. Keywords : abusive children, child behaviour problems, child criminal exploitation, exclusion from school, homicide, youth justice > Read the overview report

2023 - Blackburn with Darwen - Child F

Death of a 16-year-old boy in December 2020 by three young people over a drug debt. All four young people had a history of involvement in either drug supply at street level and or involvement in anti-social behaviour and violence between young people. Learning includes: understanding safeguarding within adolescence as a developmental life stage; the importance of considering the dual identities of young people as victims and perpetrators of harm; practitioners needing to hold the concepts of the autonomy of the young person and their dependence in healthy tension; the role of poverty and inequality as a driver for harm and adversity; the importance of providing a personalised and tailored response; the role of adultification – seeing children as older and more responsible than they are chronologically or developmentally; whether the current legal and policy framework facilitates or inhibits effective responses to extra familial harm; the importance of a trauma informed approach to working with young people where practitioners look for what lies beneath a young person’s behaviour; the connection between young people’s trauma and unmet developmental needs; and viewing trauma through developmental and relational lens enables better sense making of young people’s worlds and the impact of their experiences. Recommendations include: commit to the implementation of the national exploitation principles when published; develop a range of early intervention services to support children and families at risk of or in the early stages of child criminal exploitation; ensure that practice always explores the strengths within the immediate and wider families of children at risk of or being criminally exploited; and recruit workers with the personal skills to undertake relational work with children and families and gives them the training to develop those skills further and time to develop relationships with children and families which do not preach or judge. Keywords : child criminal exploitation, drugs, exclusion from school, police, risk taking > Read the overview report

2023 – Bradford – Babies who sustained injuries

Three cases where babies sustained injuries believed to be non-accidental in 2022. Considers and compares the learning from previous reviews with the learning in respect of the 2022 babies, to enable reflection on the impact they have had on practice and safeguarding systems in the partnership, and where progress is still required. Learning themes include: impact of a parent’s own vulnerabilities, including their poor childhood experience of being parented and on-going mental health issues; domestic abuse and violent behaviour, both historic and on-going; thresholds for neglect, including consideration of accidental injuries as a sign of neglect and understanding of cumulative harm; consideration of the child’s lived experience; the need to engage with and consider the father of a child, or the partner of a mother who lives with, or spends a lot of time with the family (including same sex partners); the need for relationship-based practice, with children, with parents and the wider family and across agencies. Recommendations include: to ask the national Child Safeguarding Review Panel to request that the Department of Health provides clear clarification to GPs regarding how they can safely and legally record information on adult records when there has been domestic abuse; consider alternative models of professional challenge, for example Portsmouth Safeguarding Children Partnership’s model ‘Re-think’; help professionals to ensure that practice is both culturally and individual family sensitive and that safeguarding responses are consistent, including professionals working with families having a safe space to consider their own values and biases. Keywords : adverse childhood experiences, bruises, family violence, infants, parents with a mental health problem, unknown men > Read the overview report

2023 - Bradford – Child A

Death of a 7-year-old boy in the summer of 2020. Child A was struck by a car and killed at a time when there was no one at his home address caring for him. Also addresses the neglect of Child A and his two siblings by their mother. Learning themes include: identifying and assessing neglect; thresholds for intervention for child protection enquiries; impact of parental mental ill health on parenting capacity; barriers to hearing the children's voices; the inclusion of extended family assessments and interventions; use of formal routes by agencies to escalate concerns; issues arising from diversity and intersectionality and how these may have influenced service delivery; and impact of Covid-19 on service delivery. Recommendations include: update and re-launch the existing neglect strategy, associated tool kit, and training strategy; audit the effectiveness of the multi-agency response to neglect as part of the Quality Assurance Framework; review and relaunch the inter-agency escalation policy and provide clarity for practitioners on when to use it; ensure ongoing work from all agencies includes the child's voice and experience (including family relationships); oversee the development of a 'Think Family' joint protocol with the partnership's safeguarding adult's board; ensure that all partners train their practitioners to be confident dealing with families where domestic abuse is a factor, and that the training strategy includes the importance of professional curiosity about all relationships and exploring potential ongoing risks when parents separate; and provide a training programme for practitioners covering intersectionality for families who experience multiple oppressions. Keywords : child neglect, ethnicity, voice of the child, family violence, parents with a mental health problem, professional curiosity > Read the overview report

2023 – Bradford - Sara, Edvina and Danuka

Neglect of female siblings aged 11-months-old, 1-year-old and 6-years-old. A home visit found the two younger children living in significantly neglectful circumstances with unexplained injuries. The eldest child was not in the accommodation at the time and was found to be physically unharmed. Findings include: the importance of professionals working in a culturally competent way; the importance of robust consideration of the need for pre-birth assessments and pre-birth early help and support plans; the need for a proactive, holistic, and robust response to domestic abuse to increase safety for survivors and their children; the need for professional recognition and response to the early signs of neglect of young children by their caregivers; and an analysis of responses to referrals, completion of assessments, child in need processes and multi-agency working. Recommendations include: produce guidance on working in a culturally competent way, including information about the culturagram framework; the Child Safeguarding Practice Review Panel look into why neglect tools developed over the last ten years are not having an impact on practice; seek information from the Child Safeguarding Practice Review Panel on what work is underway to address the lack of guidance about the appropriate response to referrals and information from family, the public and anonymous sources; and seek clarity about when and in what circumstances child and family assessments are shared with agencies who will be supporting children subject to child in need plans. Keywords : child neglect, siblings, culture, poverty > Read the overview report

2023 – Bradford - The Siblings

Covers an 18-month period of a parent suffering complex and enduring mental health problems including intrusive thoughts about harming their own children. Learning themes include: mitigating the risks of harm to children where parents have mental health difficulties; the impact of the parent’s mental health difficulties on the children; ensuring that children with disabilities and differing communication styles are supported and heard; young carers and help-seeking behaviour; and stability in practical living arrangements and attachment relationships. Recommendations include: update the guidance ‘Children at Risk where a Parent has a Mental Health Problem: Inter Agency Safeguarding and Child Protection Procedure’ to include the needs of children specifically and what help and support they might need, including children with disabilities and the requirement for a young carers assessment and factors to consider; update practice expectations to take account of the needs for children with disabilities, making clear that children with disabilities will have many professionals and family members who are experts on a child’s preferred communication style; make clear the circumstances in which child and family assessments will be shared with agencies who will be supporting children who are subject to Child in Need plans; update the guidance regarding Child in Need meetings to consider timetabling requirements so that all those agencies working with a family can attend and make clear that the decision to end a Child in Need plan should not be made without a clear step-down process. Keywords : children as carers, children with learning disabilities, child safety, non-verbal communication, parents with a mental health problem, siblings > Read the overview report

2023 - Bromley - Patrick

Evaluates Patrick’s journey through the care and criminal justice systems between 2016 and 2022 (12-18-years-old). Patrick experienced 17 placements in two years, mental health problems and routinely went missing from home, care and education. His violent behaviour and criminal activity led to placements in secure settings. Learning themes include: preventing permanent school exclusions; adultification of children; understanding and applying ‘intersectionality’; mental health support for children in secure settings; ongoing support for children in semi-independent living; escalation about education; and the child’s voice being central to effective help and protection. Recommendations include: seek reassurance on the effectiveness of early help when children are at risk of exclusion from school, including intervention when there are adverse childhood experiences; develop policy, guidance and training on adultification and intersectionality; through ongoing engagement with children placed in secure settings, ensure their experiences of the placement are routinely established with concerns addressed; local children’s services and police to provide reassurance about the effectiveness of return home/return from missing interviews for children placed both in and outside of the borough; revisit recommendations from the ‘Leo’ case, ensuring the provision of support for young people displaying risk factors for violent offending; ensure children in secure settings and semi-independent living have access to a trusted adult; review the standards expected for personal education plans for children placed in secure settings; ensure CAMHS support is appropriately prioritised for children in care and/or secure settings; and develop means of direct engagement with children in secure settings to hear their voice. Keywords : exclusion from school, placement breakdown, secure accommodation, children with a mental health problem, voice of the child, adverse childhood experiences > Read the overview report

2023 – Cambridgeshire and Peterborough – M family

Disclosures of sexual and physical abuse by three children in M family against their mother’s partner on 23rd September 2020. The family moved to the local authority area on 1st October 2020. Learning themes include: information sharing protocols between local authorities; risk assessment including the risks that may be posed by male care givers/household members; children living in households where domestic abuse exists; lived experience of the child; victim support, including timely and appropriate support for children who have been victims of or are at risk of child sexual abuse; working with families unwilling to accept support; support for practitioners. Recommendations include: children’s social care services should ensure that when a child or family moves into the area, and a request is made for case responsibility to be taken on, a request is made for information outlining historical involvement with children’s social care, and the provision of this information is robustly challenged where appropriate; compile a template for use by practitioners within their assessments which prompts for the consideration of all family members and their roles within a unit and their relationships with one another; hold a facilitated workshop with frontline practitioners from police, health, children’s social care and education to enable the partnership to explore good practice and better understand the barriers to capturing and using the voice of the child; gain the feedback of frontline practitioners within their agencies regarding the possible barriers to working with families who refuse support or display a reluctance to engage with services. Keywords : abused children, child sexual abuse, family dynamics, family violence, information sharing, voice of the child > Read the overview report

2023 – Camden - Children G

Hospitalisation of an infant who required critical care in November 2022. A home visit was conducted as it was known the infant had siblings ranging between 2 and 13-years-old; the children were taken into care the following day. Learnings are embedded in the recommendations. Recommendations include: the need for time and space to be made for collective problem solving where there is uncertainty; multiagency communication to be strengthened with records confirming that all agencies are invited to meetings and there is a recorded discussion prior to closing S47 enquiries; reinforcement of the expectation that children are seen and spoken to alone within the S47; chronologies need to be seen as ‘live’ tools - referred to and reviewed prior to every decision making meeting; ensure a good quality, full and accessible history on each record and that this is shared with agency partners; in complex cases, particularly where there has been movement across local authority boundaries or information is fragmented it is proposed that a multiagency chronology is compiled; consideration of a CSCP multi-agency learning event to focus on how professionals work with parents who are resistant to intervention; strengthen the understanding/working relationships with NHS digital GP health providers and raise awareness of their role through the safeguarding partnerships; and multi-agency audit of all children known to CSSW/Early Help who EHE are to identify risk and share best practice to take place locally. Keywords : child neglect, transient families, voice of the child, home visiting, infants > Read the overview report

2023 - Cardiff and Vale - Toby

Fatal stabbing of a 17-year-old boy in August 2019. Four individuals were subsequently convicted of murder, and three individuals were found guilty of manslaughter. Prior to his death there had been numerous safeguarding concerns around Toby’s involvement in and continued risk of child criminal exploitation (CCE). Learning themes include: safeguarding during adolescence; information sharing and early intervention; reporting concerns, challenging decision making and escalating when required; young person’s disengagement from education, employment and training; and public protection notices submission and sharing. Recommendations include: develop training to include guidance on safeguarding concerns that arise during adolescence, and how a young person develops to understand risk and consequences; children’s services must consider the impact of exploitation on siblings as part of referral and assessment; review current support available for young people at risk of exploitation; education must always be part of safeguarding considerations, particularly where a young person is educated outside of mainstream school placements; all agencies must ensure appropriate follow up when they make a referral in relation to a young person at risk and consider appropriate professional challenge if they do not agree with the decision making; all agencies involved in meetings considering young people at risk of CCE must consider relevant historical information, mapping of associations and identified escalations in concerning behaviours held by their own agencies which must then be considered jointly by all involved agencies. Keywords : child criminal exploitation, child deaths, gangs, county lines, children missing education, drugs > Read the overview report

2023 – Central Bedfordshire – Baby Euan

Death of an 8-month-old boy in December 2021. Baby Euan had injuries that were believed to be non-accidental. Learning includes: a need for professionals to understand what the child’s daily life was like; working with families where their engagement is reluctant and sporadic; a need to share information in a timely and appropriate way; the need for more learning around themes of culture and ethnicity, including a focus on intersectional analysis into race, disability, and health conditions; and a need for front-line practitioners to be more alert to the signs and symptoms of controlling and coercive behaviours and be able to highlight possible triggers and subtle inferences and make appropriate referrals. Recommendations include: the partnership should seek assurance from all agencies that they always include the voice and lived experience of a child in their actions and assessments; seek assurance from partners to ensure that they are pursuing alternative ways of engaging families when there is resistance to bring a child to a health appointment; ensure that front-line staff can recognise the signs and symptoms of coercive and controlling behaviour as a form of domestic abuse; and ensure partners understand what the meaning of intersectionality is and that they are embedding this into their agencies procedures and actions of their frontline practitioners. Keywords : infant deaths, non-accidental head injuries, non-attendance, ethnicity, transient families, parent-professional relationships, health > Read the overview report

2023 - Central Bedfordshire - Daniel and Sophie

Death of an 8-month-old infant in June 2023 from suspected abuse and neglect by his mother. Services were previously involved with Daniel’s older sibling and the family moved three times within the review period. Learning themes include: the quality and effectiveness of risk assessment and safety planning; children in need of support, or at risk, transferring across organisational boundaries; and knowing and understanding the child’s day to day experiences. Recommendations include: update the local children’s services joint protocol on children subject to child protection plan moving between local authority boundaries to include children that are subject to child in need processes; provide guidance that sets minimum expectations about the quality of transfers; promote the use of ‘day in the life’ assessment tools to help practitioners gain a better understanding about a child’s lived experiences, and the quality of care they are receiving from parents/carers; remind practitioners about the importance of assessing a child’s age and stage of development to make an informed decision about whether a child for whom concerns have been raised, are spoken with to gain their views; and promote awareness of procedure and guidance in relation to prebirth planning and assessments. Keywords : infant deaths, child abuse, child neglect, parenting capacity, transient families, voice of the child > Read the overview report

2023 – Cheshire East – Child J

Death of a 26-day old boy in November 2021 as a result of unsafe, co-sleeping. At the time of his death, he was being cared for by his father in the home of his mother. Learning includes: a need for safe sleep guidance to be seen as the business of all professionals, to be covered as part of multi-agency planning, and for guidance and advice to be shared more widely than the mother; a need for pre-birth assessments to be completed in a timely way, clearly address risk factors and safety plan to mitigate risks; a need for multi-agency planning meetings to provide an opportunity for information sharing, development of safety plans and appropriate professional challenge as well as professional curiosity; a need for professionals to consider and engage fully with both parents to inform assessment and develop safety plans. Recommendations include: seek assurance that safer sleep messaging is embedded into multi-agency safeguarding practice; seek assurance that fathers are fully involved and engaged in assessment and planning processes; and seek assurance that there is a robust approach to Child in Need planning. Keywords : infant deaths, sleeping behaviour, professional curiosity, safety measures, fathers, family violence > Read the overview report

2023 – Cheshire East – Child K

A 17-year-old girl exposed to significant and serious harm between June 2021 and January 2022. Child K made several serious and life-threatening attempts to self-harm during this period and experienced multiple placement moves. Learning includes: multi–agency planning meetings should provide an opportunity for information sharing, development of safety plans, co-ordination of care planning and appropriate professional challenge; when children are the subject of numerous multi–agency planning meetings the most appropriate forum for this should be agreed; appropriate placement identification needs to be supported by a co-ordinated multi-agency approach and consideration of joint commissioning, particularly when children and young people have complex and multiple needs; and frontline workers who are working with children in the context of significant risk need working conditions and a culture that promotes well-being and creates a safe supportive environment. Recommendations include: when children are cared for and there are significant safeguarding risks, the frequency of care planning meetings should reflect the needs of the child and professionals should hold each other to account; collaborative working to ensure the child is at the centre of all decision making; agreement of the multi–agency safeguarding plan before hospital discharge following a serious incident; gateway meetings and the use of the risk stratification tool to support co-ordination of multi–agency plans for high-risk children to be safely supported in community settings; and the corporate parenting board addresses multi–agency approaches to joint commissioning arrangements for complex and vulnerable children where there are significant safeguarding concerns and how agencies work together to identify placements and manage risk. Keywords : children in care, placement breakdown, self harm, children at risk, interagency cooperation, child mental health > Read the overview report

2023 – Coventry - Anya

Discovery of a 2-year-old girl at home alone after her mother had died in the family home in March 2022. Learning themes include: inter-agency communication and information sharing; how risk was understood and how safety planning was achieved; and consideration of Anya’s daily life. Recommendations include: consider the implications of using the emotional harm category in child protection planning, as opposed to the neglect category; raise awareness of the importance of paying attention to the language used in safeguarding work; support multi-agency practitioners in understanding and recording a child’s lived world with particular reference to children living in households where there is domestic abuse and/or substance misuse; ensure that practitioners and managers are fully aware of private fostering regulations, the limitations of written agreements and the legal steps required to secure a child with connected carers where there are concerns about a child’s safety; contingency planning that includes legal action to safeguard a child should form a consistent part of the child protection plan; learning from this CSPR, about the need to promote an equal partnership of fathers and extended families in safeguarding children, should inform future service design; local domestic abuse services should demonstrate how the voice of the child, in cases of domestic abuse, is understood and reflected in service provision; and review how cultural competency is promoted as a practice model in relevant policies, training and supervision. Keywords : alcohol misuse, death, domestic abuse, ethnicity, mothers, neglected children > Read the overview report

2023 – Croydon - Chloe

Death of a 17-year-old girl, Chloe, by suicide when in a state of mental crisis. Learning includes: the need for resources to be available to support families in a child’s early years; language used by professionals to describe help seeking behaviour can infer judgement or nuanced negative undertones; the importance of family, friends and kinship for children who are looked after; the importance of a sense of self for children who are looked after. Recommendations include: consider how to build a child’s sense of identity using existing processes; assess progress made following the vulnerable adolescent thematic review, with a particular focus on how trauma-informed practices are being enacted in services provided, and are supporting the multi-agency workforce; guided by the national reviews, embed relevant learning in mental health and wellbeing services for survivors of CSA; ensure the therapeutic work a child needs is detailed in a child’s care plan; criminal compensation should be pursued for all children who have been the victim of sexual abuse; identify opportunities to provide support to carers in the local area and for this scaffold of care to be detailed in a child’s care plan; consider how to reduce false transition points within agencies (including the private and voluntary sector) to maximise opportunities for practitioners to build consistent relationships with children; promote the briefing by the NSPCC on findings from young people who complete suicide, in particular the advice that suicide threats should be routinely assessed for motivation and level of intent. Keywords : child deaths, child sexual abuse, child sexual exploitation, children in care, suicide, trauma > Read the overview report

2023 – Croydon - Thematic review: serious youth violence

Thematic review focussing on seven children/young people who were charged in association with the unlinked deaths of three children in 2021. Recognises that children or young people involved in serious youth violence often experience the dynamic interplay of being both a victim and a perpetrator. Learning considers: the children’s experiences of involvement with statutory services at an early age; domestic abuse; difficulties in parental/carer relationships; mental ill health; exclusion from education; offending behaviour; missing episodes; poverty; intersectionality; adultification; support provided to the children/young people and reasons why support ceased; the voice of the child, their daily life, and reasons why support may not have been accessed or effective; the experiences of the children’s families (including the families of the children who died); community support provision; and the experiences of front-line practitioners. Recommendations include: the partnership to actively seek evidence to demonstrate how the 10 key principles of K.I.D.S. V.O.I.C.E.S. (knowledge, identity, duplication, stick with it, voice, outcomes, innovate, community, education, spaces) are being applied across multi-agency services, schools, panels and strategy forums, and seek evidence of impact; the voices of children and young people, family members and the community should be actively sought to achieve co-production in the future design of services; and the partnership to highlight the national issues raised in this CSPR with relevant national bodies such as the Child Safeguarding Practice Review Panel. Keywords : voice of the child, violence, contextual safeguarding, child criminal exploitation, exclusion from school, interagency cooperation > Read the overview report

2023 - Derby and Derbyshire - MDS20 and PDS20

Serious neglect of two young people from two separate families. Learning themes include: disguised compliance and professional curiosity; escalating concerns at an earlier stage; the welfare of pupils who become long term absent from school; identifying potential neglect of young people and assessing the abilities of parents to respond appropriately; safeguarding pupils who are the subject of applications to be electively home educated; the voice of the child and action taken following repeated concerns from a parent followed by cancelled appointments; ensuring the safety of children whilst they are on CAMHS waiting lists; parental mental health and its impact on their ability to address the neglect of the young person. Recommendations include: all child protection training should remind practitioners that procedures and guidance apply to all children irrespective of age; include the risks related to prolonged periods in bed into existing child protection training; consider how practitioners/managers can be supported to reframe the concept of service users ‘failure to engage’ to that of how can practitioners work persistently and creatively to engage children and their carers; work with schools to identify training packages/requirements for attendance workers and seek to strengthen the arrangements for assessing the welfare of children not in school; ensure that all agencies understand the routes to an Early Help Assessment and that such assessments are completed where required; and ensure that all practitioners are familiar with, and use where appropriate, the Graded Care Profile along with other tools that can be used when undertaking assessments. Keywords : adolescent development, body weight, children missing education, child neglect, depression in childhood, maternal depression > Read the overview report

2023 - Dudley - Safeguarding children when there are adults in the family who pose a sexual risk

Three siblings potentially at risk from two known sex offenders in their family. Learning includes: professionals working with children should be aware of adults in a family who may pose a sexual risk; when assessing the ability of a parent to protect their children from a risky adult in the wider family, there needs to be an understanding of the relationship, contact and whether the adults, as well as the children, have been groomed; if there is no conviction for child sex abuse, there can still be a risk to children from an individual of concern; child protection procedures need to be used when information is shared that a person of concern is having contact with children; professionals need to be curious about a child’s behaviour and consider other indicators of sexual abuse even if they don’t disclose abuse. Recommendations include: seek assurance about the use of the complex and organised abuse procedures in cases where there is a risk of child sexual abuse in the wider family; ensure that the relevant professionals and carers of children are aware of the risk to children in care of technology being used to locate and contact them; request agencies consider how to improve professional awareness and practice in respect of how perpetrators may conceal their abuse, how a non-abusing parent/carer may be complicit or unaware of abuse and how to work with children when they do not disclose sexual abuse but are likely to have been exposed to it. Keywords : abuse allegations, child sexual abuse, grandparents, grooming, siblings, sex offenders > Read the overview report

2023 – East Sussex - Child V

Non-accidental bruising and fractures to a 7-month-old infant in August 2018 leading to the arrest of Child V’s parents. Child V’s parents were living in temporary accommodation and both experienced difficult childhoods with domestic abuse a feature. Learning themes include: the impact of living in temporary accommodation on the child; the impact of single-agency and multi-agency working; professional awareness of parental substance misuse; professional awareness of the legal processes concerning care proceedings; the role of GPs as part of the child protection planning process; recognising and understanding domestic abuse and the risks to small children; sympathy for parents leading to optimism; importance of full investigations of all injuries to infants; and workload pressures in the safeguarding system. Recommendations include: receive progress reports from agencies where there were single-agency limitations, specifically regarding workload pressures, invitations to child protection conferences, GP recording practices and children under one being examined; improve practice regarding GP input to conferences, housing involvement in child protection plans, and the use and recording of strategy discussions; re-launch the protocol regarding ‘Unexplained Injuries to Young Children’ focussing on the importance of strategy discussions and medicals; consider whether safeguarding procedures around domestic abuse include enough focus on the risks of physical harm to young children and infants and how emotional harm may manifest; consider whether services for perpetrators of domestic violence include provision for couples where there is evidence of mutual abuse; and review whether current escalation policy is sufficiently understood by managers across all agencies. Keywords : injuries, physical abuse, family violence, substance misuse, temporary accommodation, optimistic behaviour > Read the overview report

2023 - East Sussex - Family CC

Significant neglect of a large sibling group by their parents. Learning themes include: working with parents who are highly resistant/hostile to agency approaches or display disguised compliance; safeguarding children who are electively home educated in the context of neglectful parenting; relevance of neglect/abuse of animals when assessing risks to children; relevance of family history when screening for service delivery; and role of voluntary sector agencies in providing support to vulnerable families. Recommendations include: review processes for professionals working with resistant parents with sufficient focus on understanding the relevance of family history and the lived experience of the child; request that health agencies consider the issue of fabricated illness in this context and require health professionals to not rely solely on evidence reported by parents; adapt child social care audit processes so that any child protection plan that ends after three months is audited by a senior manager; develop the neglect policy and training for professionals to consider the needs of children who are electively home educated, with any concerns triggering an assessment of parenting skills; request all agencies review their recording systems to ensure that workers screening referrals or starting assessments can review the wider family history and any previous agency involvement; consider how to better involve voluntary sector agencies in the multi-agency safeguarding processes; and consider whether multi-agency safeguarding assessments have sufficient focus on fathers and other significant males. Keywords : neglected children, home education, neglecting parents, parental involvement, voluntary organisations, voice of the child > Read the overview report

2023 – Enfield – Andre

Fatal stabbing of an adolescent boy. At the time of his death, Andre was subject to a child protection plan and to a youth referral order with intensive supervision and surveillance. The incident took place in a park where Andre should not have been due to an exclusion requirement as part of this order. Learning includes: to work effectively to support a parent in becoming a consistent protective factor where a young person is facing risk in the community, practitioners must understand the history and trauma of the past and current vulnerabilities in the parent’s life which contributes to their style of parenting; relational practice with individual young people needs to sit within a strategic approach of developing community-based assets. Recommendations include: prioritise and focus on acknowledging and reflecting upon what good culturally competent and anti-discriminatory practice is and how to embed it in safeguarding practice; ensure that multi-agency assessments and planning of children include an assessment of parenting in that goes beyond the practical capacity to provide care and explores the parent-child relationship in the light of the family’s history of vulnerability and risk; ensure strategic oversight of the operational multi-agency arrangements for responding to young people who experience significant adversity and risk in different contexts; ensure that the nature of engagement with families is reflected upon, and that effective engagement is evidenced in changes made in the family. Keywords : child deaths, contextual safeguarding, gangs, home environment, murder, weapons > Read the overview report

2023 - Enfield - Nadja

Forced marriage of a 14-year-old girl in 2020 by her parents to a man aged 27-years-old, who on the same day as that ceremony went on to rape and physically abuse her. Learning is embedded in the recommendations. Recommendations include: when there is the need to seek expert advice to support the work with children and families, the need to engage with an expert should be taken into account when setting the timescale for assessment in order to ensure that sufficient time is given to support this work; children should not be seen at home or in the presence of family members when making enquiries into forced marriage or parents contacted and alerted in advance of initial assessments, this puts the child(ren) at greater risk, as per the ‘Home Office Practice Guidelines for Forced Marriage’; a professional interpreter should always be used to support the work with children and young people; review the arrangements for monitoring attendance and escalating concerns for children who are missing education, and test these against the possibility of some future event resulting in the closure of school buildings and lessons moving online; where there is an allegation of rape of a child, the forensic examination of smart devices should be a priority action; when a Forced Marriage Protection Order is made, consideration should be given to taking fingerprints, DNA sample and photograph and whether the order can be beyond the child’s 18th birthday; and explore how cultural competence and professional curiosity can be promoted through easy timely access to relevant advice. Keywords : adolescent girls, disclosure, forced marriage, interpreters, professional curiosity > Read the overview report

2023 – Essex – Child C

Death of a 17-year-old girl in October 2020 by suicide. Learning includes: the importance of understanding the interplay between physical and mental health needs and neurodiversity; the importance of agencies taking a whole family approach; autism diagnosis in adolescence can result in social, emotional and cognitive needs in childhood not being addressed in agency responses. Recommendations include: child and family assessment and child in need plan should be the recognised and expected mechanism for coordinating a whole person approach where a child/young person has complex needs; disabled children should be recognised as children in need in their own right when living in a family environment where there are multiple stressors affecting their siblings; consideration should be given to how to achieve an environment which supports critical reflection and challenge in multi-agency work with complex families; social care practitioners should be aware of the protocol supporting implementation of s117 Mental Health Act 1883, this should be updated in relation to young people, including the mechanism for accessing necessary funding; parental responsibility and next of kin should be clearly recorded and guidance provided as to how this should inform decision making; all agencies should increase awareness of neurodiversity including recognising signs, indicators and impact on the young person, promoting positive self-identity, identifying when a formal assessment may be offered; guidance on the use of virtual meetings should ensure that the circumstances of each child and young person are assessed, to mitigate any risks associated with using this approach. Keywords : autism, suicide, child mental health, family dynamics, mental health services, siblings > Read the overview report

2023 – Essex – Child I

Death of a 15-month-old child who was found by father caught in a high chair, became asphyxiated and subsequently died. Learning: is embedded in the recommendations. Recommendations include: consider developing criteria for professionals meetings to be formally integrated into local child protection procedures to provide a multi-agency reflective space to consider risk and support for families; develop a multi-agency substance misuse strategy to provide clarity on the impact of different substance misuse, particularly cannabis on parenting capacity and guidance for practitioners in relation to escalation and effective interventions; consider how to support practitioners to manage the interface with one plan arrangements for children with special/additional needs within early help arrangements; consider the learning and undertake a multiagency self-assessment and any resulting actions from the national panel's thematic review ‘The myth of invisible men’ (2021) to support practitioners in improving the engagement, involvement and assessment of male carers; and consider the learning from this review and the national panel's review ‘Child protection in England’ (2022) to ensure that the views of family members are always considered in assessments of risk. Keywords : home environment, parenting capacity, risk assessment, accidents, substance misuse > Read the overview report

2023 – Gloucestershire - Child C

Child sexual abuse of a 16-year-old adolescent by their male foster carer. Between 2016-2020 Child C made several disclosures concerning an older child in their foster family, the female foster carer, and the male foster carer. Child C had experienced early trauma through neglect and abuse by their birth family. Learning considers: listening to the child, hearing their voice and seeing their true experience; not placing judgments on the accuracy of child allegations; enabling early disclosure of concerns by children; explaining to children what is appropriate treatment in the foster placement and how to raise concerns confidentially; acknowledging that ‘terrible things can happen’ to children in care; and providing a consistent trusted professional for children in care, aside from those who have caring responsibilities. Recommendations include: the local authority to lead on talking to children about healthy relationships so children in care understand appropriate treatment in their foster placement; professionals to ensure the role of the trusted professional or adult is explicit within the children in care planning process and never seen as being undertaken solely by a foster carer; to review all single agency training so the voice of the child is present and for agencies to provide evidence of impact on practice; practitioners to be confident in always being alert to the potential for, identifying and responding to signs of child sexual abuse; and the local authority to undertake a review of its allegations management processes to address concerns relating to an adult focus within statutory functions. Keywords : child sexual abuse, children in care, foster parents, voice of the child, child abuse identification, disclosure > Read the overview report

2023 – Greenwich – Child C and D

Death of two children as a result of a house fire, believed to have been started by their mother, in March 2021. Learning includes: practitioners should think more holistically about families and consider all the presenting needs; recognition of practitioners’ role and responsibilities for parents caring for children with disabilities and how legislation and guidance can support their work; assessment of the impact of domestic abuse and its emotional effects on family members; practitioners to be cognisant of the impact of intrusive thoughts and for those to be risk assessed at an early stage; understanding children’s day-to-day lived experiences; and the support that families receive from their faith and from their church should be assessed as a vital part of their support network. Recommendations include: ensure awareness of revisions to existing protocol with front-line practitioner events and audits of practice; ensure that carer's needs are sufficiently considered and assessed in line with the expectations of parent carer assessments; review training strategy to ensure that all partners equip their practitioners to be confident when dealing with families where domestic abuse is (or has been) a factor; ensure assessments and ongoing work includes the child's experience and emotional impact of these experiences as well as the child's voice; and professionals should be equipped with cultural competency together with an understanding of intersectionality to properly identify and consider these factors when assessing and managing the risk to children. Keywords: family violence, filicide, fire, mental health services, parenting capacity > Read the overview report

2023– Guernsey and Alderney – John

Examines the involvement of agencies and services with a young adult. There were concerns around John exhibiting harmful sexual behaviours, which reached a criminal threshold. Learning includes: early identification, plus early and targeted intervention are important in helping children through childhood, transition positively into adolescence and onto adulthood; assessment of risk and safety planning, in cases of potential harmful sexual behaviours (HSB), needs to be viewed as a multi-agency activity but with a clear lead role coordinating the combined efforts of all professionals involved; supporting young people that have experienced adversity in their lives, and who go on to follow negative pathways through adolescence, is achievable by developing meaningful and trusting professional relationships. Recommendations include: information sharing guidance for practitioners providing services to children, young people, parents and carers should be reviewed by explicitly naming all the signatories of the guidance so that it carries greater authority and weight, it should also be strengthened with practice examples to aid professional understanding about when information can legitimately be shared; online procedures should be reviewed and, where necessary, strengthened to reflect practice relating to HSB and specifically the practice challenges for professionals when responding to those children & young people who are victims of abuse but also pose a risk to others; use of professional challenge and escalation guidance should be further promoted to all professionals; and oversee the implementation of the action plan arising from the NSPCC audit, and should work together to identify, and where possible remove, any barriers to implementation. Keywords : adverse childhood experiences, harmful sexual behaviour, information sharing, victims, interagency cooperation > Read the overview report

2023 - Hartlepool and Stockton-on-Tees - Child Joe

Considers the multi-agency safeguarding responses in relation to child criminal exploitation (CCE) in respect of a young person who was involved in a serious and violent incident where he severely harmed a male as part of a robbery. Learning includes: recognising and understanding CCE; strengthening knowledge, skills, and confidence in working with children and the family network affected by extra-familial harm and criminal exploitation; appreciating the significance of predisposing vulnerabilities, adversity, and developmental issues such as cognitive ability; robust advocacy for children cared for by the local authority missing from education and in need of additional support for their learning needs; recognition and challenge of victim-blaming language as a barrier to protecting children; and appreciating and responding to ‘reachable moments’ to engage with children where they may be more receptive to engagement and change. Recommendations include: the statutory partners to provide clear leadership and challenge about victim blaming culture and response when working with children involved with CCE; the statutory partnership to consider the long-term impact on the mental health of children involved in CCE; the safeguarding partnership to consider the development of multi-agency reflective practice forums facilitated by subject experts/operational leads for exploitation; and the safeguarding partnership to seek assurance from the police that there is a clear and unified risk management framework that is arranged around the child, built on evidence-based practice. Keywords : child criminal exploitation, grooming, professional attitudes, secure accommodation, crime, child behaviour > Read the overview report

2023 – Islands - John

John was a young adult, whose issues relating to his childhood and adolescence indicated opportunities had been missed to provide support and protection. Learning includes: early identification, plus early and targeted intervention are important in helping children through childhood, transition positively into adolescence and onto adulthood; balancing the needs of children who are at risk alongside managing them when they pose a risk to others and not unnecessarily criminalising them, is a perennial practice dilemma; assessment of risk and safety planning, in cases of potential harmful sexual behaviours, needs to be viewed as a multi-agency activity but with a clear lead role coordinating the combined efforts; and supporting young people that have experienced adversity in their lives is achievable by developing meaningful and trusting professional relationships. Recommendations include: the partnership’s 2019 Information Sharing Guidance for practitioners should be reviewed by explicitly naming all the signatories of the guidance so that it carries greater authority; it should also be strengthened with practice examples to aid professional understanding about when information can legitimately be shared and disseminated to all relevant agencies and briefing sessions provided to frontline practitioners and managers; procedures should be reviewed and, where necessary, strengthened to reflect practice relating to harmful sexual behaviours and specifically the practice challenges for professionals when responding to those who are victims of abuse but also pose a risk to others; the use of professional challenge and escalation guidance should be further promoted to all professionals; and the partnership should continue to oversee the implementation of the action plan arising from the NSPCC audit, and should work together to identify, and remove any barriers to implementation. Keywords : provision of services, mental health, risk taking, harmful sexual behaviour, professional curiosity > Read the executive summary

2023 – Kent – Baby T

Death of a 7-week-old boy in December 2020 while co-sleeping with his mother. Learning includes: N/A Recommendations include: propose a practice model recognising a continuum of risk of sudden unexpected death in infancy (SUDI), with support reflecting the differing needs of all families, including those with identified, additional vulnerabilities; promote safer sleeping within a local strategy for improving child health outcomes; multi-agency action to address pre-disposing risks of SUDI for all families, and with targeted support for families with identified additional risks; review existing 'reducing the risks to babies' NICE guidance with a view to developing a local policy; produce a briefing paper for multi-agency circulation that highlights the predisposing and situational risks of SUDI and appropriate guidance and referral pathways; audit current understanding and use of motivational interviewing across partner agencies and explore what training is already being offered; and incorporate safer sleep arrangements into threshold guidance. Keywords: sleeping behaviour, sudden infant death, postnatal depression, substance misuse, interagency cooperation > Read the overview report

2023 – Kingston Richmond – Child V

Death of a young boy in the summer of 2021, thought to be due to a chronic health condition. At the time of Child V’s death there was also evidence of malnutrition. Learning themes include: awareness and management of Child V’s health condition; response to medical neglect including not being brought to medical appointments/accessing support offered; and response to domestic abuse. Recommendations include: ensure all practitioners working with children with health conditions have a good understanding of how it affects the health and development of the child, and any risks of mismanagement; adapt safeguarding processes and procedures to support practitioners to request information about the needs of children with medical conditions through each stage of safeguarding activity; support practitioners to have the skills to confidently explore how the cultural background, attitudes and beliefs of any carer affects care of the child, including each parent’s attitude to health conditions and treatment; ensure there are clear arrangements to ensure the co-ordination of healthcare for those children with complex health conditions who are particularly vulnerable or where there are emerging concerns about medical neglect; consider best practice in parental education about health problems and how to recognise and respond when parents are struggling to meet a child’s health care needs, including exploring the reasons for missed appointments; make representations to NHS digital about the benefits of adding a Was Not Brought (WNB) code to all NHS recording systems to help identify those children who may be vulnerable to medical neglect. Keywords : Asian people, child deaths, children with a chronic illness, malnutrition, medical care neglect, non-attendance > Read the overview report

2023 – Kirklees – Paul – Child Q

Death of a 15-year-old-boy in August 2021 from complications due to multiple, non-accidental rib fractures. Learning includes: the need for all professionals to understand the challenges of being a new arrival to the UK; the importance of understanding relationships in families and a full background history where new arrivals are concerned; the need for professional curiosity and allowing practitioners the freedom and space to exercise it; concerns around domestic abuse in families over lockdown during the coronavirus pandemic, and whether they may be under pressure not to report. Recommendations include: ensure that practitioners have the training to be able to understand the challenges for a new arrival into the UK, including how to access health, education, and support services; ensure that practitioners can access information from originating countries to assist in the care of children arriving in the UK; ensure that support is being provided to practitioners to provide resilience within the workforce; ensure the workforce have been given the tools and training to support children and young people coming out of the pandemic to aid their recovery; ensure that where professionals have identified risks within families that the risk is thoroughly assessed and recorded; ensure multi-agency assessments of risk are taking place on which plans of action are based; the National Panel are to engage with the border force to explore the processes in place when a child or young person enters the UK and gain clarity on how safeguarding concerns are identified and communicated to the relevant local authority. Keywords : abused boys, child deaths, fractures, physical abuse, provision of services, voice of the child > Read the overview report

2023 – Leeds - Ruby

Long term sexual abuse of female child by her legal guardian. The abuse was only detected after the female disclosed that she was pregnant and requested a termination, where genetic testing established that her legal guardian was the father. Learnings includes: education establishments to review and scrutinise a child’s casefile when the child has transferred in from another school and has had children’s social work services involvement, been subject to a child protection plan and/or has been or is still subject to court proceedings; seeking to raise awareness of the concerns resolution process across a wider range of police departments to ensure that colleagues understand how to access guidance on how to pursue resolutions when one agency perceives risk to be higher than another; review how information is shared between children’s social work services, police safeguarding teams, and a public protection officer; and reinforce the importance of professional curiosity when working with children and families. Thematic analysis includes: professional curiosity/disguised compliance; management of complex cases; trauma-informed practice; the voice of the child and her lived experience; understanding barriers to disclosure; and the effects of the Covid pandemic on the support offered. Keywords : child sexual abuse, sex offenders, disguised compliance, guardianship, professional curiosity > Read the overview report

2023 – Lewisham - Lilo

Fatal stabbing of a 17-year-old in 2021. At the time of his death, Lilo was a Child in Need who had a diagnosis of autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), as well as limited mobility because of a moped accident. Learning themes include: access to education and delays in assessments for Education Health and Care Plans (EHCPs) and the experiences of neurodiverse Black boys in education; recognising and responding to risk in the context of extra-familial harm; understanding the impact of trauma in the context of extra-familial harm and wider trauma; and understanding the impact of trauma on the workforce. Recommendations include: education must undertake a review of the EHCP process; the local safeguarding children’s partnership should commission further learning to improve professional understanding across all agencies to ensure a better understanding of trauma, intersectionality, adultification bias and neurodiverse children in the context of extra-familial harm, always considering language and framing of children; ensure that the voice of the child is heard and integrated into planning; ensure that all social workers and managers can recognise and respond to extrafamilial harm, especially for children with additional needs; improve the quality of support and child protection responses, with increased understanding of the role of a statutory safeguarding partner; improve the quality of record keeping and assessments; child and adolescent mental health services should introduce multi-disciplinary review meetings when a child is referred more than three times and does not meet threshold for intervention as well as monitor and improve access and support for Black and ethnic minoritised children. Keywords : adolescent boys, autism, Black children, child deaths, child mental health services, contextual safeguarding > Read the overview report

2023 - Luton - Thematic review

Fatal stabbing of a 16-year-old boy in June 2021. In the preceding months there were other assaults and multiple exclusions from school; gang associations and conflicts were also known about. Learning includes: multi-agency response to risk, including sensitivity when working in a diverse population and understanding subtleties associated with gang networks; the background and profile of the young people, including effective early intervention, recognising that complex cultural and relational dynamics require insight from those with lived experience, the importance of early identification of additional educational need and/or learning disability, and balancing the use of exclusions from school; and frameworks for assessing risk, threshold decisions and interventions, including acknowledging the cultural role of extended family and providing support for young people when taking a case to prosecution. Recommendations include: to map and evaluate arrangements for identifying and responding to contextual safeguarding and safeguarding children at risk of violence and criminal exploitation, and examine whether there are differences in how some children might receive a ‘safeguarding’ response versus those that may receive a ‘criminal justice’ response; to understand whether there are other young people with unassessed or undiagnosed learning difficulties who are not having their needs met; to ensure that all key agencies are fully informed about core child protection processes; to refer children to the MASH who are on the cusp of being permanently excluded from education and where there are contextual safeguarding concerns; to improve the offer of mediation with young people and their families that are at high risk of harm through culturally competent service providers; and to ensure that processes are followed within educational settings where there are known risks to pupils from gang associations. Keywords : gangs, criminal exploitation, contextual safeguarding, children with learning difficulties, exclusion from school, diversity > Read the overview report

2023 - Manchester with Trafford - Child N, B, YK

This review considers three young people, two of whom were fatally injured with the third suffering serious injuries, following two separate knife crime incidents. The incidents took place in July 2020 and November 2020. Learning includes: the importance of earlier multi-agency intervention; the importance of understanding the impact of earlier life experiences, trauma and loss; the importance of sharing accurate information and ensuring prompt multi-agency responses, utilising critical moments more effectively and completing assessments and convening planning meetings in a more timely fashion; accurate and timely information sharing within and between schools; and holistic and creative planning to ensure that young people remain in education. Recommendations include: promote the use of the National Referral Mechanism and review its effectiveness for vulnerable children in relation to safeguarding from criminal exploitation; the partnership should be assured by school leaders that arrangements regarding fixed term and permanent exclusions consider issues of vulnerability or risk of harm; and be assured that effective quality assurance systems are in place which ensure that records accurately reflect the correct spellings of names, dates of birth, addresses and family details. Keywords : early intervention, ethnicity, child criminal exploitation, children missing education, weapons, exclusion from school > Read the overview report

2023 – Medway - Isabel

Death of a 3-month-old infant in March 2022. It is thought Isabel’s death was an accident linked to an unplanned sleeping environment where drugs and alcohol were present. The mother’s extended family were known to services regarding domestic abuse. Learning themes include: responding to the needs of the child, including the unborn child; safeguarding procedures around co-sleeping; consideration of the pre-birth assessment pathway; male figures in the family and father’s engagement with antenatal and post-natal services; recognition of potential indicators of abuse; issues arising from moving to different local authorities; parents’ previous involvement with adult or children’s services; disguised compliance; response to lack of engagement and Did Not Attends (DNA); interaction of services during the antenatal and perinatal period; and assessment of parental needs including domestic abuse, mental health issues, substance misuse and difficulties with housing. Recommendations include: review the antenatal pathway to ensure the referral system identifies concerning families of unborn babies; oversee a review of the local maternity safeguarding hub; ensure all partner agencies have systems to actively consider fathers and other significant males in assessments; review practices about how safe sleeping messages are delivered; oversee an audit of multi-agency practice in relation to domestic abuse at the front door; oversee partner agencies’ reviews of their supervision practices and ensure managerial oversight of decisions in relation to children and unborn babies where there are safeguarding concerns; and ensure robust liaison between Midwifery services and GPs for pregnant women, including exchanging information about both parents (and partners) during pregnancy. Keywords : sudden infant death, sleeping behaviour, substance abuse, disguised compliance, family violence, antenatal care > Read the overview report

2023 – Merton – Franklyn

Death of a 4-month-old boy in 2022 from an out of hospital cardiac arrest. Franklyn was born with a life-limiting disability and complex health needs. Learning includes: the importance of a holistic trauma-informed practice model as a planned action by the network of professionals; a need to continually build strong relationships with families, adopting a family-focused, compassionate approach which accords parents respect and recognition; and an intersectional approach is needed to understand the unique challenges faced by families. Recommendations include: the adoption of a trauma-informed model of support; gather and analyse feedback from those with lived experience in the ongoing development of bereavement and loss services; family focused communication in assessment practice; and the partnership to take note of issues of bias and how they play out in safeguarding around children with complex needs. Keywords : children with disabilities, Black people, trauma-informed practice, health, infant deaths, communication > Read the overview report

2023 – Mid and West Wales - CYSUR2/2020

Sudden unexplained death of a 12-week-old infant in spring 2019. Learning themes include: the cumulative risk factors of domestic violence, substance misuse and mental health; assessment and support of children of looked after children and care leavers; co-sleeping; and housing. Recommendations include: develop further policy and practice guidance in respect of the professional responsibilities for referral, assessment and support provided to young parents in and leaving care; all areas who support statutory childcare teams (including support to parents) should ensure that an understanding of safeguarding responsibilities and the statutory duty to report concerns for children or adults at risk is embedded in day to day practice, including domestic abuse incidents and referrals for unborn children; children’s services should review the process of recording and responding to multi-agency referral forms (MARFs) on open cases to ensure they are formally recorded on the child’s record; the safeguarding board should ensure that all agencies’ internal information sharing policies and practice guides are up to date in line with current legislation, policy and procedures, and all staff are able to access ongoing training in the context of safeguarding; there should be a housing strategy for care leavers that ensures a holistic response and robust multi agency partnerships to meet the support needs for individuals and families; the Teaching Health Board should provide clear, service specific guidance for practitioners to follow in response to domestic incident notifications; ensure that there is an effective local response to reduce the risk of SUDI to support local/regional multi agency learning and development in this area of work. Keywords: adolescent fathers, adolescent mothers, housing, sleeping behaviour, sudden infant death, termination of care > Read the overview report

2023 – Milton Keynes – Children N and O

Fatal stabbing of a 16-year-old-boy by a 17-year-old boy in November 2020. Child N and Child O knew each other through peers but had no contact until a few days before the murder. Learning themes include: agency responses to both boys criminal activity; the complexity of working with vulnerable children with links to gangs, who have police, social work and youth offending service (YOS) involvement, especially when a child is in care and moves placements between local authorities; the importance of education as a protective factor for children; and the importance of practitioners having strong relationships with young people as a significant factor in reducing offending behaviour and improving outcomes in general. Recommendations include: supporting the development of arrangements which will result in detailed operational multi-agency, multi-disciplinary risk management pathways for individual children most vulnerable to being involved in violent incidents due to their involvement in gangs, including children moving areas for their own protection; supporting the development of more alternative educational and training options for children who have disengaged or been excluded from school; reinforce with practitioners the importance of young people having strong and enduring relationships and recognising the impact on young people when practitioners change; ensure risk assessment checks are completed for every potential change of address prior to accommodation being confirmed; improve information sharing arrangements between the Criminal Justice Liaison and Diversion (CJLD) service and the YOS; and improve the availability of placements for children at risk in the community. Keywords : child criminal exploitation, children missing education, exclusion from school, family violence, gangs, murder > Read the overview report

2023 – Norfolk – Child AK

Death of a 4-week-old girl while co-sleeping with her mother. The services provided to Child AK’s siblings are included in the scope. Learning includes: the risks posed by neglect; the impact of neglect on the children’s lived experience; family dynamics and the role of the fathers in the lives of children; the impact of domestic abuse on children; understanding the risk of physical harm within a family, especially with regards to ‘physical chastisement’; the risks of substance misuse within the family; the impact of Covid-19 restrictions; use of language by services, practitioners and managers. Recommendations include: the revised Norfolk graded care profile (GCP) must be used when there are concerns about child neglect and an audit of neglect cases from across the child’s journey used to assess how it impacts on planning and interventions within 12 months; babies born into large sibling groups receiving interventions should be recognised as increasingly at risk; to produce and promote sector specific good practice guides on working with fathers and father figures; to write a position statement about ‘physical chastisement’ and substance misuse and be clear about how to promote and endorse these; professionals should be mindful of the extent of current and historic substance misuse and the impact on the unborn child as well as any existing sibling groups, including financial impact, parental ability to regulate mood and neglectful and/or emotionally abusive parenting. Keywords : child neglect, infant deaths, parenting capacity, sleeping behaviour, threshold criteria, voice of the child > Read the overview report

2023 – Northamptonshire – Child Ba

Death of a 3-week-old baby in June 2020. At the time of their death Child Ba was co-sleeping with their mother who was intoxicated through alcohol and had taken cocaine. Learning themes include: the child’s voice and lived experience; alcohol use and misuse; unsafe sleeping arrangements; the step down process and basis for decisions; the impact of over optimism by professionals; safeguarding within East Midlands Ambulance Service (EMAS); and the impact of Covid-19 restrictions. Recommendations include: ensure that all professionals have a better understanding of the implications and risks associated with parental alcohol misuse including historical alcohol misuse and how this is harmful to children; ensure parents and carers are aware of safe sleeping advice through the ‘Every sleep a safe sleep’ campaign; consider implementation of the National Panel’s suggested ‘prevent and protect’ practice model for reducing the risk of SUDI; seek assurance that step down procedures are operating effectively and rigorously; consider what needs to be put in place to support grandparents, and other family members, who are acting as a protective factor to parental risks to safeguarding children; and training partners in the ‘Signs of Safety’ model of practice which includes all family members that are to be regarded as a protective factor. Keywords : alcohol misuse, child neglect, family violence, prison and prisoners, sleeping behaviour, sudden infant death > Read the overview report 

2023 – Northamptonshire – Child Bi

Death of a 6-week-old infant. It is believed that ChiId Bi was overlaid by an adult sharing the same bed. Learning themes include: response to concealed pregnancy; safe sleeping; working together to safeguard children and decision making about level of intervention, including child protection or child in need plans; managing parental non-engagement and hostility; and children's voice and lived experience. Recommendations include: the partnership reviews their guidance and procedures on concealed pregnancies, with more focus on why the parent might have concealed the pregnancy, and how to ensure hypotheses are shared and recorded even if parents deny the pregnancy was concealed; multi-agency audits on: public protection notices, the timeliness of strategy meetings after referrals on open cases have raised safeguarding concerns, and children not made subject to child protection plans at initial child protection conferences; a multi-agency task group to consider how detailed descriptive language is used when sharing information about a child's voice and lived experience, especially at child protection conferences, and considering how to convey relevant content from police body worn cameras; the police force review the timeframe, nature and level of detail shared with social workers and at child protection conferences about incidents of domestic abuse with previous partners, to ensure that effective decisions about risks to the children of new partners can be made; and partner agencies review the guidance on recording and reporting threatening or abusive behaviour to include sharing details about incidents with statutory partners and education agencies. Keywords : infant deaths, sleeping behaviour, pregnancy > Read the overview report

2023 – Northamptonshire – Child Bj

Suicide of 13-year-old male in March 2022. He had for several years displayed physical and verbal aggression to himself and others, self-harm and suicidal ideation. A number of agencies had various involvements with him. Learnings is embedded in the recommendations. Recommendations include: ensure that agencies and professionals know and understand how they can utilise the Early Help Framework and how they are expected to contribute to individual cases; the need for individuals and agencies to ensure that they work collaboratively and make best use of available resources to be able to effectively engage with Early Help assessments; seek assurance from partners that the pathway for service provision to children that self-harm and have suicide ideation is updated and wider than just those children that attend hospital settings, to include, if possible, those children suffering from acute emotional distress, including those children suffering from chronic school phobia; ensure that all frontline staff working with children and young people who are 10-years-old and over are supported to access learning related to suicide prevention and ensure they are aware of the findings from the National Child Mortality Database study into child suicide; ensure that frontline staff who are affected by the suicide of a child that they are/were working with, are suitably signposted for support for themselves; and ensuring that the child's voice is captured in cases of acute emotional distress, including those self-harming and expressing suicide ideation, and the child is at the centre of all planning. Keywords : suicide, voice of the child, self esteem, aggressive behaviour, anxiety, bullying > Read the overview report

2023 – Northamptonshire – Children N and O

Death of 16-year-old boy who was stabbed in the street and fatally injured by a 17-year-old boy in November 2020. Learning includes: young people who have disengaged from education can be motivated to obtain employment; referral orders can be effective in supporting young people and reducing their offending behaviour; prompt and effective liaison between police youth offending service (YOS) and children’s social care in both local authorities when a child involved with gangs moves to live in another area; usefulness of better arrangements for criminal justice liaison and diversion (CJLD) to have timely access to background information about the children they see in custody; usefulness of CJLD staff sharing information with YOS about the children they see in custody as standard practice; awareness of the employer’s responsibility to do a risk assessment for any employee working in construction who is under 18; when children subject to a care order are placed with parents at short notice a statutory review should be held to discuss this and ensure the meeting and care plan includes attendance or a contribution from all practitioners working with the child and parents; deterioration in behaviour and increase in risk can be very swift if young people involved with gangs in one area connect with gangs in a new area; children vulnerable to being involved in violent incidents due to their involvement in gangs need to be supported by detailed operational multi-agency; the importance of practitioner and agency records being clear; and where children have moved areas to keep them safe from gangs the importance of reciprocal information sharing between police forces if they are different in the host and home authorities. Recommendations include: embedded in the learning. Keywords: child deaths, aggressive behaviour, exclusion from school, gangs, risk management > Read the overview report

2023 – North East Lincolnshire – W Siblings

Neglect and abuse over several years of seven siblings aged between 16-years-old and 1-year-old. The siblings’ circumstances were discussed at a rapid review meeting in early September 2021 after suspected sunburn injuries which were the subject of a police criminal investigation. Learning includes: importance and workload implications of focussing on individual children within larger sibling groups; behavioural and emotional symptoms of persistent neglect and how they are reflected in risk statements such as the signs of safety scaling; the importance of considering children’s lived experiences when the cumulative effect of neglect and the impact on children’s development and well-being is a factor; the importance of chronology and holistic assessments; need for GP practices to be involved in enquiries and assessments; procedures for escalating concerns about children through internal systems and how they can be linked with local partnership escalation pathways; importance of a clear strategy for responding to neglect that is owned by all respective organisations; the importance of providing trauma-informed early intensive help for parents who have experienced trauma in their own childhood; and aligning legal and child-based risk discussions. Recommendations include: the Director of Children’s Services (DCS) should satisfy themselves with the effectiveness of signs of safety in supporting effective assessment and management of risk for children; DCS should ensure that advocates for children can be appointed and are routinely considered in complex and/or longstanding cases involving neglect; DCS and Director of Legal Services should ensure appropriate arrangements are in place for social workers to seek emergency protection for children when necessary. Keywords : child neglect, neglect identification, parenting capacity, physical abuse, siblings, voice of the child > Read the overview report

2023 – North Wales - Wrexham 2020/1

The child was found unresponsive at the family home, a subsequent coroners inquiry recorded a verdict of death by misadventure. Learning includes: the need to promote a multi-agency response to bullying, in relation to specific incidents and in relation to the development and implementation of school and local authority action plans following the school health research network; and the National Guidance does suggest that the decision to exclude should include consideration of whether the incident may have been provoked, e.g., by bullying or by racial or sexual harassment, all incidents should consider if they are out of character for the child and those involved. Recommendations include: awareness sessions to promote regional understanding of adoption support framework and good practice guidance; develop guidance regarding approaching adopters when siblings require placing; secondary schools to provide evidence to the chief education officer regarding the dissemination and implementation of the child and adolescent mental health services (CAMHS) self-harm pathway; review documentation and referral process from the school to the school nurse; raise awareness of who can refer to CAMHS and the preferred route for receipt and recognition of referrals; promote a multiagency understanding and escalation of the school health research network data; develop multiagency guidance response to supporting the emotional health and wellbeing of children who experience bullying; and review the process of information sharing between the school nurse and any special health file. Keywords : adverse childhood experiences, voice of the child, bullying, self harm, risk assessment > Read the overview report

2023 – Nottinghamshire - David and Daniel

Harmful sexual behaviour between 11-year-old and 14-year-old male siblings who were in a long-term foster care placement. Learning includes: professionals in looked-after and fostering teams need to feel confident about how to respond to child sexual behaviour; relevant professionals need to be aware of and confident to use recommended professional frameworks and toolkits; euphemistic or imprecise language can be unhelpful in understanding whether behaviour is normative or concerning; understanding that early neglect, trauma, exposure to abuse, poor attachment, and the development of inappropriate sibling relationships seeking support are some factors that create latent conditions for harmful sexual behaviour; not all siblings are best served by living in their family group; and social work professionals should maintain professional curiosity with foster carers and not assume that experienced and well-regarded carers are managing the situation and responding appropriately all of the time. Recommendations include: ensure that the policy and practice guidance about the use of any measures of control, monitoring or restraint of children living in family-based settings and residential care is being effectively implemented; ensure that social workers in looked after children's services receive the appropriate training in harmful sexual behaviour (HSB) and that they access support from HSB specialist practitioners when appropriate; ensure that the learning and improvement board give sufficient priority to the role of the Independent Review Officer, to be assured that it is performing in line with policy expectations and making an impact on children’s outcomes including effective and timely escalation responses. Keywords : children with learning difficulties, foster children, foster parents, harmful sexual behaviour, sibling abuse > Read the overview report

2023 – Nottinghamshire - Harlow Academy

An Ofsted inspection of a special educational needs school carried out in January 2022 raised a number of serious safeguarding matters. Ofsted concluded that pupils were not being kept safe and were at risk of immediate and imminent harm. Learning includes: a need for the Department for Education (DfE) to strengthen processes for matching academy sponsors to special schools; there was sufficient information for Ofsted to decide to undertake a no notice inspection of the academy earlier; the need to put in place a process to address the multiple safeguarding concerns about the care of children in the academy; and a need for agencies to recognise that regardless of what Ofsted would do they have a responsibility to take action to safeguard the children. Recommendations include: the DfE to revise its process for identifying academy sponsors for special schools; professionals should always consider what other routes they should explore when a referral about a child or about the behaviour of an adult does not meet the safeguarding criteria they use; and the partnership should agree a document for parents and carers that outlines how to raise concerns in relation to children with disabilities and what to do if these concerns are not responded to. Keywords: special schools, management and organisation, institutional care, inspection, children with multiple disabilities, education > Read the overview report

2023 – Nottinghamshire - VN21

Multiple injuries to a 3-year-old girl between 2020-2021. There were four episodes of unexplained injuries, with two episodes requiring significant medical treatment. Alison and her siblings became looked after children in 2020. Learning: N/A Recommendations include: obtain information from the local authority on the difficulties of securing placements for children; ensure the pathways for communication between children's social care and NHS acute children's services are clear, clarifying who can provide authoritative information about safeguarding concerns, including the progress of child protection enquiries, related medical assessments, and the treatment and health of looked after children in acute hospital settings; seek assurance that transfer arrangements between acute health services include explicit reference to safeguarding concerns where these are present; and develop a SMART action plan to address how new concerns for looked after children are responded to, including effective multi-agency communication and consistent application of the relevant procedures about strategy discussions and discharge planning meetings. Keywords : injuries, health services, foster children > Read the overview report

2023 - Oxfordshire - Child G

Young person Child G experienced trauma and instability at an early age, including emotional and sexual abuse, and a lack of certainty about who was there to look after her. As a teenager this manifested in mental health issues and substance misuse, leading to her becoming care experienced and subject to sexual exploitation. Learning points include: practitioners to develop an understanding of ‘trauma-informed practice’ to identify the emotional abuse of adolescents and recognise the impact of fractured attachments; a move from ‘what is wrong with you?’ to ‘what has happened to you?’ in responding to children and young people who have experienced abuse and neglect; awareness of the damaging effect of victim blaming and pathologising language; ensure definitions and advice clearly outline the unacceptability of children being physically punished, with practitioners challenging parents who suggest this is an appropriate disciplinary approach; recognise the importance of a child or young person’s relationship with one or two trusted professionals; where child sexual exploitation is suspected, assessments should consider risks which emerge from vulnerabilities arising from past abuse, loss and trauma; schools to ensure that any decision to exclude a pupil (subject to a child in need plan or protection plan) is only done after a discussion with the multi-agency team; consider what practitioners and managers can do to support help seeking behaviour in children and young people; and professionals to maintain a questioning and curious response to what they are told or see. Recommendations are embedded in the learning points. Keywords: child sexual exploitation, physical punishment, emotional abuse, language, children with a mental health problem, trauma-informed practice

2023 - Oxfordshire - IFSA Thematic Review

Summarises key findings and learning points from cases of intra-familial sexual abuse (IFSA), including sibling sexual abuse. Learning points include: acting on early concerns, using the Strengths and Needs Form; remaining alert to the possibility of all types of bias including ‘unconscious gender bias’ and female abusers; awareness of how practice can be influenced by family social status; considering the viewing and sharing sexual images online in the context of family history and response to trauma; effective communication, with practitioners both sharing and seeking information, and using clear language; using available tools to identify different types of IFSA, for example a multi-agency chronology; ensuring that assessments consider and include the whole family and that all children in the family have been seen individually and had their voices heard; analysing parental motivations and capacity as part of risk assessments; reflecting on the impact of inter-generational abuse on parenting capacity and the need for practitioners to be trauma aware; understanding practitioners’ confidence levels around specific types of IFSA, especially sibling sexual abuse; consideration of what additional support may be needed when ending work with a family if parents are vulnerable; encouraging fathers to be included and participate in discussions; the impact of Covid-19 on families and service delivery; and the need to update the national practice of categorising abuse in the child protection process when there are multiple risk factors, for older children, or where there is intra-familial (sibling) abuse. Recommendations are embedded in the learning points. Keywords : sibling abuse, child sexual abuse, cycle of abuse, harmful sexual behaviour, family dynamics, child abuse images > Read the overview report

2023 - Pan Dorset - Brian

Stabbing of adolescent boy who was taken to intensive care in a critical condition. There have been escalating concerns about Brian’s risk to extra-familial harm and he has been involved in several criminal incidents and escalating youth violence, individually and with his peers. Learning includes: assessments should be holistic and focus on the risks from inside and outside of the family home and that these are not mutually exclusive; children and young people at emerging risk of extra-familial harm could benefit from targeted interventions that address those risks at an earlier stage, including from Early Help services; the level of skill, expertise, and knowledge of practitioners outside of the complex safeguarding team (CST) needs to be enhanced to enable them to manage the risks and needs from extrafamilial harm; schools, colleges and learning establishments have a key role to play in addressing extra-familial harm alongside safeguarding partners; emerging intelligence about children and young people needs to be shared appropriately across the safeguarding system; children, young people, parents, carers, and wider family should be actively engaged in safety planning; the voices of children need to be heard and responded to and the culture of working alongside children and young people encouraged; youth justice and safeguarding systems should work in tandem; and practitioners need to develop their understanding of neurodiversity and the impacts that childhood experiences can have on children and young people. Recommendations are embedded in the learning. Keywords : child neglect, gangs, exclusion from school, social deprivation, information sharing > Read the overview report

2023 - Pan-Dorset - Charlie

Focuses on Charlie’s life between October 2019 and February 2022, when Charlie was a child and transitioning to adult services. Charlie was diagnosed with high functioning autism and generalised anxiety disorder. Learning is embedded in the recommendations. Recommendations include: all partners should ensure that their staff and teams are aware of the diversity of organisations in relevant agencies and partner organisations, moving away from generic terms such as local authority or health; review the current training on child sexual abuse, ensuring that when professionals are working with a disabled children who are the victims of or witness of sexual abuse the course highlights the increased risk these children are living with due to a broad range of disability; ensure their workers are aware of the vulnerabilities of children who have a disability and are electively mute or non-verbal; assurance that disguised compliance and being able to recognise this early as well as being aware of what actions to take when sporadic and reluctant or disguised compliance is suspected is embedded in training; monitor attendance at child protection conferences to ensure conferences are quorate with sufficient agencies present to enable safe decisions to be made, escalation should be made immediately; and ensure where there is a medical diagnosis offered as an explanation for the presenting features of neglect, all aspects of the child’s health and wellbeing should continue to be considered to avoid the potential for diagnostic overshadowing. Keywords : child neglect, autism, voice of the child, transition to adulthood, home visiting > Read the overview report

2023 - Pan-Dorset - Samuel, Shay and Joy

Three siblings, Samuel (17), Shay (15) and Joy (13), known to services as potential victims of criminal exploitation. In 2022 Samuel was involved in two altercations and received knife wounds. In December 2022, Shay was arrested regarding an assault with a knife which led to another arrest for class A drug possession. Learning themes include: working with the family, alongside the wider contextual issues regarding child criminal exploitation and serious youth violence; evaluation of assessments and interventions; the role of schools; use of knives and police and criminal justice interventions; use of social media and agency assessment of its significance; extra-familial harm versus criminal activity; use of the National Referral Mechanism (NRM); and managing the needs and risks of siblings. Recommendations include: adopt the term ‘extra-familial harm’ to describe ‘child exploitation’; review the existing system of alerting senior managers to ‘high risk’ children in children’s social care; ensure that front line practitioners have a clear understanding of adolescent development and the impact of ACE’s/trauma; consider a multi-agency learning audit for children involved in the Section 47 process where there is an extra-familial harm concern; school leaders should review the effectiveness for children of separate ‘on site’ alternative learning provision; embed training on children’s use of social media and its associated risk factors into existing training; ensure one safeguarding partner takes sole responsibility for tracking children subject to the NRM process; and where extra-familial harm is evidenced ensure siblings are appropriately assessed and interventions are put in place. Keywords : adolescent boys, drugs, child criminal exploitation, children missing education, exclusion from school, violence > Read the overview report

2023 - Perth and Kinross - Child G and Child D

Concerns the hospitalisation of two babies from separate families who were both found to have sustained significant harm. Child G’s urine toxicology was reported as positive for cocaine and Child D suffered multiple fractures consistent with non-accidental injuries. Child G and their parents were known to multi-agency child protection services and agencies. Child D’s mother experienced housing, unemployment, and mental health stressors. Learning considers: child protection policy for children admitted to hospital who are on the child protection register; drug exposure to babies and children in a hospital setting; recognition of disguised compliance; identifying risk to unborn babies; recognising indicators of physical abuse; professional curiosity; supervision of children being cared for in hospital who are subject to a child protection investigation; and understanding of skeletal surveys. Recommendations for the child protection committee include: ensure that disguised compliance is included in inter-agency child protection staff learning and development opportunities; ensure that inter-agency training programmes and new employee inductions include professional curiosity themes; and ensure there is a multi-agency policy in place for the supervision of babies and children in hospital settings who may have been abused or neglected. Recommendations for the NHS trust include: develop guidance on ‘suspicion of poisoning’ from substances and share concerns promptly with the child protection team and police; appoint a single-point-of-contact when a child is transferred to another health board area where there are child protection concerns; ensure NHS staff are adequately trained in recognition and response to physical abuse; and ensure the unborn baby protocol is embedded into day-to-day practice. Keywords : infants, physical abuse identification, children of addicted parents, disguised compliance, professional curiosity > Read the overview report

2023 – Sandwell – Young Person SC

Death of a 17-year-old boy as a result of multiple stab wounds sustained. Learning is embedded in the recommendations. Recommendations include: seek assurance that there are formal processes to collect and analyse data around fixed or permanent exclusions and managed transitions; undertake a review of the themes and patterns of behaviour which constitute a 'persistent breach of school behaviour policies' and provide evidence of the effectiveness of approaches used to prevent exclusions for those who are overrepresented and at risk of exclusion from education; undertake work to understand young people's experience of alternative provision in the borough, especially young people with complex needs, being exploited/at risk of exploitation or who are disproportionately affected by exclusions; undertake a consultation process with Black and ethnic minority children, practitioners, community groups and families to understand the reluctance to engage with early help services and devise an action plan which addresses the barriers; undertake a review of referrals received, support offered and take-up of services for ethnic minority groups; and assurance that school behaviour policies have clear guidance and a definition of 'persistent breaches and school exclusion' and that they are based on guidelines provided by the Department for Education (DfE) regarding behaviour and discipline in schools. Keywords: child criminal exploitation, exclusion from school, gangs, parents with a mental health problem, youth justice > Read the overview report

2023 – Slough - Harry

Possible neglect of a boy since birth until an incident in January 2019 when he was 11-years-old. Harry was seen with facial injuries by staff at a local leisure centre where he attended alone. Police were initially unable to contact his mother and she was later arrested for neglect. Learning themes include: the voice of the child; recognising the signs and symptoms of neglect in children, the assessment of risk and enhanced professional curiosity; supervision, sharing information, communication and record keeping; professionals working together, compliance to policies and procedures and escalation processes; disguised and varied compliance; and child protection medical examinations. Recommendations include: be assured that all partners keep focussed on the child or young person, and that a professional meeting can be called by any partner to ensure communication and challenge of safeguarding concerns; review and update the local ‘Multi-Agency Threshold Guidance ’; make sure all staff utilise the available ‘Neglect Strategy and Tool’ to assist in identifying the signs and symptoms of neglect and abuse and to take immediate and necessary action if required; ensure agencies’ record keeping systems are robust, accurate and efficient for purpose and staff are complying with policy; ensure staff are supported and trained in dealing with difficult and confrontational parents or guardians; include within child protection training the range of options practitioners can take, including legal advice when a parent or guardian refuses consent to a child protection medical. Keywords : Black children, child neglect, disguised compliance, hostile behaviour, medical assessment, physical abuse > Read the overview report

2023 – Solihull – Baby JS

Death of 4-month-old-baby after being found unresponsive in bed with its mother. Learning includes: reinforcing messages about potential risks to a child’s safety of alcohol use by parents, even where there is no dependency; adequately managing every stage of the social care response from screening to the allocation of support; allowing for disclosure of domestic abuse by female perpetrators at routine domestic abuse screenings of pregnant women and new mothers; ensuring multi-agency co-ordination takes place as soon as the need for early help is identified and before a threshold for social care involvement is met; and keeping the lived experience of the child central to practitioners’ work. Recommendations include: learning from the National Review into SUDI in families where children are considered at risk of significant harm should be fully implemented in their area; changes introduced to the referral process should be monitored to ensure all cases are being appropriately screened; relevant partner agencies should review their internal systems and guidance around making and following up referrals including providing feedback to all referrers in a timely way; screening questions used for domestic abuse should be reviewed and if necessary reframed to avoid any unconscious bias; action should be taken to ensure that all practitioners are confident to explore situations involving domestic abuse, including establishing who is using abusive behaviours and who is the victim; and communication around the potential risks to a child’s safety of alcohol use by parents should be reviewed and strengthened. Keywords : alcohol, family support services, family violence, parents with a mental health problem, sleeping behaviour, sudden infant death > Read the overview report

2023 – Southampton - Stephen

Chronic neglect of an 8-year-old boy in 2021, discovered after the police executed a warrant with regards to Stephen’s stepfather and attended the home address. The police raised concerns around poor home conditions as well as Stephen’s presentation. Stephen’s mother reported that Stephen was autistic, did not like wearing clothes, and was being electively home educated. Learning themes include: the impact of the COVID pandemic and the response of services to the family; the impact of ‘was not brought’ to health appointments; information sharing and professional challenge; professional curiosity; and the importance of following statutory guidance. Recommendations to the partnership include: raise awareness amongst partner agencies of ‘Working with resistant parents guidance’, to reinforce its importance as a tool for working with children who are vulnerable; remind practitioners of the importance of considering a child’s lived experience of their home environment and to question whether the care offered to a child is ‘good enough’ to guarantee their safety, health and wellbeing; ensure that provision of bespoke, professional therapeutic intervention is in place for a child after their return to the family and/or if they remain a looked after child; remind practitioners to verify accounts provided by parents/carers and to ensure that information is shared within and between agencies to enable a holistic approach to safeguarding children; consider sharing information between the local NHS Trust and early years to identify children who have not been brought for their health review at age two and who have not taken up the offer of two-year funding. Keywords : child neglect, home education, home environment, non-attendance, family reunification, professional curiosity > Read the overview report

2023 – Southampton – Uma

Rape of a 14-year-old in 2022. Uma was vulnerable due to a history of being sexually abused in the family environment. Learning themes include: early identification of those at risk of exploitation; the importance of seeking information about a child’s history when they have lived in another area; language used about vulnerable children; retracted allegations; impact on the child when professionals change; and responding to children at risk of exploitation when they go missing. Recommendations include: ensure that the learning from this review informs the other work being undertaken on a similar theme; consider what can be done differently to ensure the early identification of children on a trajectory to exploitation and provision of multi-agency support and preventative/educative work; raise with other local safeguarding children’s partnerships and agency partners the need for system wide support for practitioners in respect of good practice when working with children who are exploring their gender identity; get detailed feedback from the police on the work being undertaken in respect of missing children; ask agencies to provide information on progress and challenge in respect of the language used in respect of vulnerable children; ask the relevant partner agencies to provide assurance regarding what is being done to prevent school exclusion for children who are at risk of exploitation. Keywords : abuse allegations, children in care, child sexual abuse, child sexual exploitation, online abuse, rape > Read the overview report

2023 – Southampton - Willow

In January 2023, a 16-year-old made a number of non-recent reports of sexual assault and rape against adult males. All of these reported incidents took place whilst Willow was in care. Learning explores: the reporting and review of missing child episodes, including appropriate use of the Philomena protocol, the grading of missing episodes, and use of the ‘3 in 90’ procedure; the use and grading of the child exploitation risk assessment framework (CERAF) tool; listening to the voice of the child or young person; the convening of strategy discussions and compliance with ‘Working together to safeguard children 2023’; and the support and training of carers with regards to the risks outside the home (ROTH) for vulnerable children or young people. Recommendations include: assurance from statutory partners of compliance with ‘Working together to safeguard children 2023’ to ensure that the appropriate professionals are invited to and are attending strategy discussions; allocated social workers and supervising social workers to ensure that alongside generic training for carers, each young person has a package of support in place tailored to their individual needs; assurance that the language used in respect of children, young people and their families is appropriate and not derogatory or victim blaming; and asks the relevant partner agencies to provide assurance regarding what is being done to prevent school exclusion for children who are at risk of exploitation. Keywords : children in care, child sexual exploitation, abuse allegations, runaway adolescents, voice of the child, foster care > Read the overview report

2023 - South East Wales - Child E

Death of a boy aged 9 years and 11 months in November 2021. He was found unresponsive in the family home with a scarf around his neck. Learning themes include: co-ordination of assessments and plans; the significance of family history; understanding of the child’s lived experience; professional differences; the presence of inappropriate sexual behaviour, especially in younger children, as a potential indicator that they are experiencing or have experienced child sexual abuse; and systems and processes around care and support plans and opportunities to progress to strategy discussion and child protection enquiries. Recommendations include: consider developing practice guidance on the lived experience of the child to assist practitioner insight, to ensure that the voice of the child is actively heard and to support effective action to safeguard children and young people; consider raising awareness across all agencies of the Multi-Agency Practice Guidance, Resolving professional differences; consider raising awareness across all agencies of the Multi-Agency Chronology Guidance; consider strengthening the written guidance around Multi-Agency Supervision; consider developing a regional protocol for responding to harmful sexual behaviour by children and young people. Recommendations to the local authorities include: consider enhanced management oversight and review of cases where children and families are supported on a care and support plan for extended periods; consider how the views of education and school can be represented in child protection processes that take place during school holidays. Keywords : abuse allegations, child behaviour problems, child deaths, harmful sexual behaviour, parents with a mental health problem, residence orders > Read the overview report

2023 – South Gloucestershire and Bath and North East Somerset – Baby M

Significant injuries, thought to be non-accidental, to a 3-month-old baby in May 2022. There are likely lifelong health implications as a result of the injuries sustained. Learning themes include: identifying and responding to the vulnerability of babies; pre and post birth levels of need; the importance of understanding contextual parental factors; keeping a focus on the child when there are moves between areas; the role of housing providers in understanding risk; health services information sharing; record keeping; and critical thinking in practice. Recommendations include: health recording systems should include a holistic assessment of a child’s needs which includes contextual maternal and paternal family factors; ensure all health professionals have access to information and guidance when assessing any adults who may be care experienced; implement training for NICU staff about increasing confidence and knowledge when working with domestic abuse; further embedding the ICON ‘babies cry, you can cope’ programme and increasing awareness of non-accidental injury in babies; ensure effective transfer of information between areas and services; develop a communication pathway between midwifery, health visiting, and GPs to ensure the learning from this review is included in the standard operating procedure (SOP) so that it adequately covers families that move between areas; and safeguarding supervision arrangements for community health professionals should ensure there is a safe space for critical thinking in practice, promote professional curiosity, and enable a trauma informed approach to the family’s needs when working with a pre and post birth situation. Keywords: adults in care as children, homeless families, housing, low income families, maternal depression, neonatal intensive care units > Read the overview report

2023 – South Gloucestershire – Family A

Mother of three children under 5-years-old convicted of father's murder. Murder was witnessed by one of the children. Learning includes: assumptions about domestic abuse can lead to plans for children that are not reflective of their experience and do not mitigate risk; fathers need to be considered and involved in assessments and plans for their children, even in cases of domestic abuse or where the father does not live with the children; professionals must have a full understanding of a parent's history and vulnerabilities and consider the impact of this when undertaking assessments and working with families; practice and systems need to be child centred and consider a child's lived experience so that work with a family is not dominated by adult issues; Covid-19 is likely to have had an impact on the family and support provided to them. Recommendations include: consideration of the findings of the Child Safeguarding Practice Review Panel's 'Multi-agency safeguarding and domestic abuse briefing paper' (2022); ensure that the requirement for timely assessments and the need to understand the nature of the abuse in each relationship is covered in domestic abuse training; ensure that partner agencies specifically request and record details of the GP for all children and adults in a household and that information is shared with all GPs; information about domestic abuse orders and plans should be shared with all professionals working with children in the family. Keywords: murder, family violence, fathers, assessment, information sharing > Read the overview report

2023 - South Lanarkshire - Young Person C and Young Person D

Murder of a 16-year-old girl after being reported missing from care in November 2021. Young Person D’s 19-year-old brother Young Person C was found guilty of her murder in July 2023 and sentenced to life imprisonment. Learning themes include: placement decision making and sibling assessment; management of sexual abuse allegations and subsequent legal proceedings; child victims of sexual abuse; harmful sexual behaviour; working with young people at risk of significant harm; transitions in throughcare and health/mental health services; and support structures for workers working with young people with challenging behaviours and needs. Recommendations to the child protection committee (CPC) include: where a decision has been taken not to place siblings together, it should be ensured that permanency decisions have a robust evidence base and that any variation in the care plan is recorded and under constant review by relevant agencies; there should be a comprehensive multi agency risk assessment and risk management framework for working with young people displaying harmful sexual behaviours; the implementation of a contextual safeguarding approach should be considered to include young people up to the age of 18-years-old, and include care experienced young people who are supported by Continuing and Aftercare; a positional statement should be requested from CAMHS as to the future development of services for young people up to age of 18-years-old who are not care experienced; and CPC should request that work is undertaken to identify the need for a practice forum for practitioners to bring high risk and complex cases for discussion. Keywords : child deaths, harmful sexual behaviour, sibling relations, permenancy planning, children in care, child behaviour problems > Read the overview report

2023 - South Tees - Angel

Death of a child in the first weeks of their life. The cause of death has not been established at the time of the report being published. Angel and their siblings were on a child in need plan due to a history of domestic abuse, physical abuse and neglect. Learning includes: the need for agencies to recognise that children who live in the area are their responsibility, including children who have just moved into the area; the need for robust and timely information seeking and sharing when a family move into an area, without relying on a parent’s self-reporting; the need for improvements in practice when children on child in need plans move to another area; the need for curiosity and vigilance in identifying the impact of moves of home area on children; increase professional confidence in introducing the use of interpreting services when a family do not speak English as a first language, and where there are potential cultural differences to be explored and understood; consideration of the impact of a family coming from a minority culture on their engagement. Recommendations include: reinforce that children with a safeguarding history who move area are potentially some of the most vulnerable children, seeking assurance from partner agencies that systems acknowledge local ownership and meet the needs of these children; remind professionals of the value and importance of using interpreting services, including provision of the cultural awareness required to work in a meaningful way with families; and ensure health visitors are involved in assessments and planning for unborn children. Keywords: infant deaths, transient families, culture > Read the overview report

2023 – Staffordshire - Beta

Covers the period Sept 2018 until June 2021 when there was a disclosure of sexual abuse by a girl against her stepfather. The family had been well known to services since 2012. Beta and her siblings had been subject to child protection plans historically and there had been a previous Serious Case Review following the death of a sibling. Learning themes include: the need for conversations around risk, including people’s perception of risk, the different risk assessments, and the interface between them; ensuring all partners are informed, and a multi-agency approach taken when a local authority contests a Special Guardianship Order (SGO), or there is a change in circumstances within a family unit; making sure children always remain the focus and are central to processes so that if adults caring for children experience medical issues, grief etc, consideration should always be given to the impact on the children; ensuring all partners are aware of a family being involved in a SCR/CSPR and that records reflect that; building trust, providing opportunities for children to disclose, and asking the right questions at the right time; professional curiosity and considering issue of disguised compliance; where multiple types of abuse are taking place, making sure attention is given to each form of abuse rather than allowing one type of abuse to overshadow the other; and ensuring the voice of the child is heard. Recommendations are embedded in the learning. Highlights examples of good practice. Keywords: child sexual abuse, child neglect, disclosure, risk assessment, special guardianship orders, step parents > Read the overview report

2023 – Staffordshire - Child I

Intra-familial sexual abuse and indecent images of a 2-year-old child by their maternal uncle, which came to light in June 2022. There was a history of intra-familial and inter-generational sexual abuse within the wider family and further allegations were subsequently made. Learning themes include: professional response to inter-generational and intra-familial sexual abuse; understanding the significance of family history, particularly where there is a history of harmful sexual behaviour and abuse; sharing cross border historic information; professional application of a Think Family approach to safeguarding concerns, including an understanding of the wider family and the family culture; professional knowledge of specialist sexual abuse support services, such as the Lucy Faithfull Foundation, and how to access them; identifying barriers which prevent professional curiosity and helping professionals to overcome them; agencies reviewing risk management of complex family circumstances; managing the potential risk of an alleged perpetrator of child sexual abuse who is not charged and/or convicted; understanding the lived experience and voice of a non-verbal child; and the impact of the Covid-19 pandemic on support services. No formal recommendations. Question-based learning incorporated in the learning themes. Keywords : voice of the child, child sexual abuse, intergenerational transmission of abuse, extended families, sexually abused children, child abuse images > Read the overview report

2023 – Stockport - Dylan

Life changing injuries to a baby, thought to be non-accidental. The incident is subject to an ongoing police investigation at the time of the review. Learning includes: parental vulnerabilities and the potential impact on parenting; the need to consider if neglect is an issue when a child has emerging special needs; maintaining a focus on the child and their lived experience over time; processes and practice that safeguards babies who have unexplained bruising; the impact on children of a parent’s mental health difficulties; the effective and robust consideration of fathers/non-birthing partners; and parental engagement, including understanding the barriers to meaningful engagement. Recommendations include: seek assurance from partner agencies about the impact of the on-going focus on working effectively with fathers and non-birthing partners; seek assurance that professionals understand and assess the impact of mental health and trauma on parenting, including the development and use of a clear mental health pathway for safeguarding in pregnancy and after the birth of a child; ask the relevant partner agencies for an update on the work undertaken to improve the response to bruising in non-mobile babies; seek assurance on how agencies are balancing high support with high challenge when required; request an update from the relevant partner agencies on work being undertaken in respect of using chronologies which incorporate the history of siblings and parents to inform safeguarding work; seek assurance from agencies regarding work being undertaken to ensure increased use of the Graded Care Profile by trained professionals, and for this to be monitored and appropriately challenged. Keywords : bruises, fathers, infants, injuries, parents with a mental health problem, police > Read the overview report

2023 - Stockport - Molly

Assault of a teenage girl in a residential children’s home. The incident is subject to an ongoing police investigation at the time of the review. Learning themes include: managing the risk of harmful sexual behaviour (HSB) in residential settings; support for adoptive parents; support available for families where child to parent violence is a feature; child blaming language used by professionals; and placement sufficiency and impact on finding placements for children with complex needs. Recommendations include: the national working group reviewing the adoption support arrangements should take action to ensure that the needs of adopted children are addressed at key transition points, such as when they move area or school; consider developing a pathway to support an effective professional response to child to parent violence; seek assurance that partner agencies have guidance which addresses victim blaming language and ensures that professionals record with the child in mind on the understanding that the child may one day ask to see their records; suggest to the National Panel that they consider concerns about the impact on children and young people of the cost and shortage of appropriate placements for traumatised children; when seeking placements for children the commissioning team should seek reassurance about harmful sexual behaviours; propose that the children’s home develop a harmful sexual behaviours policy and systematic approach to keeping children safe from sexual harm; identify whether other LSCPR’s have highlighted a lack of guidance within children’s homes about HSB and whether this issue is currently being sufficiently addressed through Regulation 44 Visits. Keywords : adolescent girls, abusive adolescents, adoption, harmful sexual behaviour, record keeping, residential child care > Read the overview report

2023 – Surrey – Child Rowen

Death of a 4-month-old-boy in Spring 2022. A post-mortem found that Rowan died from sudden unexpected infant death syndrome. His parents were children themselves at the time of Rowan’s birth. Mother was 13-years-old and father was 14-years-old. Learning themes include: the importance of parenting and pre-birth assessments; recognising that the parents were themselves children and the support offered to young parents; child protection planning; and professional advice on safe sleeping. Recommendations include: ensure all practitioners read the briefing ‘Learning from Pre-Birth Assessments’; if a vulnerable baby is living in the care of grandparents (with or without the presence of their parent), an assessment of their parenting capabilities and skills should be a pre-requisite before any such placement is made, especially if the child is subject to a child protection plan; when parents are children themselves, their needs and wellbeing should be recognised, and considered a priority, together with that of the need to safeguard their child; explore the possibility of young, teenage mothers being offered the services of the perinatal mental health team when it is evident that their health and wellbeing is at risk; GP practices should be informed when a child is subject to a child in need plan, to ensure that relevant safeguarding information is shared; seek assurance that the framework concerning safe sleeping is embedded for use by practitioners and that it includes a requirement that professionals visiting the home ask to see where a baby is sleeping. Keywords: adolescent fathers, adolescent mothers, adverse childhood experiences, county lines, exclusion from school, sudden infant death > Read the overview report

2023 – Suffolk - Samantha

Murder of a 12-year-old girl and her mother in September 2022. Samantha’s father was found guilty of both murders. Learning themes include: risk analysis in respect of domestic abuse; recognition of Samantha’s verbal and non-verbal cues; support for parents; impact of the Covid-19 pandemic; and exploring cultural issues. Recommendations to the partnership include: conduct a multi-agency audit in respect of domestic abuse case referrals to determine whether thresholds are being appropriately applied; provide guidance for children’s practitioners on where to record information which relates to one parent and is not to be shared with the other parent for confidentiality reasons; where a parent’s perception of the level of risk to a child is relied on to formulate the professional risk analysis or safety plan, this should be carefully explored and challenged by the multi-agency risk assessment conference (MARAC); all partner agencies should refresh their training offer in respect of domestic abuse to ensure practitioners are equipped to look for and identify patterns of coercive and controlling behaviour and how this may present in the context of a child’s situation and learning needs; the integrated care board should review what mental health, mediation and counselling services are available across the wider partnership to perpetrators of domestic abuse; partner agencies should use supervision and training to challenge stereotypes in respect of parenting roles for men and women; develop a strategic approach to tackling extremist misogyny and toxic masculinity; and ensure that frontline practitioners can access advice in respect of the cultural experiences of people from different countries or religions. Keywords : autism spectrum disorder, child deaths, children with a learning disability, culture, domestic abuse, murder > Read the overview report

2023 - Surrey - Maple

Suspected suicide of a 15-year-old in September 2021. Maple self-harmed for several years and made three attempts to end their life during their teenage years. Maple and their brother were made the subject of a child protection plan for neglect when Maple was 12. Learning themes include: celebrating difference and building belonging; responding to neglect and cumulative harm; and multi-agency responses to children with mental ill health. Recommendations to the partnership include: ensure gender identity is a key strand of equality action planning across all agencies; review its neglect strategy to consider what is needed to strengthen early identification and responses to neglect, and multi-agency responses to children with mental ill health who may have experienced neglect; lead on developing a shared multi-agency framework/practice model to guide multi-agency work with children with mental ill health, including the importance of engaging and supporting families; make representation to the relevant national qualifying authorities raising the importance of the training and support provided to practitioners in understanding and responding to adolescent mental ill health and wellbeing; and consider how confidence may be built in the children’s workforce in talking to children at risk of self-harm/suicide and how the availability of safe places may be promoted/facilitated. Keywords : adolescents, child deaths, child mental health, child mental health services, gender identity, suicide > Read the overview report

2023 - Surrey and Gloucestershire - Ash

Suicide of a 17-year-old boy in 2021. Police found prescribed and unprescribed medication, a ‘burner phone’ and a BB gun in Ash’s room. Ash had an ADHD diagnosis and was known to children’s social care and police due to concerns around criminal exploitation. Learning themes include: multi-agency understanding of the child’s lived experience, mental health and the impact of parental conflict; effectiveness of information sharing; criminal exploitation and contextual/adolescent safeguarding; elective home education and child protection; medical or psychological assessments in the private sector; cross border working; understanding known behaviours in relation to past trauma and present risks; and impact of ADHD on learning and daily functioning. Recommendations include: partnerships to work with parents to explore barriers to open dialogue with statutory agencies; all agencies to evaluate the quality of supervision, particularly around professional curiosity, elective home education, and consulting all adults with parental responsibility when parents are separated; relevant bodies to remind private consultants to comply with GMC and NICE guidance on who must contribute to the safe transfer of patients between healthcare providers; ask the Department for Education to consider placing a duty on parents to inform the local authority when a child is being home educated and if the child moves to a different local authority; develop multiagency elective home education safeguarding procedures for children at risk of criminal exploitation and ensure practitioners can recognise the signs of exploitation; and where there are concerns, ensure that risk assessments are based on the full facts of the case and the voice of the child is obtained. Keywords : suicide, child criminal exploitation, contextual safeguarding, home education, family conflict, drugs > Read the overview report

2023 – Swindon - Alan

Accident and emergency presentation of a 16-year-old boy in March 2021 following a social work visit. The home visit revealed significant neglect and malnourishment. Learning focuses on: multi-agency barriers and enablers to safeguarding adolescents from neglect including the application of mental capacity assessments; strengthening child protection processes for older teenagers who are experiencing neglect; the use of threshold criteria; the escalation procedure; and the impact of the Covid-19 pandemic on the child’s well-being, parenting capacity and the multi-agency response to the child. Recommendations include: agencies providing intervention at the early help level of need should feel like their voice is heard with authority and respect across the system; decisions about step-up and downs should be informed by multi-agency perspectives of those professionals involved with the child, and not taken solely on the grounds of threshold definition; decisions should be flexible with a willingness to use the skills and expertise in both early help and social care together; existing practice guidance on neglect should be reviewed, adding guidance for practitioners about working with adolescents who are difficult to engage with; the escalation process and its implementation should be reviewed to ensure it encourages both the airing of concerns about children and an expectation that those concerns will be received positively and responded to proactively; and procedures should focus more on expected behaviours and responses, on promoting the importance of escalating concerns within the system and include an approach to managing ‘stuck’ cases. Keywords:   adolescent boys, autism, child mental health, emotional neglect, medical care neglect, threshold criteria > Read the overview report

2023 - Waltham Forest - Kubus

Death of a 15-week-old baby boy in July 2021. Kubus died while sleeping on an inflatable mattress along with his mother and was sleeping on his stomach. Learning includes: pregnancy care through antenatal, perinatal and postnatal stages; housing; disclosure of domestic abuse; cultural competence; inaccuracies in documentation and record keeping; communication and escalation pathways; and risk assessment processes embedded during Covid-19, which may have contributed to reduced visibility and support. Recommendations include: explore the barriers and operational challenges to having contemporaneous accessible electronic records, with a view to identifying solutions to prevent gaps in information sharing which can lead to risk and result in harm; gain assurance that operational systems are robust in ensuring they hold the most recent contact information for service users; commission and sustain Identification and Referral to Improve Safety (IRIS) provisions in primary care; ensure that staff understand the cultures of the demographic that they work with; if English is a second language ensure that information delivered and received is checked to avoid miscommunication and consider an offer of an interpreter if necessary; recognise the importance of including fathers in assessments, whether absent or living in the household; and ensure that accurate quality documentation is maintained, irrespective of the challenges posed to staff. Keywords : culture, family violence, housing, language, sleeping behaviour, sudden infant death > Read the overview report

2023 – Wandsworth - Lloyd and Mark

Death of a 16-month-old boy due to non-accidental injuries in August 2019. Mother's partner was charged with murder and Mother was charged with causing or allowing the death of a child. Learning focuses on: the effectiveness of local multi-agency safeguarding children thresholds and pathways; the child's lived experience; the formulation and management of child protection plans and core groups; working with parents who are reluctant to engage; the impact and management of house moves on safeguarding systems; responses to domestic abuse; parenting education; parental drug and alcohol misuse; and the use of written agreements. Recommendations include: agencies, midwifery services and adult services review their assessment guidance and procedures to ensure curiosity about and consideration of the welfare of other household or family members, especially children under 5-years-old; a review of the protocol for re-housing families where children are subject of child protection plans to minimise moves away from the borough and key safeguarding networks, except where a move is essential to safeguarding a child or parent; relevant staff in partner agencies to have sufficient training in domestic abuse awareness, including the use of risk assessment tools and when to refer a case to a Multi-Agency Risk Assessment Conference (MARAC); a review of the use of written agreements with families when they are not part of agreed Child Protection Plans or Public Law Outline work, with guidance needed on when to share information about these agreements with key partner agencies. Keywords : child deaths, physical abuse, injuries > Read the overview report

2023 – Warwickshire - Anna

Suicide of a 21-year-old mother in October 2019. Anna had a baby at 15-years-old and both Anna and her daughter were considered as ‘children in care’. Anna had long-term physical and emotional difficulties, including personality disorder. Learning considers: effective information sharing to support both the parent and child; a ‘Think Family’ approach; collective consideration of the bigger picture; assessing a parent’s physical and mental health needs; non-attendance of appointments and the decision to discharge; a trauma-informed approach; and the role of corporate parent. Recommendations include: children’s services to consider how they have the skills and knowledge to support people with personality disorder and for all front-facing staff to have appropriate training; the establishment of a multi-agency task and finish group to address the gap in information sharing and better embed the ‘Think Family’ approach; relevant agencies, including the police, to consider the impact of their actions related to the protection of children on vulnerable adult family members; those working with children to be aware of the role that social care can play in supporting adults with care and support needs; seek assurance that the Escalation Protocol is fully embedded and being used effectively across all agencies; consider reviewing existing supervision methods, with a focus on the use of reflective practice and evidence-based processes; the partnership to produce short briefings on the issues of disguised compliance, the rule of optimism (around ‘new partners’ joining vulnerable families) and the poor care of pets; and to ensure step up/down processes are effective in cases where family mental health concerns have been identified. Keywords : adolescent mothers, suicide, borderline personality disorder, non-attendance, children in care, trauma-informed practice > Read the overview report

2023 - Warwickshire - Simon

Suicide of a 16-year-old boy in March 2021. Simon suffered a serious fall in 2018 which left him with a brain injury which is said to have affected his behaviour and led to mental health problems. Learning includes: assessment of risk which considers the cumulative effect of adverse childhood experiences; effectiveness and closure of child in need plans; dealing with allegations of sexual abuse; voice of the child in decision making; cultural and language challenges; impact of Covid-19; and the relationship between brain injury and mental health. Recommendations include: the partnership should seek assurance on effectiveness of child in need plans in the context of providing support to young people at risk of suicide and how these relate to other relevant plans; local children services and partners should review the process of receiving and responding to notifications under section 85 of the Children Act 1989; police should provide assurance that victims, and where appropriate parents, reporting offences of rape and sexual assault are appropriately updated and offered support; consider how learning on this review links to the Exploitation Strategy and is used to help develop a trauma informed approach for child sexual abuse; where there is a risk of suicide, to consider a ‘Think Family’ approach, with particular consideration to areas of culture; the partnership should consider a multi-agency audit on the use of interpreters; the partnership should seek to embed a new model into the CAHMs contract to move towards a needs led approach; and all professionals should seek to work with families when proposing measures involving the removal/storage of items potentially used to cause harm. Keywords : suicide, abuse allegations, child sexual abuse, children with a mental health problem, interpreters, children in need > Read the overview report

2023 – West Glamorgan - N56

Covers the period from December 2018 to December 2019 when Child X attended the hospital following identification of his injuries which were consistent with shaking. Learning themes include: multi-agency working; information sharing between health professionals; the importance of separating fact from opinion when recording; domestic violence; professional curiosity; and use of the strategy meeting. Recommendations include: agencies should strengthen their guidance and training provided in respect of recording information to ensure relevant individuals are identified clearly in recordings whilst also differentiating between self-reported information and diagnosed conditions; midwifery and health visiting services should be reminded of the guidance and importance of effective communication and information sharing between their services; all key agencies should be reminded of the importance of their involvement at the Initial Strategy Meeting; training around working with families who are experiencing domestic abuse should include the importance of involving fathers and extended family to fully assess risk and maximise opportunities for better outcomes; if the referring agencies are not content with the proposed action they must challenge the decision and if necessary escalate their concerns by implementing the Multi-Agency Protocol for the Resolution of Professional Differences; and panel members should be reminded of their responsibilities in the Child Practice Review process which includes that all key professionals involved in the case are invited to the learning event to maximise discussion and learning. Keywords : eyes, family violence, infants, record keeping, shaking, parents with a mental health problem > Read the overview report

2023 – West Glamorgan - N63

Neglect of a sibling group of six children covering the period from October 2018 to November 2020. Learning themes include: cross border working; neglect of neglect and focussing on parental support rather than parenting capacity; extra familial harm; voice of the child and advocacy. Recommendations include: local authorities should have clear policy and practice guidance to ensure safe and timely sharing of information when children’s names are not on the child protection register, and use of the Resolution of Professional Differences Protocol if this is not being complied with; local authorities should consider each child’s circumstances fully when allocating workers to ensure the risks of extra familial harm are not absorbed within the wider family dynamic; each organisation should consider advocacy through a broader lens such as non-instructed advocacy and use a trauma informed approach when considering an appropriate advocate; practitioners should ensure children are seen on their own, away from parents and carers, in an environment where they feel safe, so that the child can speak about the circumstances which have prompted safeguarding concerns; paediatric review should be considered and requested earlier in neglect cases and become standard practice for all child protection neglect cases which do not show significant progress when they reach second review conference stage; all practitioners should have access to training on disguised compliance and demonstrate professional curiosity and respectful uncertainty; all professionals should understand the significance of children missing appointments; and all agencies should ensure relevant representation at multi-agency meetings includes professionals with the relevant expertise and knowledge, to inform decision making processes. Keywords: child health, child neglect, dentists, non-attendance, neglect identification, parenting capacity, transient families > Read the overview report

2023 – West Lothian – Child F

Non-accidental injuries to a 2-week-old-infant. During the mother’s pregnancy, a range of services had been working with the parents and the unborn baby’s name had been placed on the child protection register in 2022. Learning includes: pre-birth support for vulnerable pregnancies including the vulnerable pregnancy service should be reviewed and a clear pathway established; transfers between duty and child protection team, and practice teams should be more timely; child protection plans should be more explicit and focus on the specific interventions to address identified risks; and decision-making at child protection case conferences should take account of risks, vulnerabilities and the likelihood of future significant harm. Suggestions for the child protection committee to discuss include: setting up a working group to review practice in relation to earlier allocation of cases of unborn babies and pre-birth assessment completed by practice teams; identify specific actions within child’s plans to include frequency and purpose of all contact with the family and clarity about the role of each professional involved including when interventions start and finish; the quality assurance subcommittee should observe child protection case conferences/planning and should also consider the role of reviewing officer; consider awareness raising about bail conditions and the need to confirm changes reported by the perpetrator; and consider awareness raising about the use of restricted access information and how it is taken into consideration when making decisions. Keywords : adolescent parents, decision making, parents with a mental health problem, physically abused infants, Scotland, youth justice > Read the overview report

2023 - West Sussex - Hazel and Lilly

Death of a 16-year-old girl in 2021. Hazel took her own life. Hazel and her sister Lilly received multi-agency services in response to concerns about maternal care in childhood and in response to emerging mental ill health in adolescence. Learning themes include: understanding and responding to the risk of suicide as a safeguarding concern; safeguarding children across multi-agency boundaries; schools knowing children and understanding risks; caring for traumatised children; the importance of family networks; paying attention to the language used when recording what children say; and the impact of the coronavirus pandemic. Recommendations include: seek representation from services to understand how the risk of suicide and the impact of related factors are understood, and what service changes are in place that prompt a timely safeguarding response to children in real time; consider how a trauma-informed culture across the multi-agency partnership is being implemented, including how parents/carers of children are supported to understand the impact of trauma on the child and family; evaluate how wider family and kin-networks feature in safeguarding activity, including involvement in safety planning; consider what changes may be needed to enable the sharing of a child’s story across services to minimise re-traumatisation, and how nominated trusted adults might be supported to understand a child’s lived experiences; and make representations to the relevant national qualifying authorities, raising the importance of training and support for practitioners in understanding and responding to adolescent mental ill health and wellbeing, and the impact of secondary trauma. Keywords : adolescent girls, suicide, child mental health, trauma > Read the overview report

2023 - Wigan - Elliot

Concerns a 12-year-old boy who was made the subject of an Emergency Protection Order in 2021. Elliot attempted suicide in his respite care placement and was admitted to hospital, where he communicated extreme distress through self-harm and violent behaviour towards staff. Learning considers: understanding of Mental Health Act assessment processes; child and adolescent mental health services (CAMHS) support to the paediatric ward; hospital as a ‘place of safety’; children’s social care (CSC) support and placement provision; planning and escalation procedures; and service re-design and planning around managing children and young people with complex needs. Recommendations include: local NHS foundation trusts should clearly outline the process for a child to be referred for a Mental Health Act assessment, criteria for inpatient CAMHS admission and the routes for professional challenge when there is a disagreement; a joint Health and Social Care Escalation Policy should be developed to ensure that when there is a risk of a child remaining on a general paediatric ward inappropriately, there are clear processes to alert senior leaders; the local Mental Health NHS Foundation Trust should review out of hours psychiatry provision for children; the local Hospitals NHS Foundation Trust should consider developing a ‘safe place’ where children who have been admitted can be assessed and cared for; CSC should explore the provision of suitable registered residential therapeutic placements; staff should develop skills to reflect on how children communicate through their behaviour, interaction and physical presentation, and how this can be used to plan their care; and the development of a joint health and social care escalation policy, ensuring the focus remains on the child. Keywords : emergency protection orders, child mental health services, self harm, physical restraint, placement, children’s rights > Read the overview report

2023 – Wirral - Noah

Death of a two-year-old boy in May 2021 from natural causes due to a bacterial infection. There had been prior social care and multi-agency involvement with the family and issues of parental neglect, domestic abuse and alcohol abuse by the children’s father. Learning includes: consideration needed of the level of support given to victims of domestic abuse who repeatedly resume relationships with perpetrators; better promotion and oversight of use of the Graded Care Profile (GCP2) tool is required; a need to review how support is delivered and co-ordinated for families with complex needs; and a need for better use of professional curiosity with families, particularly in relation to disguised compliance. Recommendations include: ensure all multi-agency professionals are aware of, and have access to training and resources for the systemic practice model; examine the role of Multi Agency Risk Assessment Conference and how wider support for victims of domestic abuse is managed; ensure the use of the GCP2 tool in all cases of suspected or known neglect; and highlight the features and impact of disguised compliance and parental alcohol misuse on safeguarding children. Keywords : child neglect, family violence, disguised compliance, home environment, alcohol misuse, non-attendance > Read the overview report

2023 – Wirral - Ollie

Death of a 13-week-old boy in February 2021. Ollie's death was the result of a co-sleeping incident with his father which resulted in brain injury. Prior to his death, toxicological analysis of Ollie's urine revealed the presence of cocaine, which resulted in an interim care order for Ollie and his siblings. Learning themes include: identification of and response to neglect; the importance of home visits to identify poor living conditions; the effectiveness of safer sleep messages; the impact of parental mental health and substance misuse concerns as additional stressors in the family; the role of disguised compliance; and the impact of Covid-19 on supporting families and the capacity of services to respond to their needs. Recommendations include: recommendations for the local safeguarding children partnership include: publish a multi-agency neglect strategy with actions to improve the awareness, understanding, assessment, and response to neglect, and how neglect interacts with parental mental health and substance misuse; review and update the approach to safer sleep messaging as part of a new prevent and protect model for preventing sudden unexpected deaths of infants (SUDI); develop a campaign targeting casual substance misuse amongst parents and carers and warning of the dangers to their children; undertake a review of the local impact on families of Covid-19, lockdowns and the absence of face-to-face visits; and deliver a series of locality based information events for parents and carers with access to advice and guidance. Keywords : sudden infant death, sleeping behaviour, parents with a mental health problem, drug misuse, child neglect, coronavirus > Read the overview report

2023 - Wolverhampton - Thematic Review - Knife Crime

Thematic review in response to three incidents of serious youth violence (SYV) that occurred between April and June 2022. Incorporates 929 survey responses from young people aged 11-18-years-old, capturing their views of knife crime. Learning themes include: prevention and education; demography and problem profiling, including gender and ethnicity, cannabis misuse, cumulative harm, and carrying a weapon to feel safe; partnership working and information sharing; assessment and risk management; and understanding the voices and lived experiences of young people. Recommendations include: provide specialist training to ensure that practitioners understand the concepts of adultification and intersectionality, their relationship to SYV, exploitation and knife crime, as well as the intersection between poverty and SYV, and the role that social media plays in the amplification of issues; provide support so practitioners understand how intra and extra familial experiences interface and increase likelihood of risk; help practitioners to identify when a child may be ‘freelancing’ and the harms associated with this concept; support schools to facilitate them carrying out effective peer mapping; give children access to relatable practitioners with lived experience, including male practitioners; use local intelligence to better understand the drivers that underpin weapon carrying behaviour in females and the role of females in co-offending peer group contexts; develop educative strategies to ensure that information reaches those not in full time or mainstream education, including home educated young people; align the violence against women and girls (VAWG) and exploitation agendas to recognise how gender roles and socialisation intersect with SYV; and develop a children’s substance misuse strategy. Keywords: child criminal exploitation, drug misuse, weapons, violence, contextual safeguarding, risk assessment > Read the overview report

Case reviews published in 2022

A list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2022. To find all published case reviews search the national repository .

2022 – Anonymous – Adam

Death of a child in a road traffic collision in 2020. Adam was believed to have been at risk of criminal exploitation at the time of his death. Learning includes: always follow safeguarding procedures to assess and manage the risk of harm to a child in parallel with any criminal investigation; practitioners should professionally challenge and escalate any decisions that they do not agree with; ensure the risks and the impact of non-engagement to the child have been assessed before closing a case and consider escalating the concerns if those risks are still prevalent. Recommendations include: practitioners need to be able to distinguish between factual information and hearsay evidence that needs to be utilised to inform a risk assessment; consider adverse childhood experiences (ACEs) and trauma informed practice as a strategic priority together with the need to provide training on the impact of ACEs on children, including where there has been a history of criminality; adopt the Child Safeguarding Practice Review Panel's recommendation that all safeguarding partnerships have an understanding of the nature and scale of the problem of child criminal exploitation, and are able to identify children engaged with and at risk from criminal exploitation; strategic partners to agree and implement a contextual safeguarding response that will engage and empower members of the community. Keywords: child deaths, child criminal exploitation > Read the overview report

2022 – Anonymous – Anya, Rosa, Whitney and Lena

Intrafamilial sexual abuse and neglect of four girls in an extended family over a number of years. Learning focuses on: identification of intrafamilial child sexual abuse; harmful sexual behaviours and siblings; intrafamilial sexual abuse by women; enabling children to talk about child sexual abuse and responding appropriately; understanding help seeking behaviour; the sexual abuse of disabled children; recognising the importance of safe adults and the non-abusive parent and family; understanding the motivations and behaviours of adults who pose a sexual risk to children; responding to adult disclosures of sexual abuse in childhood; responding to the needs of parents with learning disabilities; assessment of the connection between parental learning disability and neglectful parenting; the importance of understanding family history. Recommendations include: consider the appropriate commissioning of services for children who have experienced child sexual abuse and for families who are supporting children in the aftermath of child sexual abuse; reinforce the importance of children's access to appropriate therapy while police investigations are continuing; develop guidance regarding complex and historic abuse investigations; remind police of the importance of considering a range of risk management measures including sexual risk orders; local and regional safeguarding procedures regarding child sexual abuse need to include the requirement to undertake criminal injuries compensation processes and raise with children and their parents the Victims Right to Review scheme. Keywords: child sexual abuse, child neglect, incest, harmful sexual behaviour, parents with learning disabilities > Read the overview report

2022 – Anonymous – Babies with injuries

Two cases of non-accidental head injuries and bruising of 14-week-old infants. A bruise was observed on Baby 1 two months prior to injuries. Baby 2 was in the care of their father at the time of the incident. Learning includes: advice on safe sleeping and safe handling needs to be provided to both parents; professionals need to consider how they can meaningfully engage with fathers, including those who do not live with the child; awareness of the impact of having a new baby on fathers as well as mothers; if information about a new baby is not shared directly with a health visitor, it cannot be guaranteed with current systems that all important information will be known by them; even a small bruise on an infant needs to be recognised as a potential warning injury by professionals; family members should not have unsupervised contact with their child in hospital if a non-accidental injury may be the reason for attendance. Recommendations include: use learning from the next national child safeguarding practice review to explore what can be done to improve the involvement of fathers in work with families with new babies; undertake work to provide a better understanding of the role of fathers and the need to engage with fathers, and consider projects in other parts of the country; seek assurance from partner agencies regarding knowledge and use of the injuries in non-mobile babies policy. Keywords: infants, physical abuse, non-accidental had injuries, bruises > Read the overview report

2022 – Anonymous – Charley

Murder of a young child by their mother's partner. Learning includes: investing time both strategically and operationally in improving work with fathers will contribute significantly to the welfare of children, their families and communities; practitioners would be helped and supported in responding to the complexities of domestic abuse through the introduction of a practice model that systemically helps the whole partnership and external stakeholder to work to a holistic domestic abuse informed approach; a decision to cease multi-agency planning in totality without the necessary consideration of threshold step down risks children being exposed to escalating harm without adequate review mechanisms; no assessment that considers risk of domestic abuse should be accepted as complete without exhausting all options to include the alleged perpetrator of the abuse. Recommendations include: strengthen the multi-agency approach to domestic abuse by exploring and adopting a specific practice model that provides a perpetrator based, child centred, and survivor strengths approach; ensure that robust step-down and transfer processes that promotes independence at a pace that supports embedding of change are in place; develop a plan to publicise and generate the use of Clare's Law by educating both professionals and the community; ensure that step down and maintenance support is built into the commissioning of domestic abuse services to support sustained change for both victims and perpetrators. Keywords:  child deaths, family violence > Read the overview report

2022 - Anonymous - Child 9

Child sexual abuse in the context of child sexual exploitation and trafficking of a 14-year-old child over a significant period of time. The abuse was perpetrated by males ranging from older adolescents to adult men, who were known either to Child 9's mother or some of her relatives. Learning includes: frequent local movement around education providers is an indicator of risk; the use of victim blaming language is careless and should be avoided to ensure the presenting behaviour is seen as a representation of the child's distress; there should be no delay in monitoring and information sharing when vulnerable children who live in a cross boundary area are subject to elective home education or are missing education; practitioners in urgent care centres should always be prepared to "think the unthinkable", and finding the time to secure communication with a child alone should be a central focus; the use of hypothesis in safeguarding assessment and planning is crucial; attendance and active participation in child protection meetings should be a priority for services to ensure effective information sharing. Recommendations include: highlights the ongoing development needs of the multi-agency workforce when working with children who have escalating and complex safeguarding needs, working with troubled children, hypothesis in safeguarding work, reflective supervision and the use of victim blaming language in safeguarding work; ensure that responsive restorative services are available for children who are victims of rape and sexual assault; examine issues and demonstrate improvements around children missing education and children subject to elective home education. Keywords:  child sexual abuse, child sexual exploitation, child trafficking > Read the overview report

2022 – Anonymous – Child A

Death of a 12-year-old child by suicide in 2020. Learning includes: wider consideration of issues relating to children electively home educated (EHE), children from the Jehovah's Witness faith, child and adolescent mental health services (CAMHS) and triage arrangements and information sharing in tertiary hospitals. Recommendations include: consider how to engage local faith communities to undertake a proportionate Section 11 process to provide assurance to the safeguarding children partnership on the effectiveness of those arrangements; the local authority EHE team continue to lead the work on improving the identification and assessment of children who are electively home educated and ensure the voice of the child is included; engage with the Department for Education in the development of local guidance for schools on children electively home educated; request the National Safeguarding Practice Review Panel considers the recommendations from the Independent Inquiry into Child Sexual Abuse (IICSA) report and its final report on the safeguarding arrangements within religious faiths to ensure they are addressed and implemented at a national level; alert the National Child Safeguarding Practice Review Panel, and contact all child death review leads, to raise awareness of the need for child death review processes requiring referrals to the coronial process to be explicit about any potential safeguarding concerns. Keywords: suicide, home education, religion > Read the overview report

2022 – Anonymous – Child G

Attempted suicide by a 7-year-old child at the family home. Sixteen months prior to this event, Child G had disclosed that they had been sexually abused on two occasions by their stepfather. Learning includes: it is important to continue to communicate with children about their world; professionals need to be reflective in the context of what may be a change in the child's priorities rather than adhere exclusively to an adult assumption of what the child requires; consider a more judicious use of care planning forums when there is lack of clarity about what the options are in reducing risk within families; there should be more effective planning, assessment and recording at all stages of the achieve best evidence (ABE) process. Recommendations include: for agencies to consider the importance of not making assumptions about the source of a child's distress in the absence of speaking to the child directly, and the clarity about a plan to work together concerning how the child's needs are met while awaiting specialist assessment; ensure that procedures for convening multi-agency meetings are followed, to allow for clearer planning and communication between agencies; ABE interviews should be carefully planned and appropriately documented, in line with expected good practice and guidance, and there should always be consideration as to whether a further strategy meeting is required following the ABE interview. Keywords: suicide, child sexual abuse, disclosure, interviewing > Read the overview report

2022 – Anonymous – Child N

Life-threatening injuries to a boy in August 2020. Child N fell from a second-floor window and sustained serious injuries Learning includes: work with families should demonstrate an understanding of the impact race, culture and religion can have on parents' behaviour; agencies should obtain contact details of a parent not living in the household and should engage them in important decisions regarding their child, unless there is a reason not to do so; practitioners require the knowledge and skills to promote engagement with families who are resistant to co-operating with services offered; for children experiencing neglect there can be a range of factors which mean that incidents have some element of forewarning; the category of harm should reflect the risks to the child, which should be articulated in the child protection plan; statements for family court proceedings should articulate all the risks of harm to a child. Recommendations include: consider how agencies can develop practitioners' knowledge and skills in working with resistant families; when a section 47 enquiry is initiated all circumstances should be reviewed to ascertain if the threshold is met for a joint agency investigation; undertake a review of safeguarding training to ensure that cultural awareness and sensitivity is promoted; the child protection service should undertake an audit of the categories of harm identified for children who are subject to child protection plans to ascertain if the categories reflect the identified risks. Keywords : child neglect, injuries, autism > Read the overview report

2022 – Anonymous - Children O, P and Q

Three siblings aged between 6-15-years-old who experienced a significant domestic abuse incident in August 2021. The abuse was perpetrated by their father against their mother and lasted over 11 hours in the family home. Learning includes: agencies should be cognisant of the assessment, chronology, and history of families, before making judgements about risk based upon the decisions of others; children’s case closure should highlight ongoing support offered to the family and identify risk factors which would result in the case being escalated and re-assessed; agencies need to follow up and follow through when parents are tasked with self-referring for agency support or services; significant low attendance at school should at least prompt an early help assessment; supervision should consider gender bias and ensure that discussions focus on the risks presented by both parents; agencies working with children and young people would benefit from hearing from domestic abuse survivors and their experiences of statutory interventions. Recommendations include: agencies should alert the multi-agency safeguarding hub (MASH) if it is known or becomes apparent that children have been the subject of care proceedings or child protection planning in another local authority; safeguarding partners should consider how learning from the Covid-19 pandemic is embedded into organisational forward plans; raise practitioner awareness of young carers and their routes for support, and the link between the young carer role and neglect; child protection plans, child in need plans and early help plans need to reflect the actions that safeguarding agencies take if parental relationships and contact is resumed without formal agreement. Keywords: family violence, physical abuse, abusive fathers, substance misuse > Read the overview report

2022 – Anonymous – Daisy

Life-threatening injuries to a 4-year-old girl who was struck by a road vehicle in June 2021. Police commenced an investigation into possible neglect following reports of mother being intoxicated at the time. Learning includes: disproportionate/issues of professional optimism in the context of substance abuse addiction and domestic abuse; the voice of the child and the child's journey was not understood by all professionals; engagement and communication with the family was not always/could have been more robust and concerns raised by relatives were not given/could have been given adequate weight; the family's history, including an older sibling being subject to a Special Guardianship Order, should have been considered more when assessing parenting capacity; engagement and service delivery were impacted by COVID-19. Recommendations include: ensure families are systematically used to inform decision-making, information sharing and managing risk, with extended families able to contribute to the plan for a child; ensure a full understanding of a family's history is collated and this is considered in all assessments; children placed on Special Guardianship Orders with family members must be comprehensively included in assessments and planning; police should ensure that incidents of domestic abuse are linked to the same family network so that the cumulative impact is understood and risks can be assessed; partner agencies working with adults must share information with relevant children's professionals where there are concerns which could impact on parenting capacity. Keywords: accidents, injuries, child neglect, family violence, alcohol misuse, information sharing > Read the overview report

2022 – Anonymous – Family M

Death of a 5-year-old child in November 2018 due to injuries sustained in a serious and reckless incident at the family home. Learning includes: gathering and analysing family history, which includes history of contact with services, is a core task when working with children and families; it is important that appropriate empathy towards the parents does not cloud professional judgement or challenge; supervisors and managers should consider how busy frontline workers make trade-offs in order to resolve goal conflicts and cope with uncertainty and system pressures, and ensure this does not compromise children's welfare and safety; the language used to describe services, forms, tasks and activities carries weight and can create expectations; exploring and reconciling differing perspectives about the risks a child or family is experiencing is a necessary task when operating in a multidisciplinary context; when working with parents who are, or become, resistant it is important that expectations are transparent about the professional response to such resistance and that these are clearly stated from the outset; when new, and potentially serious information emerges about risk to children the response should be measured and match the level of seriousness; when undertaking assessment work, professionals should be alert to all risks that children may face, and not make assumptions about mothers naturally being protective. Recommendations include: to ensure the learning is disseminated across the multi-agency safeguarding partnership. Keywords: child deaths, children at risk, mothers, maternal behaviour, language > Read the overview report

2022 – Anonymous – Joshua

Neglect and sexual abuse of an 8-year-old boy by two associates of his mother. The abuse took place prior to and during the time he was subject to a child protection plan. Learning includes: the need to assess and understand parental ability to protect when making decisions around supervised contact; limitations of an evidence-based response to child sexual abuse (CSA); importance of requesting and sharing police intelligence at the earliest opportunity; the need for the development of a strong and robust response to CSA that is not a purely evidence-based approach and includes the provision of appropriate tools and training; recognising when the Graded Care Profile 2 (GCP2) tool should be used to help identify and address neglect; understanding the purpose and effectiveness of written agreements and assessing whether they should be used within current practice; the importance of perpetrator disruption. Recommendations include: develop an overarching multi-agency strategy for responding to CSA; develop a CSA training programme for practitioners across the multi-agency partnership; review the way in which multi-agency meetings facilitate the discussions and recording of confidential information and how that information is shared with families to facilitate an increased understanding of the risks; explore and understand rationale for not sharing information with parents and carers, and ensure that the information not shared is kept to a minimum. Keywords: child neglect, child sexual abuse, police, neglect identification, information sharing > Read the overview report

2022 – Anonymous – Marie

Death of a 16-year-old girl in January 2020 by suicide.

Learning includes: the need for a clear model for managing high risk self-harming young people; ensure clarity between professionals about responsibilities to coordinate, and ensure timely information gathering and effective intervention; the importance of a family assessment to provide background context and allow opportunities to assess parenting capacity; ensure concerns and worries raised by a child are considered and investigated; ensure professionals exercise professional curiosity to ask more questions and understand what a child has experienced, and to learn what other agencies know; and ensure initial early interventions are appropriate for meeting the child’s needs. Recommendations include: update the local documentation on self-harm and suicidal thoughts to develop an interagency “team around the child model and procedure” to assess and intervene with young people where moderate and high risks have been identified, ensuring that there is clarity about coordinated multi-agency care with clear plans and timely reviews; for young people where moderate and high risk of suicide has been identified, there should be a dedicated range of preventive and treatment resources available without long waits; and consider whether a new local response should be developed to prevent further deaths when a young person has died by suicide, considering new models for enhanced joint working and integrated provision emerging nationally. Keywords: suicide, adolescent girls, child sexual abuse, professional curiosity, voice of the child, information sharing

> Read the overview report

2022 – Anonymous – Pippa

Death of a 15-year-old girl in September 2018 by suicide. Pippa was subject to a care order and lived in a care home at the time of her death. Learning  includes: the importance of considering how childhood experiences can impact the behaviour and vulnerabilities of troubled adolescents; child sexual abuse in the family will often come to the attention of agencies because of a secondary presenting factor, which then becomes the focus of intervention; practitioners need to proactively assess and engage with all significant men in a child's life; where child sexual exploitation is suspected, risk assessments need to consider risks which emerge from vulnerabilities arising from past abuse, loss and trauma; professionals need to maintain a questioning and curious response to what they are told or what they see; a lack of knowledge among professionals about the evidence base related to risk indicators for adolescent suicide could leave them ill-equipped to discuss or recognise signs and respond accordingly. Recommendations include: support the development and implementation of a multi-agency framework for work with vulnerable at-risk adolescents; ensure that agencies have systems which can evidence robust managerial oversight of actions, decisions and plans relating to work with adolescents; ensure that practitioners have regular supervision from a senior manager, safeguarding lead or an appropriate external source; provide learning and development opportunities about adverse childhood experiences, trauma and familial child sexual abuse; audit the effectiveness of meetings to ensure that they lead to improved and timely outcomes for children and young people. Keywords: suicide, adolescents, children in care, child sexual abuse, professional curiosity > Read the overview report

2022 – Anonymous – Riley

Life-threatening injuries to a 17-year-old boy. Riley was hit by a car and assaulted by the driver. Learning  includes: recognise and reflect on cumulative risk, including parenting history and adverse childhood experiences; the need for active communication between agencies involved in assessing need; undertake joint assessments to ensure all needs are identified; see a child's behaviour as their way of communicating and be reflective about what the behaviour could be telling us; use language that recognises a child's behaviour as a means of communication; recognise the impacts of neglect and trauma, understanding how this can manifest in adolescence; not overloading a child with referrals/workers but considering what needs to be prioritised and who is the best person to deliver; understanding a child's needs, and being needs led rather than service led; practitioners work together to respond to multiple needs such as underlying learning needs and child protection concerns; creativity about where and how appointments take place to maximise engagement and attendance. Recommendations include: a review of children who have disengaged with school/ learning to ensure that robust multi-agency plans are in place to meet their needs; explore the use of a communication passport which can be reviewed at key stages in a child's life, so all agencies understand the strategies needed to engage with a child with additional needs; consider the partnership's approach to adolescents receiving hospital treatment. Keywords: injuries, adolescent boys, contextual safeguarding, family violence, crime > Read the overview report

2022 – Anonymous – Ruby

Death of an infant girl in 2020 found to be an accident, linked to an unplanned unsafe sleeping environment. Ruby was on a child protection plan due to risk of neglect when she died. Learning focuses on: awareness of a parent's history; considering and involving fathers; assessing wider family members who play a key role in supporting or safeguarding a child; sharing concerns about the impact on a child of changes of circumstances; the impact of alcohol and substance misuse on children and unborn babies; safer sleeping advice; using virtual technology for key meetings; strengths-based models of assessment and planning; avoiding over-optimism and losing focus on the child; knowledge of multi-agency safeguarding procedures and professional confidence in challenging when they are not followed. Recommendations include: promote the involvement of fathers; ensure that the implementation of sleep assessments includes bespoke explicit and detailed safer sleep advice, including an explanation of why vulnerable babies are more at risk of sudden unexpected death in infancy (SUDI); ensure that key meetings such as child protection conferences being held by video conference or telephone have the optimum involvement of parents; ensure that professionals have the knowledge and confidence to challenge other agencies, including the use of escalation policies; consider how to ensure that accurate information about medication being prescribed to a pregnant woman is available to all health professionals working with the family. Keywords: infant deaths, sleeping behaviour, substance misuse, fathers, optimistic behaviour > Read the overview report

2022 – Anonymous - Young Person Joe

Fatal stabbing of a 15-year-old boy while intervening to protect another young person during a robbery in 2019. Concern about the family had escalated throughout 2018 particularly in relation to Joe and his sister being at risk from criminal and sexual exploitation. Learning themes include: the family context; understanding and managing risk; partnership working; and management oversight. Recommendations include: agree, implement and monitor the impact of a relationship-based, trauma-informed practice model across all agencies which includes an approach to working with fathers; review the current training and development opportunities regarding disabled children, to ensure professionals are clear about the threshold for access to services and the impact on parents of caring for a disabled child; review its approach to the provision of services which create diversionary activities and resources to mitigate the ‘pull’ of exploitation; engage the council in a review of and relaunch of the Young People at Risk Strategy to specifically incorporate a review of existing child protection systems in relation to extra familial harm and a transitions protocol for children moving from primary to secondary school; reinforce the early help and social work practitioners’ understanding of their ‘key worker’ role through training, development, and supervision; agree a model approach to supervision and training across all agencies that supports the development of professional curiosity in all practitioners to ensure a greater understanding of the lived experiences of children; and children’s social care should develop a protocol with housing providers which clarifies processes and thresholds for housing transfers on safeguarding grounds. Keywords : child criminal exploitation, child deaths, contextual safeguarding, exclusion from school, housing, pupil referral units > Read the overview report

2022 – Argyll and Bute – Child A

Explores the circumstance around the suicide of a 17-year-old boy in February 2021. Learning includes: ensure that communication between CAMHS and partner agencies is robust and that the needs of the child/young person (YP) are fully understood by all partners involved in the child/YP’s care, for those YP at risk the CAMHS manager should consider agreeing a process for a child’s planning meeting prior to discharge from the service with partners to ensure information is being shared and plans are being regularly updated to reflect changes in circumstances; the initial work undertaken by both the Child and Adult Protection Committee’s in the development of the Young Person Support and Protection Procedures needs to be built upon and discussion between Children and Adult Heads of Service should take place to progress this joint work; review and refresh local practice guidance and ensure that practitioners are trained in the model in the Getting it right for every child (GIRFEC) practice guidance and are confident in its use; review current IRD thresholds and satisfy themselves that professionals understand the threshold and that situations are being appropriately assessed and managed when concerns are raised by any partner; and review existing Early and Effective Intervention (EEI) guidance with a view to amending practice guidance to include the gathering of information about all children within a family home where there are concerns about the impact of an individual’s behaviour on other children within the family home. Recommendations are embedded in the learning. Keywords : child deaths, child mental health, education, family functioning, suicide > Read the overview report

2022 – Barnet - Leo

Large number of unexplained injuries to a 3-year-old boy in April 2021. Leo was assessed to be showing signs of neglect of his physical care. Children's social care and universal services had been provided across two local authority areas. Learning themes include: assessment of injuries to young children and the need for child protection medicals; holding the child and their experience in mind; consideration of child protection processes while a child is subject of a supervision order and the role of the lead professional at step down to universal services; supporting parents who experience mental health problems; information sharing with busy GP Practices; case supervision and multi-agency management across two local authorities; maintaining significant relationships for care leavers being rehoused; the need for a wider perspective in domestic abuse work; work with care leavers as parents; and the impact of Covid-19 on service provision and identifying vulnerable families. Recommendations include: seek assurances that the role and skills of the lead professional are understood and embedded within any team around the family arrangements, especially when a case is being closed to social care and the lead professional role is not held by a dedicated early help specialist; a standard child protection data sharing form is sent to GPs for completion and that this is a form based on the template developed by the National Named GP Group; to develop best multidisciplinary practice guidance where services are provided across more than one local authority, to ensure that the needs of children and their parents who are care leavers are met; and to review the skills of frontline practitioners in supporting the emotional attachment between carers and children. Keywords : child neglect, injuries, parents with a mental health problem, termination of care, children’s services, information sharing > Read the overview report

2022 – Bedford - Thematic review of serious youth violence

Thematic review commissioned following two cases of serious youth violence (SYV) which led to the death of one adolescent boy and the serious injury of another adolescent boy in 2018. For both the young people involved there were concerns about the misuse and selling of drugs and potential involvement in gangs. The cases are considered in relation to service responses, informing a wider case audit of young people identified as vulnerable or at risk of SYV. Learning themes include: home life and family backgrounds characterised by extreme levels of violence and physical abuse; peer groups and gang involvement; school histories with exclusions and school moves; neighbourhoods as key contexts of harm; and harmful online contexts. Recommendations include: the local safeguarding children board should ensure that early risk indicators arising from adverse childhood experiences (ACEs) are identified and responded to through early help assessments; schools and alternative education providers should carry out assessments where there are concerns about peer groups or harmful behaviours and develop intervention plans; the board should seek assurance that schools are preventing exclusions at the earliest opportunity and when young people are permanently excluded from school and being placed in alternative education provision they are provided with immediate wrap-around support for the transition; interventions with young people and families to address the impact of SYV and CCE should be evidence based, sensitive to ACES and the experience of trauma, and characterised by flexible, persistent and relational working. Keywords : adolescent boys, adverse childhood experiences, child criminal exploitation, child deaths, child mental health, children in violent families > Read the overview report

2022 – Berkshire West – Aiden

Severe burns and injuries to a 1-year-6-month-old boy in December 2019. Medical opinion was that the injuries were non-accidental, and were likely to have been inflicted or were due to a significant lack of supervision and neglect. Learning includes: experiencing significant trauma, adversity or loss as a child may contribute to parenting capacity being compromised; where there are multiple risk factors, the importance of thoroughly assessing each one to understand which needs might be associated with which risks; practitioners should link and analyse facts about parental issues which may have an impact on a child’s safety, with records reflecting thinking processes; the importance of consistency and continuity of social workers, to build trust and to monitor any developments that may negatively impact a child; the importance of revising initial assessments about a child’s circumstances, as failing to review these may result in risk to the child; chronologies can be key for understanding needs and risks, and can support assessment and risk management. Recommendations include: consider an audit of open cases where anonymous referrals are made, to ascertain the quality and effectiveness of the assessment and response; consider a multi-agency audit on how thresholds are applied by children’s services in cases where there are concerns about unborn children; raise the profile about the need for practitioners to be professionally curious about male associations with vulnerable women. Keywords:   burns, injuries, parents with a mental health problem > Read the overview report

2022 - Berkshire West - Serious Youth Violence

Serious incidents in early 2021, including the fatal stabbing of a teenage boy and an adult. One adult and six young people were convicted of offences including murder and manslaughter. Learning includes: difficulties identified in school attendance and behaviour, and the professional response; the involvement of boys in criminal behaviour in early adolescence and the response of services; patterns of social care and early help service involvement, team allocation, assessment, and thresholds; child and adolescent mental health (CAMHS) and other specialist health services; and incidents of violence against girls and women. Recommendations include: services should jointly develop a ‘problem profile’ of serious youth violence and child exploitation; services should evaluate the profile of children at risk of exploitation to provide a better understanding of any disparities in service provision and outcomes associated with race, ethnicity, and disability; there should be improved information sharing with schools about pupils who may be at risk of exploitation; the time taken for cases involving young people to be investigated and resolved should be reduced; the role that the Pupil Referral Unit can play in combatting child exploitation should be reviewed; the number of professionals who are involved with children and young people should be reduced; there should be earlier referral and engagement with CAMHS for children who are at risk of school exclusion; and the role of speech and language services in relation to young people at risk of entering the youth justice system should be reviewed. Keywords: adolescent boys, adverse childhood experiences, child criminal exploitation, children missing education, gangs, young offenders > Read the overview report

2022 – Birmingham – Hakeem

Death of a 7-year-old boy from asthma in November 2017. Hakeem’s mother was convicted of gross negligence and manslaughter. Learning includes: confusion by professionals around significant harm thresholds for neglect where a child has a chronic medical condition that is being poorly managed by a parent; a lack of communication between those responsible for non-school attendance and children’s social care which resulted in the two processes not taking account of the neglect that Hakeem was experiencing; little professional understanding of the daily lived experience of the child, resulting in a lack of assessment of what Hakeem’s reality was like and the level of neglect experienced; failure by agencies to consult and inform the birth father of the growing concerns for the child, resulted in professionals not adequately taking account of his ethnicity and background, alongside the potential for extended family support. Recommendations include: where children have had hospital admissions for chronic conditions there is a robust discharge plan that includes identifying if any other agencies are involved; improvement work on engaging fathers includes those who may be on remand or serving prison sentences and makes appropriate reference to their ethnicity and family support networks; need for pharmacists to have specific safeguarding training that makes links between parental drug misuse, prescription medical equipment and childhood asthma. Keywords: c hild deaths, child neglect, children with a chronic illness, drug misuse, father-child relationships, manslaughter > Read the overview report

2022 - Blackburn with Darwen, Blackpool and Lancashire - Child AB

Two siblings, aged 15 and 6-years-old, removed from their mother’s care in May 2020. There was an investigation concerning sexual offences against the children involving an unrelated male who had been sent images of Child B by his father. The father was at the time a convicted sexual offender having been found guilty of downloading indecent images of children in 2014. Learning themes include: the child protection plan; the team around the family plan; effectiveness of universal health services; the voices of the children and their lived experience; disguised compliance; assessment and management of the father’s risks to the children; and elective home education (EHE). Recommendations include: GP practices should be fully compliant with all relevant safeguarding procedures, including information sharing, knowledge of a child’s safeguarding status and when to refer to children’s social care; the EHE service should provide guidance, including an integrated decision and action pathway, that enables professionals to assess that children are receiving a suitable education, that also meets any safeguarding needs and which is subject to the prevailing statutory provisions; the Department for Education should produce practitioner guidance that seeks to integrate EHE and safeguarding policy and practice, including a decision-making flowchart; National Probation Services and the local constabulary should take steps to ensure that offender manager practice of sex offenders is informed by a more holistic approach to assessment and risk management planning; and the College of Policing should review the active risk management system tool and consider including wider family dynamics and additional corroborative evidence beyond offender self-reporting. Keywords : child abuse images, disguised compliance, fathers, home education, probation service, sex offenders > Read the overview report

2022 - Blackburn with Darwen, Blackpool and Lancashire – Child C, D and E

Deaths of Child D aged 24-days-old and Child C aged 21-months-old seven months apart in 2013 following breathing difficulties at home. Several years later Child E was admitted to hospital with breathing difficulties. In 2018 Child C and D’s father was arrested and found guilty of murder and attempted murder. Learning themes include: perplexing presentations (PP)/fabricated or induced illness (FII) and physical abuse in children; medically unexplained deaths in children including sudden unexpected death of children (SUDC) arrangements, child death overview panel (CDOP) arrangements and criminal investigation; and coercive control and domestic abuse. Recommendations include: review the implementation plan developed in support of the new local arrangements for perplexing presentations or fabricated or induced illness in children and consider the inclusion of the proposals for learning identified in this review; request paediatricians consider a review of using an assessment tool such as the Brief Resolved Unexplained Event (BRUE) model to support their clinical practice and to improve the risk assessment of children attending with brief resolved unexplained events; conduct a partnership wide audit with their acute hospital trusts to review the effectiveness of the arrangements for facilitating strategy discussions/meetings in the hospital setting; request that the integrated care systems across the partnership review their child death arrangements and provide assurance that the proposals for learning have been addressed; consider how the local in-school programme on coercive control and healthy relationships can be expanded and delivered to young people not in education. Keywords : child deaths, fabricated or induced Illness (FII), sudden infant death, family violence, abusive fathers, risk assessment > Read the overview report

2022 - Blackburn with Darwen, Blackpool and Lancashire - Child LS (Thomas)

Significant head injuries to a 2-week-old boy in Autumn 2018. The injuries were suspected to be non-accidental. Thomas was alone in a room with his brother when the injury occurred. Learning themes include: early help; supporting adults with experience of adverse childhood experiences (ACES) and trauma; the impact of domestic abuse on children; abusive head trauma; safer sleep for infants; and identifying and supporting learning difficulties of parents and carers. Recommendations include: the safeguarding children partnership should require all partners to evidence their organisational focus and response in relation to the Domestic Abuse Act 2021's requirement to recognise children who see, hear or experience the effects of domestic abuse as victims in their own right; the partnership should re-promote the local area's pre-birth protocol across all partners including the examples of pre-birth strengths and concerns to ensure all practitioners have a sound awareness of when and how to consider its use; the partnership should consider how professionals across the partnership are supporting parents and carers with learning disabilities and learning difficulties, what resources are available and whether further awareness raising and promotion regarding responding well to people with learning disabilities and difficulties is required; and the partnership should request assurance from members and subgroups that housing related challenges for families remain a focus across the partnership, including all professionals becoming more aware of the cumulative risks to children which housing issues can bring. Keywords : family violence, early intervention, homeless families, non-accidental head injuries, adverse childhood experiences, adults with learning difficulties > Read the overview report

2022 - Blackburn with Darwen, Blackpool and Lancashire – Child LZ

Death of a 15-year-old girl in January 2020. Michelle was found unresponsive in circumstances that suggested she had ended her life. Statutory agencies had been involved with Michelle due to concerns around drug and alcohol use, exploitation and missing from home episodes. Learning: N/A Recommendations include: issue a reminder to safeguarding partners of the value of working together, adopting a single, whole system approach; issue a reminder to all agencies regarding the effectiveness and use of child abduction warning notices as a pro-active intervention and disruptive option to better safeguard children; issue a reminder to statutory agencies to review policy and procedure around information sharing, ensuring that staff have sufficient awareness, training and are confident in what information to share and who they need to share the information with across statutory and non-statutory agencies; issue a reminder to statutory agencies regarding the definition of domestic abuse, ensuring that staff have received sufficient awareness, training and are confident around the Domestic Abuse Act 2021; commission a review of children in need procedures and processes to ensure all agencies have an effective focus on engaging with a child when an initial contact has been unsuccessful to ensure better outcomes through improved assessment, planning and review; and develop processes to ensure a more robust and tenacious partnership response from all agencies when children known to children's social care go missing to reduce the number and frequency of such episodes. Keywords : child deaths, suicide, adolescent girls, runaway adolescents, drug misuse > Read the overview report

2022 – Blackburn with Darwen, Blackpool and Lancashire – Millie

Suicide of an 11-year-old-girl in March 2019. Learning includes: be less risk adverse and more risk sensible around working together; demonstrate professional curiosity around the effect an absent parent or role model may have on the well-being of a child; think about the bigger picture and adopt a single, whole system approach to needs and risk of a child; be alert to the impact that an increase in the number of underlying risk indicators can have on a child and to be able to spot them, and then respond to them collectively, as early as possible, even in the absence of any obvious high risk factors; have clear management intervention and involvement at critical moments. Recommendations  include: staff should be professionally curious when a pupil has not attended a drop-in session and record the reason for the non-attendance; staff training around the importance of when to share information, what information to share and who they need to share the information with; schools that have a manual paper-based safeguarding system should be encouraged to move to an online system; all designated safeguarding leads in schools should be aware of the importance of the accurate recording, cataloguing, and storing of safeguarding material; safeguarding practitioners should escalate and de-escalate cases up and down the continuum of need scale to ensure that children are receiving the proper level of safeguarding support. Keywords: suicide, schools, professional curiosity, children at risk > Read the overview report

2022 – Blackburn with Darwen, Blackpool, Lancashire – Sarah

Death of an 8-day-old baby in Summer 2017 following head trauma caused by shaking. Learning includes: maternity services should ensure written records reflect the needs of the mother and baby; support plans should be clearly documented to ensure links with early help teams; when significant support is in place for a family it is good practice to hold a professionals' meeting before that support network is closed; maternity services must ensure that there is a full transfer of information in cases where a pregnant mother moves from one area to another; where appointments are missed there should be an effective follow up mechanism; health visitors should follow standard operating procedures when a patient is transferred from one area to another; when a pregnant patient fails to attend appointments, it is critical that these failures are correctly recorded and that a follow up is carried out according to procedures; the need for professionals to have a robust discharge plan for mothers to provide protection and support, including who is responsible; professionals in health and social care need to better understand structures and processes to improve information sharing and joint working. Recommends that the local children's safeguarding assurance partnership should ensure that the learning points raised are subject to a SMART action plan. Keywords: infant deaths, shaking, maternal health services, antenatal care > Read the overview report

2022 – Bradford – Harry

Hospitalisation of 12-year-old boy with a complex range of physical and learning needs admitted with severe weight loss and numerous severe pressure sores in May 2021. Learning includes: a shared digital system is not always a guarantee of effective communication; exercise professional curiosity when there are a high number of absences from school; when domestic violence is known to occur, there should be an assessment of the impact this might have had on the children; there should be robust attempts to engage fathers when they are involved in the child's life. Recommendations include: heads of service/senior managers of education, health and care services working with disabled children with complex needs should ensure that the recommendations in NICE NG213 relevant to their service are implemented; safeguarding training for all professionals who work directly with children with disabilities and complex needs takes into account the research and learning from safeguarding reviews on how and why disabled children are more vulnerable to abuse; promote the importance of 'thinking family' via a campaign aimed at all professionals involved in assessments and/or with designated safeguarding responsibilities in their setting; agencies should review their existing training programmes to ensure that it is clear to practitioners that all children should have a voice, including those who are pre- or non-verbal; review the CSPR arrangements to ensure all relevant services are included in scope even if they were not initially involved in the rapid review; undertake a systems review to ensure a robust approach to child in need arrangements. Keywords: cerebral palsy, disguised compliance, medical care neglect, professional curiosity, voice of the child > Read the overview report

2022 – Brighton and Hove - Child Delta

Death of a 20-month-old girl in December 2019, caused by a combination of starvation and influenza, after being left alone for six days. Learning themes include: decisions about assessment of risk and safety planning; the child’s lived experience; the impact of housing need within assessments; the impact of a young parent being not in education, employment or training (NEET); significance of family history and the impact of trauma and exploitation on an adolescent parent; adultification of an adolescent parent; and issues around facilitating a child focused service for children of parents who are looked after children or care leavers. Recommendations include: review assessment guidance so that holistic multi-agency assessments take place prior to making significant changes to a child’s plan, except when emergency action is required, and include an explicit section to address risks and any necessary risk management plan; assessments of adolescent parents should always include a specific focus on the child’s vulnerable child, especially if they do not have their own social worker; assessments should include all family members who will be involved with child-care; ensure staff are aware of the allocations policy enabling senior managers within children’s social care to nominate a family for housing transfers when there is a need to keep a family together; consider practitioners training needs on the long-term impacts of trauma for children; clarify which social worker is the lead professional when there are different social workers in a family; consider what systems need to be in place to meet the needs of children NEET; and the local authority should address the range of potential accommodation needs for young parents to be able to provide a range of support provision. Keywords : adolescent mothers, child deaths, child sexual exploitation, child neglect, children in care, housing > Read the overview report

2022 - Buckinghamshire - Child AA

Death of a child in 2019. At the time of death Child AA was known to several agencies. Learning: concludes that the death could not have been predicted prior to or at the point of the mother’s mental health assessment during the critical period. Recommendations include: work with the local safeguarding adults board to oversee the review of approaches to the assessment and interventions with whole families where the criteria for a referral to adult services is met; promote the learning from this review across relevant partner agencies, and hold a multi-agency workshop in order to increase working relationships and practitioner awareness; work with the local safeguarding adults board to maximise practitioners’ skills in the assessment of parental mental health and the impact on children including an audit of single and joint training with a view to strengthening arrangements across agencies; oversee the review of multi-agency policies, procedures and protocols relating to parenting capacity and mental illness; work with the local safeguarding adults board to review and update its information sharing code of practice, including the value of working closely with and seeking information from extended family members. Keywords: child deaths, financial support, housing, homicide, parents with a mental health problem, psychiatric care > Read the overview report

2022 – Buckinghamshire – Family T

Significant non-accidental physical injuries sustained by female twin siblings aged 14-weeks-old. Learning includes: a need for risks and vulnerabilities to be effectively identified; the importance of stronger decision making procedures for unborn babies when parents have known vulnerabilities; a need to understand the impact of pregnancy on a looked after child and provide the necessary support; a need for improved information sharing; better understanding around the different roles and responsibilities of various professionals; where relationship coercion concerns are present, clarity is needed around the nature of the concerns and any support or intervention required; a clear understanding of escalation policies to ensure concerns are acted upon; the importance of following the correct policy and procedure when non-mobile infants require a child protection medical for suspected non-accidental injuries; and a robust multi-agency plan to safeguard vulnerable infants should be established during meetings prior to them being discharged from hospital. Recommendations include: timely communication with the parents if there are concerns for the infant; identification of parental support needs; clear communication between social workers for the parent and social workers for the infant; opportunity for parents to contribute to care plans for the infants; improved process and procedures for multi-agency assessments, particularly regarding the involvement of fathers and the use of historical information to inform analysis; and early identification of actions required to safeguard infants when a looked after child becomes pregnant. Keywords: infants, injuries, siblings, twins, pregnancy, risk assessment > Read the overview report

2022 – Calderdale - Baby Q

Referral of a 5-month-old baby to the multi-agency screening team after they were observed to be very pale and underweight. Learning themes include: policies and procedures for monitoring of babies' growth and development; information sharing and effective working between professionals; relationships between parents and professionals; and identification and escalation of safeguarding concerns. Recommendations include: multi-disciplinary professionals meetings should be used to discuss how the needs, wellbeing or safety of children are being met when experiencing difficulties, or plans are not meeting expected progress; there must be a clear handover between professionals who are making or receiving referrals and the management plan should be clearly documented in the child’s records; accurate recordings of a child’s clinical observations and growth parameters are essential; differences of opinion and varying perspectives about events and professionals' and families' views should be recorded as such, and not translated into 'fact'; an entry must be made in the child health record after a child is discussed at a GP safeguarding meeting to reflect the discussion and any agreed actions; make sure key professionals are involved in safeguarding discussions; growth/centile charts should be used to give a consistent overview of trends in weight, length and head circumference; when there are disparities in measurements there should be a joint approach to clarifying the issues; children with a faltering weight pattern should be kept under review to ensure progress against targets set; and individual health professionals should seek advice from their safeguarding leads when safeguarding concerns continue to escalate. Keywords : birthweight, bodyweight, feeding behaviour, health visitors, midwives, parent-professional relationships > Read the overview report

2022 - Cambridgeshire and Peterborough - Child D

Spans the period from March 2018, when concerns relating to physical abuse by Child D’s father and indicators of sexual abuse were raised, until August 2020 when Child D’s brother admitted sexually abusing his sister. Learning themes include: signs and indicators of child sexual abuse, especially the possibility of sibling perpetrated sexual abuse; cultural considerations; language barriers; the role of family members within a household; and no recourse to public funds. Recommendations include: seek assurance from partner agencies that work relating to child sexual abuse that has been undertaken in the past 12 months has been embedded; make information available to practitioners within their agencies for them to gain a better understanding of cultural considerations such as attitudes towards relationships, family life, child development and abuse; all agencies should ensure that the needs of children and families who have a limited understanding of English are met via the use of face-to-face interpreters, translated written material and additional time allowances for meetings; consider whether resources available to parents and families relating to safeguarding such as leaflets should be made available in additional language formats; seek assurance that existing tools such as genograms are utilised for the purpose of considering a family’s composition and the roles that all family members play within a unit especially male family members; and make information available to practitioners within their agencies to improve their knowledge and skills in relation to the financial pressures and impact of having no recourse to public funds. Keywords : child sexual abuse identification, children with learning difficulties, interpreters, language, sibling abuse, no recourse to public funds > Read the overview report 

2022 - Cambridgeshire and Peterborough - Nadia

Suicide of a 16-year-old girl in 2021 at a low secure (inpatient) unit. Nadia had experienced sexual assault, difficult family relationships, and suffered from anxiety and depression. She had been living in inpatient psychiatric units for 12 months. Learning includes: understanding the impact of parental conflict on children; providing the right support at the right time for children with mental health concerns; seeing a child as a whole with regards to multi-agency and multi-familial working; breaking the silence with regards to sexual violence; risks of inpatient stays; and lack of alternative placements to home. Recommendations include: further work to raise awareness about the impact of parental conflict on children and consider whether zero suicide multi-agency approaches/strategies/guidance adequately take account of the recent findings from the National Child Mortality Database (NCMD); to learn from examples of good practice and consider what more may be needed to embed a culture of muti–agency working across the system; ensure a review of multi-agency work includes mapping and engaging immediate and extended family, engaging fathers and building provision in the community to avoid inpatient admission, wherever possible; review service developments in relation to identifying and responding to child sexual abuse, including extra familial sexual assault; and explore how multi-agency partners are working across the organisational hierarchies to find bespoke solutions for children in challenging circumstances. Keywords: suicide, children with a mental health problem, psychiatric hospitals, family conflict, child sexual abuse, voice of the child > Read the overview report

2022 – Cardiff and Vale of Glamorgan – C&VSB 022019

Explores the historic sexual abuse of at least five females committed during the 1980's, 1990's, and 2000's. The majority of disclosures were made when the victims became adults, and the case was investigated fully as a result of these historic disclosures. Learning includes: progress has been made in understanding, recognising and responding to child sexual abuse and exploitation (CSAE) and that this has been helped by dedicated teams, able to contribute to the development of knowledge and expertise; confidence and understanding can be developed through discussions with peers; attention needs to be paid to staff welfare; a major issue for professionals is how to move on from being reactive, i.e. waiting for a disclosure of CSAE to being proactive and actively looking for and recognising signs of abuse; how and who can bridge this divide between communities and professional systems so that the sharing of information and concerns can be facilitated; the importance of holding the 'bigger picture' and the risk that a label can lead to a too narrow focus; professionals must move away from labelling children as challenging or difficult and consider instead why they are behaving as they are; the importance of seeing and understanding children and young people through a child development lens; a shift in the tolerance of sexually abusive and aggressive behaviour and exploitation in schools is required; and the impact on victims can be profound, long lasting, and affect future generations. Recommendations are embedded in the learning. Keywords : child sexual abuse, grooming, disclosure, child sexual exploitation, unknown men > Read the overview report

2022 – Cardiff and Vale of Glamorgan – C&VSB 042019

Death of a 16-year-old young person from suicide, who had difficulty in managing emotional regulation from a young age. The young person was receiving professional support due to adverse childhood experiences and developmental trauma experienced within the family unit. Learning is embedded in the recommendations. Recommendations include: a child or young person who is being considered as a child looked after and where placements are being sourced, should have a shared multi-agency chronology, the chronology should detail the risks and triggers for the child or young person and should be shared with agencies who will have direct involvement, to ensure they can plan and respond effectively; review the multi-agency arrangements for information sharing and planning for an effective transition of a child or young person into an out of county therapeutic placement, to ensure it is fit for purpose; agencies to be accountable for the transfer of services and care arrangements; no service should discharge their involvement until the receiving area has engaged and there is a continuous service between local authority areas; ensure that a child, young person and their families are listened to and are able to fully engage in the care planning process; ensure the voice is captured at all stages of working with a family; and all agencies to receive training and fully understand the relevance of attachment theory, trauma, and adverse childhood experiences and for this to be evidenced as embedded into practice. Keywords : suicide, self harm, voice of the child, family conflict, adverse childhood experiences > Read the overview report

2022 – Cheshire East – Children H and I

Serious sexual offences committed by the mother and a former partner, against Child I. These offences came to light in 2021 but took place in 2013. Concerns for the subject children and/or their siblings are recorded from 2000. There have been many changes in professional practice in all agencies over the course of time considered in the review. Learning themes include: escalation of practitioners’ concerns; inter-generational abuse; management of sex offenders and risk assessments; the voice of the child in assessment and planning; timeliness of forensic testing where children are at risk of abuse. Recommendations include: ensure planned review of the escalation policy is completed; increase awareness and confidence in using the escalation policy and monitor its effectiveness; ensure practitioners have access to training in respect of the impact of inter-generational abuse and tools to support risk assessments; ensure that, where convicted sex offenders are in contact with children appropriate and effective risk management mechanisms are in place; consider the arrangement for risk assessments and safety planning where the allegation is regarding an alleged offender rather than one with convictions; agencies should work together to ensure that potential risk from sex offenders in the family network are assessed in respect of other children with whom they have contact; ensure policies and procedures reenforce the importance of specific risk assessments, such as the ‘Persons who Pose a Risk of Harm’ tool, being completed pending the outcome of forensics. Keywords: abusive fathers, abusive mothers, child abuse images, child sexual abuse, child sexual abuse identification, voice of the child > Read the overview report

2022 - Cheshire East Cheshire West and Chester - Contextual Safeguarding Thematic Review

Incident in October 2020, involving five adolescent boys, in which three adults were stabbed and one ultimately died. Learning themes include: the child criminal exploitation (CCE) ‘system’; mental health and young people known to the CCE system; prevention, early identification and early help; definition of risk and vulnerability; transition for young people in the CCE system to adult services; school exclusions; empowering communities; and workforce development in relation to CCE. Recommendations include: create a multi-agency vision statement regarding contextual safeguarding that informs and directs future practice; enhance existing multi-agency universal and targeted training and support to professionals in relation to CCE; share the learning from this review with the local All-Age Contextual Safeguarding Task Group so that it informs and directs developments in relation to policy and practice (including managing demand on the system); be assured that the local early help offer focuses and responds to known vulnerability indicators associated with CCE and that there is a shared and widely understood definition of vulnerability to CCE; ensure there is sufficient focus on the physical and mental health needs of young people at risk of or involved in CCE and that pathways, such as the ADHD and CAMHS, are appropriately linked so that non-engagement is assessed in the context of potential increased vulnerability; work on communicating prevention messages to local communities and services to recognise indicators of CCE; and ensure young people transitioning to adult services are offered a transition plan and appropriate ongoing support. Keywords : adolescent boys, adverse childhood experiences, child criminal exploitation, contextual safeguarding, county lines, exclusion from school > Read the overview report

2022 – City and Hackney – Child Q

Child Q, a girl of secondary school age, was strip searched by female police officers from the Metropolitan Police Service in 2020. The search, which involved the exposure of Child Q's intimate body parts, took place on school premises without an appropriate adult present and with the knowledge that Child Q was menstruating. Learning includes: the decision to strip search Child Q was insufficiently attuned to her best interests or right to privacy; all practitioners need to be mindful of their duties to uphold the best interests of children; school staff had an insufficient focus on the safeguarding needs of Child Q when responding to concerns about suspected drug use; the application of the law and policy governing the strip searching of children can be variable and open to interpretation; the absence of any specific requirement to seek parental consent when strip searching children undermines the principles of parental responsibility and partnership working with parents to safeguard children; adultification bias is believed to have a significance to the experience of Child Q; racism (whether deliberate or not) was likely to have been an influencing factor in the decision to undertake a strip search. Makes 14 recommendations to improve practice, including: the Department for Education should review and revise its guidance on Searching, screening and confiscation (2018) to include more explicit reference to safeguarding and to amend its use of inappropriate language; police guidance governing the policy on strip searching children should clearly define the need to focus on the safeguarding needs of children; where any suspicion of harm arises by way of concerns for potential or actual substance misuse, practitioners should contact children's social care to make a referral or seek further advice. Keywords: children’s rights, racism, schools, police, supervision, adolescents > Read the overview report

2022 – Coventry - Stephen Wilson

Concerns a 16-year-old boy’s experiences as an inpatient in various mental health units since early adolescence. In November 2020, Stephen was admitted to an acute hospital, where significant concerns were identified with the care he received. Learning themes include: early intervention in transition to secondary school, CAMHS and children’s services; meeting the needs of children with autism spectrum disorder (ASD); Education, Health and Care Plans (EHCPs) and the importance of school life; responding to complexity; availability and suitability of care in general hospital wards and inpatient units; governance and assurance after a significant safeguarding incident has occurred; collaboration across the multi-agency system; voice of the child; and advocacy. Recommendations include: the partnership to seek assurance that primary schools routinely identify children who may struggle with transition, with a focus on children with ASD; the partnership to strengthen multi-agency working with children who have mental ill health; the partnership to maintain an active overview of the waiting times for ASD assessment; local education services to review the EHCP strategy to reflect the urgent need for an EHCP assessment to be expedited for children at the point of admission to an inpatient unit; for partner agencies to review their approach to children with severe complex needs arising from ASD and/or mental health needs in the community; to ensure that support provided to staff on general paediatric wards enables the best possible care to children suffering from a mental health crisis; to review referral pathways for notifying the partnership of serious incidents, including incidents involving children placed out of area; to include the importance of trusted adults in the multi-agency framework; and to ensure children in inpatient mental health units are offered an independent advocate. Keywords : autism, child neglect, psychiatric hospitals, child mental health services, children with a mental health problem, provision of services > Read the overview report

2022 – Coventry – Child T

Physical and sexual abuse of a 2-year-old boy. Child T was presented to hospital by his mother on 21st July 2020. Extensive bruising was noted on examination, including to genital area. There was a lack of recognition of the potential sexual abuse in this case, and physical abuse was the initial focus. Learning includes: the importance of recognition or consideration of the potential of sexual abuse; the importance of a robust, appropriately attended and informed strategy discussion to provide opportunities to gather information to protect a child; need for the Sexual Assault Referral Centre (SARC) to attend the strategy meeting in child sexual abuse cases; the importance of awareness, policy and guidance for practitioners regarding the accessing and coordination of medicals for child sexual abuse. Recommendations include: consider what the barriers are to professionals considering the potential of sexual abuse in the family environment; agencies involved in referring children to the SARC for examination should ensure that full relevant records of previous examinations (including body maps) are made available to the SARC to fully inform the examination and that they are available for retention; where a child is examined at the SARC, on each occasion, consideration should be given to examine the child for any signs or indications of sexual abuse where clinically and evidentially appropriate and with appropriate consent, accompanied by easy to follow staff guidance; consider what information is available to practitioners to effectively seek and record the voice of the child, in particular in young pre-verbal children. Keywords : abused boys, bruises, child sexual abuse, child sexual abuse identification, medical assessment, voice of the child > Read the overview report

2022 – Coventry – Matt

Death of 2-and-a-half-month-old boy in June 2019. Cause of death has not been formally determined. Learning includes: need for all agencies to ensure practitioners are aware of the lived experience of the child and understand the cumulative effects of continued neglect; where there is concern regarding safe sleeping, despite advice, there is a need for escalation and differentiated response; clear procedure required once disguised compliance is identified; suspected drug use by parents should be effectively considered in social work assessments, to allow this is be ruled in or ruled out; there should be a clearer pathway between children’s social care and early help; exploration required of how well children leaving care are prepared for parenthood; pre-birth assessment should be considered when there are concerns around neglect or other vulnerabilities; where a referral is made to the MASH and a strategy meeting takes place, the professional making the referral should attend, and any assessment by children’s services should seek the views of other involved professionals. Recommendations for the local safeguarding partnership include: review of the neglect strategy, including implementation and embedding of the Graded Care Profile 2 (GCP2); review the approach to safe sleeping, with particular focus on parents that are suspected or are known to use substances and/or alcohol; review the support, training and advice for professionals dealing with families demonstrating disguised compliance or who are avoidant and/or resistant. Keywords: adults in care as children, infant deaths, neglect identification, parenting capacity, preparation for parenthood, sleeping behaviour > Read the overview report

2022 – Croydon - Jake

Suicide of a 17-year-old boy. Jake was subject to a care order, living in supported accommodation and awaiting an alcohol rehabilitation placement at the time. Learning themes include: early help; the help seeking nature of challenging behaviour; drug awareness; responding to risk in adolescence, especially for high-risk children who are not engaging in services; identity and belonging and youth culture; engaging family members; and models of care for children with a complex and high-risk presentation. Recommendations include: consider how multi-agency reflective forums will be built into multi-agency meetings or panels and other current established processes; develop and promote the directory of statutory and voluntary services so that services and referral pathways are visible and known to all agencies; promote substance misuse training; raise awareness of intersectionality and the use of an appropriate framework or tools to consider a child’s presenting needs; assess the number of services involved with a child, their engagement and impact; consider how current training and awareness raising forums can be used to facilitate an understanding of youth culture; review, with services, support offered to families; oversee the development of multi-agency plans for children where contextual risks exist and when risks do not fit into the usual categories of gang affiliation and sexual exploitation; and agree across agencies the main principles for in-patient admission, welfare secure or other response including clarification about who is the lead agency in the child’s care to ensure multi-agency ownership of care for children who are known to be at high risk. Keywords : suicide, adolescent boys, substance misuse, exclusion from school, child mental health, youth justice > Read the overview report

2022 – Cumbria – Leiland-James Michael Corkill

Murder of a one-year-old male child in 2021. At the time of his death, the child was in the care of the local authority and was placed with prospective adopters. The female prospective adopter was found guilty of his murder and child cruelty. Learning includes: medical assessments of potential adopters require a thorough consideration of their medical records and include information from specialists and providers of mental health support; the system would be more robust if these assessments were updated at the point of matching and before an adoption order is made; improvements are required regarding seeking, sharing, and considering any adult vulnerabilities that could be a risk to children; adoption systems and practice must ensure that there is improved consideration of the lived experience of other children in an adoptive household; when it is apparent that there are issues with prospective adopters bonding with a child placed with them, a robust and timely professional response is required that recognises the emotional impact on the child and the pressure on carers. Recommendations include: the Child Safeguarding Practice Review Panel to ask the Department for Education to review adoption guidance considering the learning from this review. Keywords : child deaths, murder, adoption > Read the overview report

2022 – Cwm - Child M

Death of a 16-year-old boy in 2019. Child M was in and out of care throughout his life and experienced multiple placements. There were significant concerns each time M returned to the care of his mother, linked to neglect and emotional harm. Learning themes include: the importance of placement permanency planning; the importance of escalation and professional challenge; and the importance of record keeping, decision making and accountability. Recommendations include: the child’s wellbeing should be central to decision making in identifying permanency options; updated plans to support placement should be informed by the child’s multi-agency chronology, specialist reports, assessments, and research relevant to the child’s specific circumstances; the evolving view of the child should be obtained, recorded and considered as a critical element to permanency planning; clear handover arrangements should be in place when cases are transferred between teams or reallocated to a newly appointed worker; where a care and support protection plan is not keeping the child safe all involved professionals have a responsibility to challenge using existing processes; independent reviewing officer (IRO) resolution processes should be used and followed by IROs; proper consideration of S5 of the Wales Safeguarding Procedures (Concerns about practitioners and those in positions of trust) and S3(1) (Responding to a report of a child at risk of harm, abuse and/or neglect) must be followed; and agencies should provide the safeguarding board with assurances that record-keeping is robust and provides clarity of context, incorporates the voice of the child and includes records of decision-making. Keywords: permanency planning, placement breakdown, emotional abuse, child deaths, decision-making, accountability > Read the overview report

2022 – Cwm Taf – Child T

Death of a 5-year-old boy in July 2021. Child T's mother, mother's partner and the stepchild of mother's partner were subsequently convicted of Child T's murder. Learning includes: the impact of COVID-19 restrictions on the ability of agencies to implement optimum child protection processes; the complexities of adult relationships overshadowed understanding of Child T's lived experience; a lack of understanding from professionals of their duty to inform any person who holds parental responsibility of child protection concerns; professionals did not fully explore the context of Child T's race and ethnicity on his lived experience; information sharing systems not supporting multi-agency information sharing and being a barrier to systemic decision making; and an inconsistent approach within children's services to quality assurance of assessments and planning across several areas of case management. Recommendations include: the Wales Safeguarding Procedures Project Board includes guidance for child protection practitioners on their duty to include all persons with parental responsibility in child protection assessments and processes; a pan-Wales review of approaches to undertaking child protection conferences to identify effective chairing/facilitation methods and ways of ensuring full multi-agency attendance and participation; the Welsh Government considers commissioning an annual national awareness campaign to raise public awareness on how to report safeguarding concerns; the Welsh Government considers commissioning a full review of health, social care, education and police recording, information gathering and sharing systems; and the President of the Family Division considers the imposition of a12-week minimum for any social work assessment within public law proceedings. Keywords : child deaths, injuries, murder > Read the overview report

2022 - Cwm Taf Morgannwg - CTMB 5/2020 (Child O)

Key themes include: understanding the relevance and importance of chronologies; explore if there were any missed opportunities for important intervention by agencies; the relevance of good communication and handover of care/information between professionals/agencies; routine enquiry and the opportunity to explore any concerns; and the impact of COVID restrictions and challenges for all agencies. Learnings include: midwifery and health visiting services need to develop a regular, consistent information sharing process; review and update their guidance in relation to public protection notices and the assessment of the impact/risks posed to children from domestic abuse; health visiting and midwifery services to complete an audit of routine enquiries to establish compliance; use of chronologies to help identify risks, patterns, and issues in a child’s life; referrals to agencies were treated in isolation, and did not fully consider previous contacts, as individual referrals these were not sufficient to meet thresholds for child protection; be alert to patterns of coercive or controlling behaviour, as well as incidents of abuse; remain professionally curious when working with individuals and families; assist professionals to recognise when individuals are resisting engagement with services and how this can manifest itself; and ensure that information relating to anti-social behaviour is submitted to relevant agencies in line with South Wales Police anti-social behaviour process and without unreasonable delay. Recommendations : N/A Keywords : child neglect, sudden infant death, sleeping behaviour, adolescent parents, family violence > Read the overview report

2022 – Derby and Derbyshire - Baby RD

Death of an infant in 2020 while in a mother and baby unit of a psychiatric hospital. The mother admitted she had caused Baby RD’s injuries and was subsequently charged, convicted, and sentenced. Learning themes include: the potential impact of a parent’s significant mental ill-health on their children and in particular the challenge of assessing risk when the illness is of a cyclical nature; the role of early help for vulnerable parents, making a referral and planning an intervention; the benefits of the ‘think family’ message; the response to emergency situations, for example suicidal behaviour or attempts to harm a child when the adult concerned is a parent. Recommendations include: consider how best to promote and embed the ‘think family’ agenda and seek information from each agency about how they evaluate the effectiveness of the initiative; seek assurance that all agencies, including adult services, are fully engaged with the use of early help assessment; engage in discussion with commissioners of service about developing and strengthening the team working on the mother and baby unit in order to ensure a multi-disciplinary approach to risk assessment and that the voice of the child is not lost in the midst of a parent’s mental health crisis and medical treatment; seek assurance from the local Healthcare Trust that an effective protocol is in place which addresses the response to a medical emergency and that all staff are familiar with the content and its application within their working environment. Keywords : bipolar disorder, infanticide, maternal depression, parents with a mental health problem, psychiatric hospitals, psychoses > Read the overview report

2022 – Derby and Derbyshire – Child QDS 20

Death of 10-year-old girl in April 2020, found in bed with a ligature around her neck. Her father was in prison following a violent assault on the mother. Learning themes include: the lived experience of domestic abuse for a child; vulnerable children remaining the focus of agency concern when they move areas; parental alcohol abuse; cultural and language considerations; signs and triggers of emotional distress in children; and online safety and the dangers of children viewing age-inappropriate content. Recommendations include: all guidance should emphasise the importance of understanding the lived experience of the child; re-emphasise the message that domestic abuse is always harmful to children; proactively offer support to those families who are transitioning from refuge into independent living; review training needs to ensure professionals have a better understanding of the complexity of parental alcohol misuse and include training on interpretation and understanding of hair strand samples; continue to emphasise the dangers of children viewing age-inappropriate content; ensure processes are in place so that when children on a Child Protection Plan move areas, they are not removed from systems automatically and their information is reviewed; ensure schools display the appropriate level of professional curiosity and proactively seek information for new pupils transferred in; ensure that third sector organisations such as refuges share information so that partner agencies have clarity about their role in safeguarding existing and previous residents; ask the ‘Victim Care’ service to consider reviewing the current arrangements governing the sharing of information regarding the prison release of perpetrators within the family. Keywords : child deaths, family violence, alcohol misuse, culture, online safety, prison and prisoners > Read the overview report

2022 – Derby and Derbyshire - LDS 19 / OD 20

Joint review considering the experience of two infants from two separate families. Death of a 6-month-old infant from oxygen deprivation as the result of unsafe sleeping with the mother, and serious injury suffered by an infant with significant medical needs. Neglect was a feature of both cases. The review also refers to the case of a third infant who suffered serious non-accidental injury. Learning themes include: intrinsic risk to infants due to their immature anatomy, physiology and rapid development; the introduction of any infant into a household resulting in some level of stress; the need to quickly identify and assess any additional risks an infant will face, such as additional needs, challenges in the home environment, carer response to stress, and current/history of carer mental health problems or substance misuse; the importance of good multiagency communication and relationships built on understanding, valuing, and trusting each other's roles; and the importance of recognising and having ways of addressing hidden risk when carers are not accessible to assessment or there is a lack of openness by carers about potentially harmful behaviours. Recommendations include: the development of a universal risk assessment tool to guide professional practice in safeguarding infants; recognising the importance of supervision in supporting implementation of all actions aimed at keeping infants safe; child safeguarding learning programmes across all agencies to address the need for practitioners to be knowledgeable about the roles of all professionals involved in child safeguarding; and a review of current practice for partnership working at all levels in cases involving infants, including clarity about multiagency plans, and due attention given to stress points within a family. Keywords : infant deaths, children with disabilities, stress, non-attendance, parental involvement, interagency cooperation > Read the overview report

2022 – Derbyshire – Child G

Death of a 2-month-old child in June 2019 following admission to hospital with severe breathing difficulties. Child G was found to have died from non-accidental injuries; their father was charged with manslaughter. Learning includes: a need for 'hidden men' training to be reinforced on a regular basis, in order to keep this issue current to practitioners; interventions could be strengthened by a more professionally curious approach around parental history, relationships and dynamics; concerns and subsequent actions need to be clear in the GP record, and information placed on health IT systems; need for better cross border communication to help safeguarding between community midwives and hospitals. Recommendations include: the safeguarding partnership ensures their 'pre-birth protocol' is operating effectively; all assessments and interactions with families to consider the role, presence and the history of fathers to the children and male partners living in or associating closely within a household; the local parent education programme on 'shaking the baby’ is delivered by community midwives to both parents if the programme is not delivered in hospital. Keywords : infant deaths, neglect, non-accidental head injuries, parenting capacity, shaking, unknown men > Read the overview report

2022 - Dorset - The Siblings

Sexual abuse of a 13-year-old child by adults not known to them. Over three years there were concerns for this child and their siblings in relation to extra-familial child sexual abuse, intra-familial child sexual abuse and child neglect. The siblings were aged between 9-18-years-old at the start of this review. Learning themes include: working to identify, assess and address intra-familial child sexual abuse; addressing extra-familial harm; recognition, identification and addressing the neglect of children; supporting disabled parents and ensuring their participation; and cultural literacy. Recommendations include: the child sexual abuse toolkit highlights the importance of understanding a parent’s capacity, as the non-abusing parent within assessments, particularly where that parent may have additional needs such as a disability; review the local ‘keep safe’ work to respond to actual or likely child sexual abuse and child sexual exploitation in line with the emerging evidence base about this work; review the local child sexual exploitation toolkit and multi-agency child exploitation (MACE) paperwork to ensure this explicitly references the harm caused to children, has a focus on the impact of that harm, what action is to be taken, and how this will be communicated to the child in a trauma informed way; align the child sexual abuse toolkit and child sexual exploitation toolkit more closely, and provide consistent practice messages; work is undertaken to understand how child neglect tools are working in practice, considering any barriers to professionals in using these; update the ‘engaging families’ toolkit to include information on culturally literate practice. Keywords : child sexual abuse, child sexual exploitation, intra-familial child sexual abuse, child neglect, siblings > Read the overview report

2022 – Dudley – Child Y

Significant developmental delay in a 7-year-old boy due to neglect. Developmental delay issues were identified when Child Y started school in October 2020. Learning includes: when a young child is missing from education, while it is a priority to ensure that the child starts or returns to school, the possibility of parental neglect should also be considered; systems need to support information sharing between health professionals to ensure that a child's needs are met if there are indications of developmental issues or if appointments are missed; when professionals have concerns that a child is not in education, there needs to be timely information sharing and consideration of the child's lived experience, which includes the child being seen; COVID-19 restrictions have allowed parents who are hard to engage with to avoid professional contact, which indicates that professional rigour and persistence are required to meet the needs of children during a pandemic. Recommendations include: review procedures in relation to children missing from education to ensure that reference is made to younger children, and to links with neglect; seek assurance on the effectiveness of the local authority education service when a child missing education meets the criteria for a school attendance order; ensure partner agencies hold Working Together compliant strategy meetings to plan investigations and visits, and that there is consideration of a child protection medical in neglect cases. Keywords: child neglect, school attendance, coronavirus, information sharing > Read the overview report

2022 – Doncaster - Cameron

Death of an infant in 2020. Cameron was attacked in the family home by a dog owned by the father. Learning themes include: parental neglect; analysing risk in relation to ‘Signs of Safety’ guidance; parental mental health; responding to indications of domestic abuse; assessing the risks which dogs may present to children; the GP practice response to an earlier dog bite; GP practice involvement in child protection planning; and the impact of Covid-19 restrictions. Recommendations include: monitor progress against the strategic priority of neglect and associated workstreams; seek assurance the 'Signs of Safety' approach ensures that all risks to a child receive appropriate attention and that the cumulative impact of multiple risks is not obscured by a requirement to focus on a small number of risks; consider both maternal and paternal mental health and their potential impact on parenting capacity; learning from the case informs Doncaster’s domestic abuse training programme; share the concerns about the system for combining reports of the same domestic violence incident reported to different agencies by the victim and perpetrator; revise referral criteria in the partnership's 'Dangerous dogs practice guidance' to include injuries to children by a dog who are subject to child protection or child in need planning; introduce the mandatory use of the partnership's 'Assessing dogs who may pose a risk to children' alongside all pre-birth assessments where there is a dog in the family home; and seek assurance that all GP practices accurately code any involvement that children's social care has with every child. Keywords : infant deaths, pets, partner violence, child neglect, general practitioners, risk assessment > Read the overview report

2022 - Ealing - Young Person H and others

Review of three cases involving adolescent self-harm, including a young person who attempted suicide in 2021. Learning includes: professional fears around challenging conversations with young people on self-harm being rooted in a fear of making situations worse; if foster carers are equipped and supported when taking on a young person who self-harms; issues around risk management plans and working collaboratively to find the best support for a young person; issues of working across boundaries, including young people being registered for services in a different borough and in relation to child and adolescent mental health service (CAMHS) provision; if therapeutic interventions are focused enough on the impact of adverse childhood experiences; lack of knowledge or experience in discussing gender identity with young people. Recommendations include: review working practices to improve the confidence and ability of practitioners to have difficult conversations that focus on mental health; adolescents are able to have agency over their own risk management plans; training on gender identity and what this means for young people; support parents struggling with self-harming behaviour; support the training of foster carers in understanding self-harm and risk management; the young person and their parent/carer have continued access to a CAMHS clinician regardless of where they are living; agree a mechanism for managing risk across agencies; ensure gender identity is a key strand of equality action planning across all agencies. Keywords: adolescents, self harm, child mental health, child sexual abuse, gender identity, children in care > Read the overview report

2022 – East Sussex – Child AA

Stabbing of a 17-year-old in April 2021, resulting in life threatening injuries, and a need for long term medication. Learning themes include: robustness of multi-agency activity to disrupt criminal exploitation and county lines; impact of missing education for vulnerable children and young people; transfer of safeguarding information between schools; transition between educational establishments for children who are excluded from school; and family engagement and environmental factors. Recommendations include: the Multi-Agency Child Exploitation (MACE) Silver Group should review measures of effectiveness of disruption tactics currently used in plans and what legal orders, if any, would be most effective in supporting disruption plans; the police force should strengthen communication between themselves and MACE partners to ensure effective involvement of partner agencies; the local safeguarding children’s partnership (LSCP) and safeguarding adult board should develop a strategy to ensure there is adequate transition provision to support criminally exploited children as they move to adulthood; embed the referral process to MACE with schools and facilitate improved information sharing of safeguarding records between schools and colleges; develop a robust register of children who are permanently excluded which is monitored and reviewed to ensure support and a full-time education offer; the local authority should establish a clear pathway for how alternative provision is accessed and the role of the pupil referral unit for permanently excluded children; embed a protocol to follow for the transfer of records between schools; and the LSCP should encourage the use of therapeutic thinking across all secondary schools so that suspensions and permanent exclusions are used as a last resort. Keywords : child criminal exploitation, children missing education, county lines, exclusion from school, pupil referral units, young offenders > Read the overview report

2022 – East Sussex – Thematic review

Thematic review focusing on two families where adults had significant vulnerabilities, including a history of abuse and neglect in their own childhoods, previous relationships where domestic abuse featured, mental health issues and substance misuse. Learning includes: systems must enable the impact of a parent’s vulnerabilities and associated risks to be understood by all professionals working with the family; professionals require support when trying to work with resistant and hard to engage families who do not acknowledge professional concerns and refuse to ‘own’ a child protection plan; when the concerns or allegations do not meet the threshold for criminal charges, formal multi-agency consideration should be given to why this is and to the potential need to safeguard the child and/or their siblings; professionals need to understand the ongoing and reoccurring nature of domestic abuse and parental mental health issues to fully appreciate the impact on children; there is cumulative risk of harm to a child when parental and environmental risk factors are present in combination or over periods of time; as children approach adulthood, those who are known to be vulnerable, particularly those that are on a child protection or child in need plan, require on-going and focused multi-agency support with a clear plan; and COVID-19 had an impact on the families and the professional response. Recommendations are embedded in the learning. Keywords : adverse childhood experiences, substance missuse, family violence, transition to adulthood, mental health > Read the overview report

2022 – Essex - Child P

Death of a 13-year-old girl in September 2019 from suicide five days before her 14th birthday. Learning is embedded in the recommendations. Recommendations include: be able to articulate what the barriers might be to hearing the voice of the child at a system and practice level; make clear the expectation that all working with vulnerable children are alert to the depth and breadth of knowledge that they hold about the child’s history and current networks and ensure that this is incorporated into ongoing assessments and plans; where there is a significant change in a child’s circumstances a swift meeting should take place with relevant practitioners and family members in order to agree a multi-agency response and any adaptations to the Child in Need plan; work with partner agencies to clarify the expected steps to take when young people engage in sexually harmful behaviour; ensure that staff have the knowledge and skills to work confidently with young people and support families, where there are risks associated with their engagement in the digital world; ensure that strategy meetings/discussions are child focused and separately identify the vulnerabilities of the young person alongside risks to others; promote a balanced approach to discussions about whether a child should become looked after; clarify the process for the provision of financial support for family and friend carers and make sure that this is used creatively to prevent children becoming looked after; and review the training and development opportunities for staff who are expected to chair Child in Need meetings to ensure that all staff are adequately supported to undertake this task. Keywords : bereavement, foster care, sexting, children with a mental health problem, adolescent girls > Read the overview report

2022 - Gloucester – Laura and Ella

Joint domestic homicide review and serious case review. Murder of an 11-year-old girl by her stepfather in May 2018. Ella's mother was also murdered. Learning includes: the important role of family and friends as source of support; the need to consider the voice of the child; consider the impact of a new step-parent and their background on a child's life; health professionals need to know and document who has parental responsibility for a child as well as the other adults in a child's life; the need for all services to ensure they have  policy, training and record-keeping procedures to adequately address domestic abuse, and for services to benchmark themselves against best practice or national guidance; all frontline professionals need to confidently speak to survivors of domestic abuse about their situation despite any denial or minimisation, to understand where barriers come from, and to address domestic abuse beyond basic inquiry; the need for strategic boards for domestic abuse, safeguarding and health and wellbeing to work together to adequately resource and support multi-agency and best practice in relation to domestic abuse. Recommendations include: all agencies should provide domestic abuse training, including economic abuse and the homicide timeline; local safety partnership agencies to ensure stronger links with the domestic abuse board; local safety and children's safeguarding partnerships to ensure that national mapping data on domestic abuse, child fatalities and child safeguarding is applied countywide. Keywords : child death, murder, family violence, voice of the child, interagency cooperation > Read the overview report

2022 – Gwent - Elena

Death of an 8-month-old girl in August 2020. She was born with a serious heart condition identified antenatally and fitted with a naso-gastric tube for the feeding and medication routine. Learnings include: agency arrangements for responding to vulnerable families during the pandemic could have been better promoted across partners; a discharge planning meeting or multi-agency disciplinary meeting could have improved better information sharing and coordination of community and hospital-based services; health service records are fragmented with some not being recorded and stored electronically; a sleep environment assessment was not undertaken; when working with complex families, there can be misconception about the roles and responsibilities of statutory and non-statutory support, which includes, misconception about threshold criteria for access to each service. Recommendations include: in the event of significant service disruption, individual agency service delivery plans for responding to vulnerable families, are shared with partner agencies; further training in relation to recognising and responding to concerns in respect of vulnerable individuals and families and on the quality of the information submitted; promote the utilisation of multi-disciplinary meetings in cases of children with complex needs requiring care in the community and where there has been cross health board involvement; improve the systems in which information is recorded, stored and shared; and ensure awareness regarding the duties, roles, and responsibilities of statutory and non-statutory services. Keywords : infant deaths, health, sudden infant death, record keeping, home visiting > Read the overview report

2022 - Halton - Child G

Non-accidental brain injuries to a 6-month-old boy in May 2021, thought to have been caused by shaking. A subsequent investigation made adverse findings in respect of his father. Learning themes include: transfer in arrangements, and meeting the health and education needs of children; safeguarding and the importance of recognising the impact of domestic abuse on children including unborn babies; and consideration of cultural background. Recommendations include: make sure that local health and education providers have effective arrangements in place to share information about children moving in and out of the area; seek assurance from all relevant agencies that when information is shared or received about an Acute Life-Threatening Event (ALTE), steps are taken to identify and safeguard any siblings; seek assurance from the local health trusts that health visitors and midwives exercise ‘respectful scepticism’ and curiosity when parents deny reported incidents of domestic abuse, especially if the mother has previously been subject to domestic abuse, and/or she is pregnant, and consider the potential impact on the unborn child and any siblings; support partner agencies to raise awareness about the dangers of shaking babies and how to reduce the risk, ensuring that fathers are also aware of the dangers and that this is also addressed in the roll out of the programme ‘Babies cry you can cope’; seek assurance from partner agencies that they have or will develop training and briefing materials for practitioners about working with BAME people, including how to find out about unfamiliar families’ cultural backgrounds. Keywords : abusive fathers, crying, family violence, non-accidental head injuries, physically abused infants, shaking > Read the overview report

2022 – Hampshire - Amelia

Multiple injuries to an infant girl in May 2019. Amelia's mother was later charged for child cruelty. Learning includes : the local safeguarding children partnership to consider further promotion of its practitioner-based toolkits to support working with unidentified adults and adopting a family approach; children's services and the local NHS Trust to share the toolkits again with frontline staff, and ensure the toolkits are included in training; future audits of multi-agency practice to review agency record keeping, ensuring that records are clear regarding what information has been shared by service users, and what information has been passed to other agencies for further action; the need to develop information for partner agencies on the use of agreed escalation routes; seek assurance that the voice or perspective of the child is included in case files and safety plans. Recommendations are embedded in the learning points. Keywords: infants, physical abuse, information sharing, voice of the child > Read the overview report

2022 – Hampshire – Child P

Death of a 5-week-old infant in 2019 due to severe, widespread and irreversible brain injury. Both parents were arrested and subject to criminal investigations. Mother was subsequently convicted of manslaughter. Identifies learning for all agencies around the following themes: information sharing and assessment of risk; professional over optimism and professional curiosity; and substance misuse. Recommendations include: request health partner agencies to review and develop guidance on the use of vulnerable families meetings to share information and assess risk; promote awareness and undertake training on the themes of professional over optimism and professional curiosity; request that health agencies review their missed appointments policies to ensure this is identified as a potential risk factor, alongside apparent compliance; consider developing best practice guidance and training for universal services on responding to potential risk issues of substance misuse by parents. Keywords: infant deaths, risk assessment, optimistic behaviour, substance misuse > Read the overview report

2022 – Hampshire – Emma

Death of a 16-year-old girl, Emma who was staying with a relative at the time of her death. The relative's partner was convicted of Emma's murder and sentenced to life imprisonment. Learning includes: Emma's positive presentation may have resulted in professional over-optimism and disguised her ongoing vulnerability; when an adolescent is on a child in need plan the supporting professional network needs to consider the parent's ability to support the child; when children are linked to exploitation it should be established if the parent is able to understand the risk posed by contextual safeguarding issues; practitioners outside of children's social care do not always clearly record the voice of the child. Recommendations include: encourage practitioners to operate a reflective mind-set with their case work, being aware of over-optimism and ensuring continuing practice of professional curiosity; practitioners understand expectations regarding recording standards, including how the child's voice is recorded; education settings should ensure that child protection records are transferred in a timely fashion at points of transition; practitioners questioning the language used to describe a child, their presentation and context in assessments and other recording; practitioners knowing how to respond when unreported domestic abuse is raised by a child service user; the local safeguarding partnership conducting a multi-agency audit of adolescents known to agencies due to risk of harm following neglect. Keywords: adolescent girls, murder, contextual safeguarding, optimistic behaviour, professional curiosity, voice of the child > Read the overview report

2022 – Hampshire – Liam

Professional concerns regarding an 11-year-old boy admitted to hospital in April 2020. Liam's presentation at hospital was due to an accidental injury, but his appearance and history of previous medical presentations raised concerns about his care and resulted in the instigation of care proceedings. Learning includes: practitioners should take into account the impact of parental anxiety on a child's overall welfare; practitioners learn strategies for working with parents who are highly anxious; children cannot always easily articulate their day-to-day life experience, particularly when they have no ongoing relationship with an adult outside of the home; the need for practitioners to be professionally curious about information provided by parents and how that impacts upon the care provided; the challenges of working with families where there is partial engagement and disguised compliance.   Makes no recommendations but notes that learning has been incorporated into the local safeguarding partnership's workstreams, including multi-agency training, planned audits and professional guides. Keywords: injuries, disguised compliance, parents, anxiety, professional curiosity > Read the overview report​

2022 – Hampshire - William

Serious neglect of a 12-year-old boy identified at admission to hospital in April 2020. Learning includes : need to develop clear treatment pathways for specialist services; need for patient information for a family which details what the parental or carer expectations are to support the child's treatment; need for managerial oversight and supervision in complex cases, especially where there are concerns regarding parental engagement and compliance with advice and treatment; past information about a child and their parents or carers should inform the child's future health care; have honest and clear conversations with parents about their role in supporting health needs and what will happen if those needs are not met; be professionally curious about information provided by parents and how that impacts upon the care provided; professionals supplying referral information or agency reports for meetings need to be explicit when there are safeguarding concerns about a child; importance of seeking specialist support to ensure medical tests are completed in a timely manner; have robust conversations with other agencies to ensure they understand the significance of a child not having important medical tests completed. This review makes no specific recommendations . Keywords: child neglect, medical care, parent-professional relationship, supervision, professional curiosity > Read the overview report

2022 - Haringey - Baby Mary

Death of a 10-week-old infant in February 2018 from significant non-accidental injuries whilst in the care of her parents. Mary was born prematurely and spent several weeks in a special care baby unit prior to discharge home. Learning themes include: information seeking, sharing and usage to inform assessments, decision making and intervention; over-optimism in parenting capacity; professional challenge and escalation; cross border working arrangements; parents’ engagement with the professional network; transient lifestyle and housing difficulties; and practitioners and managers’ knowledge and confidence in understanding risk of harm, abuse and neglect. Recommendations include: to seek assurance that professionals across the partnership have knowledge about how to respond to professional challenge, professional disagreements and the use of the escalation policy; to review arrangements for discharge planning from hospital when there are concerns about a child’s safety and welfare, and where there are multiple statutory agencies involved; to seek an update about the progress made regarding efforts to unify and promote consistency of practice for children and families moving across London boroughs; to promote a dialogue with relevant partner agencies about how to consistently interpret, apply and evidence threshold decisions when making referrals, with the use of scaling being one tool for achieving this; and to seek assurance that the local housing service is fulfilling its statutory obligations under the Housing Act 1996 regarding notifications to other housing authorities when placing families, or pregnant women, outside of their borough, and their responsibilities under the Children Act 2004 in relation to sharing information with other professionals. Keywords: infant deaths, premature infants, injuries, housing, optimistic behaviour, parenting capacity > Read the overview report

2022 - Hartlepool - Alex

Serious injury to a 3-month-old baby in April 2019; baby was taken to hospital twice in one day, firstly following a reported choking episode and secondly with seizures. The baby was later diagnosed with a subdural haematoma and a healing rib fracture, which were determined to be non-accidental. Learning includes: information regarding parental history and any information on the children known by all agencies should be sought, shared and considered; there needs to be clarity across agencies when a case is closed to Social Care regarding what should happen if any concerns emerge or if the family do not continue to cooperate with any agreement made at closure; impact of parental risks and vulnerabilities should be considered in assessments and when working with a family; when none of the injuries in themselves are likely to meet the threshold for a child protection intervention, consideration of the wider picture may be helpful; if the case is not yet allocated to a midwife, information should be shared with the safeguarding nurse for the midwifery service if a pregnancy is known or suspected; at the point of closure information should be shared with those continuing to work with the family; GP information should be considered as part of a strategy discussion and additional information sought as part of the assessment; strategy discussions should include consideration of whether siblings require a Child Protection Medical; and professionals should be alert to whether assumptions are being made about a family and whether any professional disagreements need resolving formally. Recommendations are embedded in the learning. Keywords : premature infants, non-accidental head injuries, information sharing, parenting capacity, professional curiosity > Read the overview report

2022 – Herefordshire – Louise

Serious, life changing injuries, sustained by 18-month-old girl in June 2019 while in the care of her mother's partner. Learning includes: training on the cycle of change and motivational interviewing; escalation and professional disagreement; and recognition and prevention of abusive head injury in infants. Recommendations include: ensure that there is a joint understanding and agreement in the application of thresholds of all levels of need and that referral pathways are clear and understood; ensure that both child in need and child protection plans and processes are robust, outcome focused and clearly understood and owned by all agencies; to develop a one multi-agency safeguarding access point, that there is robust and consistent management oversight; to ensure that information is effectively shared to make effective and safe decisions including in domestic abuse cases; ensure multi-agency responsibility to identify and respond to all aspects of neglect, including educational and emotional neglect and the effects of non-dependent alcohol use by parents and the impact of these on children; to ensure the impact of domestic abuse on children is understood and prioritised. Keywords: child neglect, partner violence, non-accidental head injuries, information sharing, professional curiosity > Read the overview report

2022 – Herefordshire - Thematic learning following allegations of peer-on-peer abuse

Disclosure of peer-on-peer abuse experienced by a young person. YP1 made two disclosures to a school nurse, who referred the case to the multi-agency safeguarding hub (MASH) and the police. Learning includes: MASH decision-making should be collaborative and multi-agency, and there should be a clear process to record referrals, decisions and actions to ensure that information is not lost when more than one agency makes a referral; family history of relevance to safeguarding should be included in the social care records of all children to facilitate holistic consideration of issues which may impact on children; when there are concerns about peer-on-peer abuse, child and family assessments should be considered for both the alleged victim and the young person alleged to have caused harm; when there are concerns that a child has suffered significant harm as a result of peer-on-peer abuse, it is important that a coordinated multi-agency plan is agreed to focus on the needs and vulnerabilities of both the victim and young person alleged to have caused harm; when speaking with young people about their sexual health, it is important that professionals provide an opportunity for young people to be seen alone without a parent or carer. Recommendations include : implement action plans to improve the multi-agency response to peer-on-peer abuse; ensure that the views and experiences of young people involved in peer-on-peer abuse and their parents and carers inform practice improvements. Keywords: adolescents, harmful sexual behaviour, referral procedures, decision-making > Read the overview report

2022 – Hertfordshire – Child N

Death of a 13-week-old child due to injuries consistent with trauma. There were 41 separate injuries including fractures to her ribs and spine. Child N's mother and her partner were convicted of offences relating to her death and are serving prison sentences. Learning includes: the importance of accessing and analysing historical information about families; the potential risks from the mother's new partner were not understood; the need for practitioners to comprehend fully the significance of bruising to non-mobile infants; transfers of case responsibility between teams, individuals and services were problematic and would have benefitted from a more collaborative child centred approach; inconsistent understanding of the significance of faltering weight and growth measurements in babies; the over reliance on members of the extended family as a protective factor; and the failure to reassess when different information emerges. Recommendations are made in the following areas: antenatal identification of need and risk; background family information; bruising policy; case transfer; poor weight gain, neglect and faltering growth; and assessment of extended family. Keywords: infants, physical abuse, fractures, bruises, feeding behaviour > Read the overview report

2022 - Hounslow - Child A

Long-standing chronic neglect suffered by a child whilst in the care of her mother. She was removed from her home under police protection and admitted to hospital due to the impact of severe physical and emotional neglect in August 2020. Learning includes: the need for professionals to collate and consider information which raises concerns about the safety of a child being home educated; when a child has a history of non-school attendance professionals need to recognise this as a serious safeguarding issue; the necessity for professional challenge when there is indecisiveness and or inappropriate decisions being made during the course of child protection conferences; use of resources available to assess neglect is vital if professional practice is to be improved and children protected. Recommendations include: the Department for Education (DfE) consider amending statutory guidance so that when a parent gives notice of their intention to electively home educate their child, information should be collated from safeguarding partner agencies prior to the child being removed from mainstream education; the DfE consider amending statutory guidance so that local authorities have authorisation to seek assurance that the parent has the intellectual capability and appropriate resources to provide suitable home education to the child, and decide whether it is in the child's best interest; the Safeguarding Review Panel consider including a section on children who are electively home educated in any future revision of Working Together to Safeguard Children. Keywords: child neglect, home education, parents with a mental health problem > Read the executive summary

2022 – Hull – Child C

Death of a child who was found unresponsive at home. The cause of death was recorded as 'sudden unexpected death in childhood' (SUDIC). Several months later information was shared by family members about a non-accidental injury to another child in the family, along with allegations of domestic abuse to mother by her partner. Following a criminal investigation Child C's cause of death was concluded as 'unascertained'. Learning themes include: identifying, assessing, managing, communicating, and working with risk in relation to safeguarding children, supporting young parents, domestic abuse, and child neglect; the child's voice, and the need for continual focus on and consideration of the child's lived experience; and collaborative safeguarding, with practitioners understanding their own and others' roles and responsibilities as set out within legislation and multi-agency policy and procedure. Recommendations : N/A Keywords : child deaths, risk assessment, family violence, child neglect > Read the executive summary

2022 - Isle of Man - Child J

15-year-old Child J experienced a high number of adverse childhood experiences (ACEs) in their life. Child J’s long involvement with social workers revealed a childhood of domestic abuse. Learning themes include: Child J’s ACEs; multi-agency working and information sharing; and contextual safeguarding. Recommendations include: establish with partners a multi-agency strategy and procedural framework for contextualised safeguarding and exploitation, this should ensure it includes an information sharing protocol and consider adopting a vulnerable adolescent service strategy; seek assurance from partners that an early help strategy is being considered and developed to intervene early in the lives of children similar to Child J, this should include a professional framework to improve professional’s knowledge and understanding of the impact of ACEs, implement that understanding in response to children and young people, and for professionals to provide a trauma informed response; ensure that learning is provided that highlights to professionals the importance of identifying and acting on a ‘reachable moment’ for a child at risk of child criminal exploitation; seek assurance from the safeguarding strategic partners that they have systems and structures in place through them working as a multi-agency team with joint responsibility to be able to capitalise on this moment; and support the implementation of the proposed standard operating procedure for a ‘Child presenting to emergency department with a Mental Health Crisis Out of Hours’ as this would help to ensure there is in place actions to deal with similar situations in the future. Keywords : adverse childhood experiences, child criminal exploitation, family violence, mental health, trauma informed practices > Read the overview report

2022 – Islington - Child R

Sexual abuse, including rape of a child by their foster carer from March to July 2020. Learning themes include: children looked after (CLA) who are placed ‘out of borough’; decision making following placement breakdown; exploration of local authority designated officer (LADO) concerns; use of ‘safer care’ agreements; issues of relationships, sexual health, and contraception; and the influence of the COVID-19 pandemic on hearing the voice of the child Recommendations to the partnership include: review and update procedures in relation to sourcing fostering placements for CLA so that, regardless of their status they are subject to the same rigour as occurs for all other fostering placements; the senior leadership team should oversee a review of policy and application of safer care agreements; requests for CLA to take part in activities that involve risk should be agreed in line with the current care plan and only by heads of service; safer care agreements need to be updated in light of changing information; when children are out of borough all the professionals providing the local services should be linked into the team around the child; provide reminders and training to GPs to ensure that they understand their responsibilities in assessing risk when prescribing contraception to young people who are looked after. Recommendations to the corporate parenting board include: review care planning decisions about contraception for CLA who are victims of sexual abuse are or at risk of CSE; oversee a multi-agency task and finish group to review how sexual health is incorporated into CLA care and pathway planning. Keywords : child sexual abuse, children in care, disclosure, foster parents, placement breakdown, rape > Read the overview report

2022 – Kensington and Chelsea and Westminster - Holland Park School

Allegations of staff bullying, poor safeguarding practice, discrimination, and intimidation of students, as well as health and safety issues at a secondary school in summer 2021. Learning themes include: understanding and learning from complaints; school policies; recruitment and training; and school culture. Recommendations to the school include: revise and update the complaints policy and implement a system to review complaints on a regular basis in order to identify areas of strength and areas for development; school policies should be reviewed (annually) and approved by the governing body and shared with school staff; devise systems for maintaining staff training records centrally in line with statutory guidance and managing staff exit interviews; ensure that the staff and governors have sufficient knowledge, safeguarding training and skills to undertake their roles effectively, in order to adopt a whole-school approach to safeguarding; review the use of safeguarding recording systems in line with statutory guidance, including where there are low-level concerns about an adult; review and update its line management systems to ensure that all staff, including senior leaders, are held effectively to account; ensure school governors receive refresher training on how to manage allegations about staff, including senior leaders; review the range and purpose of sanctions in line with DfE guidance including the use of the isolation room to ensure that this is consistent with good practice; the Local Authority Designated Officer (LADO) service should review how low-level concerns about children’s settings are recorded and tracked in order to help identify patterns and trends that may indicate further concern. Keywords : complaints, secondary schools, school records, staff welfare, teachers, leadership > Read the overview report

2022 – Kent – Children O and P

Death of two 23-month-old toddlers in December 2018. Learning includes: a need for information sharing between the general practitioners (GP) and the health visitor; a need to draw on the wider healthcare team to obtain as full a picture as possible of a child’s life in order to recognise those in need; a need for insight into the impact of the breakdown in the parents’ marriage on the children; a need for information sharing with regards to updating the NHS spine when people move address; professionals need to recognise the relationship between adult mental health and safeguarding children; a need for further focus on the impact of a parent’s deteriorating mental health on their capacity to care for their children; and recognition that there is less likelihood of determining a patient’s true condition when contact with a service is over the telephone. Recommendations include: review the effectiveness of the ‘health visitor/GP link meetings’ in relation to parental mental health issues; consider how to enable patient’s addresses on local records and the NHS spine to reflect their current whereabouts; review the effectiveness of telephone and email contact and its impact on mental health assessments and practitioners’ capacity to assess risk; and ensure all professionals are aware of the risks around parental mental health, including the potential for children being harmed, and that children should not be viewed solely as a protective factor. Keywords : parents with a mental health problem, filicide, official inquiries, injuries, information sharing, health > Read the overview report

2022 – Kent – Child S

Death of a 7-week-old infant boy in August 2020. The cause of death was ruled as sudden unexpected death in infancy (SUDI). Learning focuses on: risk assessment and decision making; child neglect; substance misuse; and safe sleeping. Recommendations include: undertake an audit of the processes of convening child protection conferences to review the attendance of key agencies and the quality of reports submitted by agencies; consider learning from the Child Safeguarding Practice Review Panel's report "The myth of invisible men" to ensure the overt engagement of men in risk assessments across the partnership; raise awareness and understanding of the Public Law Outline (PLO) process so that practitioners are clear of the processes and aware of opportunities to influence risk assessment and decision making; children's services review the arrangements for risk assessment and decision making in the PLO process and the interface between the legal advice received and the decisions taken to ensure this is a constructive process with sufficient challenge; review the neglect strategy to develop a clear shared understanding of "good enough" home conditions that provide practitioners with an agreed baseline; develop a substance misuse strategy, with a specific focus on cannabis use, to support a shared understanding of risks, appropriate interventions and decisions on the threshold for escalation; and to promote and raise awareness of the need to deliver safe sleeping advice, particularly when there is substance misuse by parents. Keywords: sudden infant death, substance misuse, sleeping behaviour, child neglect > Read the overview report

2022 – Kent – Harm to Under 2s in Kent

Explores the death or serious injury to 17 under 2-year-olds in Kent to identify key themes that help us understand when and why harm occurs, and what practice can safeguard young children from harm. Learning is embedded in the recommendations. Recommendations include: seek clarification on current Health Visiting operating standards around face-to-face visits; Early Help assessments and plans to be shared with involved multi-agency partners (with family consent); the positive practice audit to be published and shared as a standalone report, as a reminder that familiar, expected, basic practice works, and avoid a sense of needing to wait for learning from individual LCSPRs to be published before seeking to change or improve practice; the need for universal services to be more inquisitive and alert to less obvious risks has been clearly identified, particularly when considering the inherent physical vulnerabilities of children under 2-years-old; that practitioners, against human instinct, must be prepared to think the worst – even where there are not clear ‘red flags’; and professionals need to understand that significant harm occurs to children in families where risk is not obvious, where universal services may be the only ones engaged, and to consider whether there is one more question which might help identify an obscured risk. Keywords : early intervention, home visiting, infant deaths, parenting capacity, safety measures > Read the overview report

2022 – Kent – Lost in plain sight

Death of a pre-school aged child in 2019. The child sustained head injuries when in the care of the mother’s partner and died some days later in hospital. Learning includes: adequate consideration must be given to the practical implications of significant changes to a child’s lived experience when planning for their ongoing care and support needs; when a child with a disability is presenting with injuries reported to be self-inflicted, there is a need for further consideration and enquiry; and a need to remain mindful that there may be factors impacting a caregiver’s ability or willingness to give an accurate explanation for a child’s injuries. Recommendations include: each agency to be aware of the challenges some staff may face in keeping abreast of safeguarding policies; update forms used in Minor Injury Units to include consent to share information and referral to onward services; and seek assurance that safeguarding concerns within Accident and Emergency and Minor Injury Units are raised to professionals of appropriate seniority and expertise, and that parental explanation is explored and challenged where necessary to consider all likely causes. Keywords : infant deaths, head injuries, professional curiosity, hospitals, children with disabilities, siblings > Read the overview report

2022 – Kent - Oliver Steeper

Death of a 9-month-old boy. Oliver choked on food at nursery school, and following admittance to hospital died six days later. It was concluded that Oliver had choked due to being fed food which was not age appropriate. Learning includes: early years settings should clearly and regularly discuss, and record, appropriate foods and progression of the introduction of solids for young children with parents; empower parents to ask questions about provisions in settings; and it should be clear and documented within settings who is responsible for ensuring food is suitable for children. Recommendations include: encourage early years settings to have a food policy which considers the individual needs of each child, and resources for practitioners documenting the individual needs of a child regarding appropriate foods; resources for parents to build confidence in pro-actively seeking reassurance from early years settings on feeding in non-familial settings; engage with early years qualification providers to include safer eating materials into foundation training for early years staff; include safer eating in the broader sense (as opposed to solely regarding allergies or healthy eating) into the early years foundation stage (EYFS) requirements; review the position of pre-2016 qualified nursery staff being included in staff ratios without current paediatric first aid; and include a 'thinking about nursery' section in the personal child health record ('red book'). N.B. This report includes a photo of the child. Keywords : infant deaths, nurseries, feeding behaviour > Read the overview report

2022 - Kirklees - Child A

Death of a 9-week-old girl in January 2018. Following the conclusion of the inquest it was confirmed that Child A died from unknown causes following unsafe sleeping environments at her home. Learning includes: children's social care assessments should ensure historical concerns including home conditions and suitable sleeping arrangements for children are explored during re-assessment; risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services as this may indicate an ongoing, abusive relationship; retractions of statements regarding domestic abuse may be indicative of ongoing contact between the victim, the perpetrator and their children; social workers should speak directly to children being 'programmed' by their parents, without the presence of their parents, to explore their wishes and feelings; perpetrators of domestic abuse should be directly spoken to about the impact of their abusive behaviour on children and included in the assessment process or safety plan for children; consideration should be given to de-escalating to a team around the family plan if low level concerns still need to be addressed when child in need plan is closed; written agreements are not effective tools for managing risk and their use should be avoided; managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information. Recommendations are embedded in the learning. Keywords:  family violence, infant deaths, parenting capacity, professional curiosity, sleeping behaviour > Read the overview report

2022 – Kirklees - Child I

Significant injuries sustained by a 5-month-old girl while in the care of her grandmother in January 2019. A pre-birth assessment was undertaken due to the mother being pregnant at 15- years-old and her being assessed as vulnerable to exploitation. Learning includes: the need for pre-birth assessments to be undertaken in a timely manner and professionals to take early action to minimise the impact of any known risks to the unborn baby; a need for professionals to establish and share a parent’s full history, to avoid missed opportunities to reassess a family situation; the importance of and need to support social workers to determine how long to spend on individual cases; and to ensure the quality of pre-birth assessments is sufficient to meet the needs of the parent(s) and unborn child. Recommendations include: the Local Safeguarding Children Partnership should review compliance with procedures for pre-birth assessments, with the aim of ensuring pre-birth assessments are undertaken to a good standard within timescales; responses to young people should be fully informed and evidenced by an understanding of adverse childhood experiences; assessments must be outcome focused, the plan reviewed regularly, and evidence collected to determine that progress is being made; and multi-agency plans for young people at risk of, and vulnerable to exploitation should be coproduced with young people to fully capture their voice. Keywords : head injuries, infants, teenage pregnancy, family conflict, adverse childhood experiences, parent-child relationships > Read the overview report

2022 - Kirklees - Child K

Death of a 4-month-old child in October 2019. Child K was found dead in the family home, after having been asleep on the sofa. Learning includes: need for greater focus on children's lived experiences and the emotional impact of substance misuse; need to develop practice of 'respectful uncertainty' as a means to combatting disguised compliance, particularly where substance misuse is a concern; risk to children was increased by parental drug misuse going undetected; need for consideration of reasons for grandparent's caring role as this can help professionals with their work with the family and the plans they develop; need for multi-agency approach to assessment of risk. Recommendations include: safeguarding children partnership to ensure all agencies are using age appropriate tools in all assessments to understand children’s lived experience, and incorporating children's lived experiences into all plans; to ensure all partners incorporate disguised compliance into all safeguarding training, supervision and managerial sessions with frontline workers; seek assurance from children’s social care and local drug services that changes to service design, and ways of working have improved the reliability of testing, communication, information sharing and risk assessing of parents who are misusing substances; ensure that, where grandparents are playing a significant caring role, this is fully explored as part of assessments and contained within all action plans; explore ways of ensuring information about risk is provided by all relevant services and incorporated into safeguarding assessments and plans. Keywords: infant deaths, substance misuse, sleeping behaviour, addicted parents, voice of the child > Read the overview report

2022 – Lambeth – Angela

Sexual abuse of a girl by her mother’s partner. Angela disclosed multiple counts of rape and sexual assault to hospital staff in June 2020. Learning includes: protection of children should not rely solely on disclosures from children; lack of grasp by professionals on the lived experience of the child; lack of awareness of the impact of domestic abuse in the safeguarding system; the need to support professional curiosity regarding recognition and response to sexual abuse; differing levels of confidence in the recognition of child sexual abuse, leading to professionals deferring to unspoken hierarchies; even for parents whose first language is not English who appear to have a good grasp of the English language, language used by professionals is more complex than conversational language. Recommendations include: consider development of a multi-agency neglect strategy; any individuals or families living in property deemed unfit for human habitation are offered temporary accommodation without delay; consider a pan-London protocol about children missing education that move between boroughs; remind partner agencies of the function and purpose of a multi-agency risk assessment conference (MARAC) and the specialist domestic abuse services available; children services to consider a practice standard requiring a strategy meeting or management overview where there have been three or more referrals of children involved in domestic abuse incidents; ensure that practitioners and managers are aware of child sexual abuse expertise available in the borough; emphasise the importance of professional difference by developing the escalation process to create space for a multi-agency professionals meeting to explore perplexing cases; ensure availability and quality of interpreters used for children and parents whose first language is not English. Keywords : abusive men, child sexual abuse identification, family violence, rape, sexually abused girls, unknown men > Read the overview report

2022 – Lambeth - Dawit

Death of a 16-year-old boy by suicide in May 2021. Dawit had arrived in the UK from Africa in October 2020 to live with his sister after both his parents had died. His family had suffered religious persecution in their home country. Learning themes include: developing a clear pathway and protocol for unaccompanied children who do not have anyone with parental responsibility in the UK to ensure their needs are met; supporting the integration of migrant children into schools and the wider community that takes cognisance of their cultural, religious, physical, or emotional needs; and the role of the partnership in safeguarding unaccompanied minors who do not have anyone with parental responsibility in the UK. Reflections suggest: every child/family should be given the right advocate/support to navigate complex systems and bureaucratic processes, to ensure that they are not just matched up with universal services but are also supported to fully access them; there is a need to increase professionals’ knowledge and confidence in being curious about and exploring parental responsibility; all services must commit to using high quality translation services for all spoken and written information and in a school environment good quality English as an Additional Language (EAL) support is essential; and children’s social care should, once they have completed their child and family assessment, share the conclusions and outline plan with partners, including GPs, schools, and housing. Keywords : African people, child deaths, suicide, unaccompanied asylum seeking children, language, parental responsibility > Read the overview report

2022 - Leicestershire and Rutland - Child R

Significant harm to a 9-year-old boy over a number of years due to alleged fabricated or induced illness (FII). These concerns became heightened when Child R was placed in foster care where he was seen to flourish, including being fully mobile and eating without medical intervention. Learning includes:  agencies, particularly health professionals, may benefit from systems that help recognise fabricated illness; when a child is under the care of multiple teams and the diagnosis is unclear, there is a need for a multi-disciplinary team meeting between health professionals; a need for continuing professional curiosity rather than relying on parental response; loss of focus on the harm to the child can occur when concentration on proving FII becomes a distraction; need for a move away from the inability to appropriately challenge parents because of concern about FII; multi-agency representation in strategy discussions is essential so that a full picture of the child’s life can be formulated. Recommendations : N/A Keywords : fabricated or induced illness (FII), feeding behaviour, information sharing, interagency cooperation, professional curiosity > Read the overview report

2022 – Lewisham – Child FA

Death of a girl due to systemic inflammatory response syndrome during a COVID-19 pandemic lockdown in England. Learning themes include: child experience of domestic abuse; child protection in complex families across households; cultural assumptions; parent-professional relationships; the impact of COVID-19 and access to healthcare; and the quality of working together to safeguard children. Recommendations include: agencies should align adult and child risk management by case mapping to ensure there is a focus on the child where there is a parent or carer involved in historic domestic abuse; seek assurance that any potential risk to siblings is fully considered via assessment when a sibling or child living in the same household is being assessed under statutory safeguarding procedures; provide a development plan to ensure practitioners have relationship-based practice skills; agencies should ensure that there is a safeguarding supervision strategy that enables staff to reflect on how their own views and beliefs impact on their work; child protection procedures should ensure that there is continuity of child in need work when a family move; and the local authority should report on work done to learn from the pandemic in checking on children who are not attending school. Keywords : family violence, coronavirus, parent-professional relationships, siblings, culture, health care > Read the overview report

2022 – Manchester – Child S

Murder of a 16-year-old boy who received fatal knife wounds during an incident in September 2021. No motive, rationale or explanation for the attack was identified during the criminal trial. Learning themes include: managing behaviour and risks at school, exclusions and elective home education (EHE), the importance of multi-agency safety planning and intervention; engagement with parents and wider family members; ethnicity and gender; responses when a parent reports a threat to life in respect of their family; the importance of mapping young people involved in serious youth violence; contextual safeguarding; and the National Referral Mechanism (NRM). Recommendations include: communicate any safeguarding concerns with regards to children receiving EHE to the safeguarding in education team and involve them in strategy meetings, section 47 enquiries and child and family assessments; housing providers should also be included in these meetings, especially when there has been information to suggest that threats to people or property have been made; review procedures and training to ensure that the learning highlighted in this review is embedded in practice; distribute it across the children’s workforce and seek reassurance from agencies that practitioners are provided with continuing professional development in trauma informed, relational practice, which address the rule of optimism, over reliance on self-reporting and the importance of holistic assessment; ensure through its training programme that staff in all agencies are aware of what constitutes a threat to life and what responsibility individual agencies have. Keywords : child deaths, contextual safeguarding, exclusion from school, home education, murder, youth justice > Read the overview report

2022 – Manchester – Jacob

Injuries indicative of physical and possible sexual abuse of a 7-year-old boy in May 2019. Learning includes: practitioner knowledge and beliefs about children and families from different ethnic groups or migrant backgrounds can influence their ability to address children’s needs; when a school records safeguarding concerns in the CPOMS electronic system, used by many schools, to report, record and track safeguarding concerns, they should notify key professionals and record any discussions and plans made between agencies; the need for clear terms of reference for safeguarding teams in schools; seek out information about significant people in a child’s life in order to recognise risks posed by some men; information about commissioned services proposed by schools should be provided to parents; designated safeguarding leads should have access to opportunities to develop their practice; well-kept records in schools are vital to keep children safe; professionals need to be supported to remain curious about children’s lives. Recommendations include: assurance sought through the local workforce safeguarding strategy, that agencies provide briefings and access to training supporting culturally competent practice; seek assurance that all professionals, including safeguarding leads in schools, are well equipped to work with diversity, culture and ethnicity in safeguarding work; explore how supervision, team learning, training and programmes can help professionals improve their skills as professionally curious practitioners in relation to relation to ‘significant males’; ensure a robust system for quality assuring safeguarding audits and action plans in schools and partner agencies. Keywords : abused boys, abusive men, child abuse identification, injuries, professional curiosity, unknown men > Read the overview report

2022 – Merton – Eddie

Overdose by an adolescent boy, Eddie, in May 2019, following an argument with a friend on the phone and following negative comments from his father. There had been four incidents of intentional self-harm since 2016. Learning themes include: taking a ‘think family’ approach that recognises successful change within the family requires working with all members as a whole; the importance of agencies constructively challenging each other; contextual safeguarding/harm; the importance of trauma informed practice; self-harm and suicide risk and prevention; continued support when making a decision to end social care involvement. Recommendations include: agencies to agree what a ‘think family’ way of working means, supported by a practical approach and the tools to deliver this; request all partner agencies refresh their escalation procedures with a reminder of professional responsibility to escalate if they consider a child is in need or remains at risk; training to be provided for awareness of the social and professional tolerance of cannabis use and associated harms, including use for self-medication to manage trauma and contextual harms; request all providers of training incorporate trauma informed practice, ‘think family’ and ACE’s in course materials and delivery; review the provision of trauma based services for boys experiencing domestic abuse, neglect, poverty and risk of exclusion; in conjunction with a ‘think family’ approach, implement a universal family friendly template for a single plan designed with users of services; support a trusted adult approach in working with young people by considering adaptive mentalisation based integrative treatment training. Keywords : adolescent boys, adverse childhood experiences, children in violent families, children with a mental health problem, family functioning, self harm > Read the overview report

2022 – Merton – SUDI review

Two cases of sudden unexpected death in infancy (SUDI). It was concluded that neither of the SUDI cases met the criteria for a serious incident notification, but a joint agency response (JAR) meeting identified that there could be learning for multi-agency partners. Learning includes: the importance of children’s services pursuing the need for housing support for families experiencing homelessness; the socioeconomic impact of poor housing on families, especially mothers and babies; agency checks should be completed and obtained in a timely manner to establish past concerns about a family and current intervention; more professional curiosity from health visitors and midwives regarding the home environment of a family. Recommendations include: safeguarding partnership to commission training or briefings on the impact of poor housing and homelessness on safeguarding children and families; undertake a review of the effectiveness of early help in dealing with issues of homelessness; provide and promote information and training around the risk factors relating to SUDI identified nationally, including signposting partners to the national SUDI review and considering the availability of safe sleeping advice in a range of languages. Keywords : home environment, homelessness, infant deaths, professional curiosity, sleeping behaviour, sudden infant death > Read the overview report

2022 – Mid and West Wales – Cysur 4/2019

Intra-familial sexual abuse of two generations of children and adults which came to light in 2018. Learning is embedded in the recommendations. Recommendations include: children’s services to reinforce the need to ensure staff are well trained on both the indicators and best practice multi-agency response to sexual abuse and exploitation; further work is needed to support practitioners to work with confidence, particularly in ‘grey’ areas of professional uncertainty where concerns exist, but where the threshold for statutory intervention is not met; the need to make improvements to their recording systems that did not always demonstrate good practice, and have introduced electronic recording for safeguarding in schools; the importance of the role of the School Safeguarding and Attendance Team who played an important role in monitoring and supporting the family outside of formal statutory intervention in safeguarding; legal challenges and professional frustration associated with obtaining consent and its link to establishing paternity raised some dilemmas for all professionals and agencies; share the learning from this case in internal safeguarding training; the GP surgery conducts regular multi-disciplinary meetings, and has introduced a flagging mechanism to alert all staff of any safeguarding concerns; and adult safeguarding recognise the need to further develop joint working opportunities with children services. Keywords : child sexual abuse, grooming, adverse childhood experiences, trauma, paternity, sexually abusive parents > Read the overview report

2022 – Milton Keynes – Child K

Alleged rape of a 16-year-old boy in May 2020. Child K disclosed that he had been assaulted by another looked after child whilst in semi-independent accommodation. Learning includes: decision-making when identifying placements for young people with autism and additional vulnerabilities should be needs led; key partners should have confidence that placements for young people with complex needs have the capacity and expertise to meet assessed needs, and that specialist services are spot purchased if necessary; effective collaboration, as directed by the Transforming Care Programme, will prevent inappropriate hospital admissions; a multi-agency discharge plan for young people admitted to a mental health in-patient unit is essential in preventing further hospital admission; professionals require appropriate knowledge, skills, and competence, to effectively support young people with autism and for a clear understanding of needs and vulnerabilities; professionals should have a shared understanding of the impact of autism on the behaviour, wellbeing and mental health of young people and work collaboratively to understand what the young person may be attempting to communicate by their behaviour; multi-agency assessments of young people with autism should inform a consistent approach to care; when young people with autism are home-schooled, effective oversight is required to ensure that education and health care needs are met; when professionals are concerned about the provision of care, a formal escalation policy is important in highlighting unmet needs and practice shortcomings. Recommendations: are embedded in the learning. Keywords : autism, child behaviour problems, placement, rape, sexually abused children, voice of the child > Read the overview report

2022 – Norfolk - AL

Death of a 17-year-old boy in January 2022 by apparent suicide. He had experienced several years of poor mental health and was in acute grief after the death of his mother. Learning themes include: agency responses to mental health/safeguarding; family approach to multi-agency safeguarding and mental health; bereavement and trauma; older children and young people living with neglect; recognition of the needs of young carers; multi-agency arrangements for risk management, service provision and children and young people in specialist education. Recommendations include: seek assurance from health commissioners and partners that protocols are in place to ensure the safe management of medication for young people known to have mental health problems, including monitoring use, and advice to carers on storage and administration; referral processes and forms should seek relevant information about family history, especially history of trauma and any concerns about current parental mental health or substance misuse, including appropriate checks to see if parents are known to adult mental health services, when children are being referred; review its guidance on thresholds in order to support practitioners’ understanding of neglect, the cumulative impact of neglect and how to identify non-cooperation of care givers, as possible evidence of neglect; produce and promote sector specific good practice guides on understanding the importance of fathers and father figures; seek assurance that there are processes in place to identify and note when vulnerable adults, including men, have parenting or caring roles; review how the Joint Agency Group Supervision process is working across services. Keywords : anxiety, child deaths, children with a mental health problem, grief, parents with a mental health problem, suicide > Read the overview report

2022 – Northamptonshire – Young Person BG

Fatal stabbing of a 16-year-old in August 2021 whilst in a local public space with a friend. BG and friend were accosted by young person A and an associate. Considers the context of six young people (including BG and A) drawn into exploitation and youth violence. Learning themes include: extra-familial harm and professional understanding of gangs, including identification, risk assessment and multi-agency responses; consideration of ADHD in relation to access to education and risk assessment formulation; consideration of cannabis use in safeguarding risk thresholds; diagnosing neurodevelopmental disorders in children; the impact of adolescent neglect and prevalent key adverse childhood experiences such as domestic abuse; the practice context of Covid-19; and ethnicity, representation and adultification. Recommendations include: the partnership develop and implement a multi-agency strategy and practice framework to support the identification, risk analysis, intervention and disruption of child exploitation; various agencies conduct a needs analysis to review domestic abuse services for young people aged 16-18-years-old who may be at risk of perpetrating domestic abuse; and the local NHS Trust in collaboration with key partners review their existing ADHD pathway, to ensure advice is given for non-medication options and to enhance safeguarding practitioner understanding of how to support young people with neuro-diverse conditions such as ADHD. Keywords: gangs, criminal child exploitation, attention deficit disorder, drug misuse, violence, child neglect > Read the overview report

2022 – Nottinghamshire – SN20

Death of a 19-month-old infant girl in March 2020. The mother was convicted of her murder. Learning includes: the importance of recording information accurately and the need to be precise in the language used, to avoid formulaic language and better support understanding of risk; the importance of implementing a holistic assessment of the adult and child which considers predisposing vulnerabilities, risks for the adult and child and the potential impact on and experience of the child in relation to those vulnerabilities and risk; ensure children's workers have access to expertise in adult factors such as mental health and substance misuse which may affect their care of a child; address any gaps in understanding between children's services practitioners and adult mental health services; and the need for empathetic curiosity and doubt about what parents say on topics which are inherently sensitive. Recommendations include: review correspondence sent out to patients when they are offered an intervention specifically in relation to waiting well whilst on the list; and explore models of integration between adult and children's health and social care services so that the services can undertake joint assessments of adults with parental responsibilities who have issues including mental health problems and substance misuse. Keywords: parents with a mental health problem, drug misuse, parenting capacity, risk assessment, mental health services, infant deaths > Read the overview report

2022 – Nottinghamshire – Tom

Death of a two-week-old boy from positional asphyxia on a sofa where his father was sleeping. Learning includes: safe sleeping is an issue for services broader than health visiting and midwifery; the importance of parents having an effective relationship with key health and social care professionals; a need for sufficient curiosity about evidence of indicators of domestic abuse; reasons for parents not wanting family support when it was offered or help from substance misuse services could have been clarified with more purposeful curiosity; there was a need for a good chronology of contacts with the family to help detect patterns and cumulative indicators; and a need for services to use tools and practice frameworks that are available to assist professionals to make a more informed judgment when dealing with complex and complicated family circumstances. Recommendations include: recognising the danger of co-sleeping has implications for any services visiting homes with infants under 12-months-old; a safe sleep assessment should result in a record being left with the family and be included in any other risk-based discussions or actions including child protection plans; and intervention is likely to be more effective through a service that can allocate a dedicated worker offering consistent relationship-based and practical help informed by a well-informed assessment. Keywords: infant deaths, professional curiosity, health visitors, substance misuse, alcohol, mental health problems > Read the overview report

2022 - North Lanarkshire - Anne

Death of a girl from an acute medical condition in 2018. Concerns were expressed that neglect of Anne's medical needs had been a factor in her death. Learning includes: issues around mechanisms for bringing the right people together to share information and make joint decisions, resulting in some children not receiving the right service at the right time; issues across children's services in relation to the use of assessment tools and frameworks, running the risk of failing to identify the point at which older children are in need of protection; and the need for opportunities for formal critical reflection within and across agencies at all levels, as not having these opportunities makes it more difficult to develop and revise shared understanding of the needs of children in complex circumstances, and exacerbates the risk that assessments may rest on untested assumptions. Recommendations: N/A Keywords: child deaths, adolescent girls, child health, medical care neglect > Read the overview report

2022 - Oldham - Child J

Serious non-accidental injuries to a 7-month-old child in July 2015. Both of Child J's parents were charged with causing grievous bodily harm. Child J had been placed in foster care from birth and was returned to the care of the parents aged six months. Learning points include: responding robustly to domestic abuse within a safeguarding plan requires an approach that works with both victims and perpetrators to support robust analysis of risk and change; comprehensive assessment of risk and planning for children is best supported through adopting a common model of assessing motivation and capacity for change; management oversight at critical points of assessment needs to support practitioners to utilise critical thinking techniques to draw confident conclusions and develop plans that appropriately address risk; for children reviewed within looked after children arrangements, systems to support multi-agency working should remain a priority where more than two agencies continue to be involved with the child and family; and the local authority must carefully and robustly exercise its parental responsibility for children placed with parents. Recommendations include: the local safeguarding children board (LSCB) should promote the use of a model of change within partnership agencies to assist single and multi-agency assessment of parenting capacity; the LSCB should require children's social care (CSC) to ensure that every child for whom they share parental responsibility and is placed with parents is subject to ‘placement with parents’ regulations reviewed alongside the child's care plan; and CSC should review and report to the LSCB how multi-agency work is promoted through systems that support children subject to care orders. Keywords : family violence, injuries, drug and alcohol services, parental responsibility, risk assessment, child protection registers > Read the overview report

2022 – Oldham - Thematic review of harmful sexual behaviour

Thematic review of harmful sexual behaviour (HSB). Focuses on cases of two 17-year-old boys. Both young people experienced significant adverse childhood experiences, including domestic abuse, and parental mental and emotional health issues. There were also communication difficulties in both cases due to learning disabilities, deafness and non-English speaking family members. Learning themes include: identification of harmful sexual behaviour; evidence informed multi-agency approaches; recognition of vulnerabilities and complexities, including wider family functioning, and safeguarding concerns including domestic abuse; learning disabilities, mental health and communication; cultural competence; and basic statutory safeguarding processes. Recommendations include: frameworks and pathways for HSB take into account responses to children and young people aligned to the Continuum of Need, as well as prevention, identification and early assessment; consider approaches to multi-agency working in the context of the lead professional role, including guidance for the workforce, as well as shared risk management, and multiagency supervision for complex cases; consider the communication strategy for children and families to ensure effective weight is given to barriers to communication, and that a plan is embedded across all levels of the safeguarding continuum; and seek reassurance from commissioning and provider organisations regarding the impact of interventions and services on HSB, including reviewing and identifying gaps in interventions, and reviewing the effectiveness of the complex needs panel in these two cases. Keywords : harmful sexual behaviour, adolescent boys, children with a learning disability, deafness, culture, language > Read the overview report

2022 – Perth and Kinross – Young Person A

Death of a 17-year-old by having completed suicide. Young Person A’s additional support needs became more pronounced following transition from primary school into secondary school, and aspects of their family circumstances were challenging and unsettling. Learning includes: a need for multi-agency holistic understanding of what the young person is actually saying; a need for a holistic assessment of risk and need within child and adolescent mental health services (CAMHS); there could have been closer working relationships between children’s services and adult services, in terms of planning; information was not always being shared proportionately; and a need for greater awareness raising and training for professionals when working with young people with gender dysphoria. Recommendations include: the voice of the child must be heard and reinvigorated and children and young people need to be given the opportunity to be involved in decisions impacting them and their families; the child protection committee (CPC) should seek reassurance that all existing and new CAMHS staff have received appropriate Getting it right for every child (GIRFEC) and child protection training; the CPC should request information from health and partner agencies about the level of unmet need for young people experiencing mental health difficulties and what crisis facilities are available; and the CPC should request information about what guidance and training is available to practitioners working with young people with gender dysphoria. Keywords : suicide, child mental health, schools, gender identity, transgender, education > Read the overview report

2022 - Redbridge - Baby A

Head injury to a 10-week-old girl in 2022. Baby A was on a child protection plan at the time of the incident due to risk of neglect. Learning includes: a need for professionals to consider and apply the impact of cumulative harm and parental history to the current situation; a need at every meeting to consider fathers as a protective factor or potential risk to a child; professional responsibility to engage with fathers or question any apparent lack of engagement from other agencies; a need to balance supporting a vulnerable parent with clear child-focused challenge about the potential for a negative impact on the child; a need for professionals to be clear about the impact of substance misuse on children and unborn babies, including on the parent/carer’s ability to protect their child from harm; and strengths-based models of assessment and planning for children need to have a clear focus on risk and ensure that all available information is considered when deciding on the safety plan for a child. Recommendations include: promote the involvement of fathers as a key focus; consider the timeliness of pre-birth assessments and assessing application and impact; review approaches to neglect and seek assurance that consistent trauma informed, strengths-based models of working are being implemented across agencies; and ensure agency policies that are applied when people “do not attend” or “do not engage” with services are reflective of safeguarding risk. Keywords : head injuries, adults abused as children, infants, adverse childhood experiences, care proceedings, child protection registers > Read the overview report

2022 – Rochdale - J1

The collapse of a boy in school in 2022 having ingested a bag of white powder, one of nine that he had brought into school in a kinder egg. He was transported to hospital where he was found to have cocaine in his system. He and sibling were removed from mother’s care. Learning includes: the importance of understanding and using history to inform practice; there was an over reliance on self-report by mother; there was a lack of professional curiosity; child and family assessments lacked breadth and depth; fathers and the wider family were not included; information was not triangulated; practice standards were not adhered to, leading to flawed assessments of risk; managerial oversight was not sufficiently robust to identify and challenge frontline practice; child in need/child protection plans were not robust; the voice of mother overshadowed the voice of the child; opportunities to gain a greater understanding of the child and sibling’s lived experience were missed; processes and tools designed to assist practitioners to keep children safe were not used effectively; and agencies were not working in true partnership, leading to disagreements that allowed mother to deflect and deceive some practitioners. Recommendations are embedded in the learning. Keywords : child abuse, drug misuse, extended families, voice of the child, risk assessment > Read the overview report

2022 - Salford - Nicholas 

Death of a 4-year-old boy in 2022 due to a serious incident whereby he was found face down in a bath. Nicholas had been subject to a pre-birth assessment in a different local authority. Learning includes: consideration needs to be had of a national, uniformed, transfer information policy; and there is a need to develop professional curiosity. Recommendations include: assure of a robust transfer of information policy to be used when a person presents safeguarding concerns from out of area, and when a person with safeguarding concerns moves to another area; assure the partnership around discharge processes and the flow of information from all maternity services; remind and encourage professionals to practice an open-minded awareness of the differences that cultural background can produce; and assure the partnership that professionals from all agencies know when and how to escalate any concerns. Keywords : drowning, information sharing, professional curiosity, injuries, transient families, early intervention > Read the overview report

2022 – Sandwell – Child LS

Death of a child in June 2018 due to significant non-accidental injuries. The stepfather was found guilty of the murder of Child LS, the mother was found guilty of causing/allowing their death, and both parents were found guilty of multiple counts of child cruelty. Learning includes: that an early help intervention may have provided support to mother and her children, as there were indications that mother was struggling to cope; Child LS’s personal circumstances and developmental issues meant that there should not have been a gap in their nursery education; whether or not any professional intervention could have prevented the injuries to LS. Recommendations include: review training provided to agencies regarding the thresholds for early help, and ensure that agencies are aware of their responsibilities to apply thresholds correctly; the local authority ensures that funded nursery provision is promoted and encouraged, particularly for families with vulnerable children; remind agencies of the need to include the voice of the child when recording information. Keywords:   child deaths, physical abuse, murder > Read the overview report

2022 – Sandwell – Child RS

Serious and potentially life changing non-accidental injuries to a 4-month-old baby in June 2019. A police investigation and care proceedings were instigated. Learning includes: bruising on non-mobile babies should always be treated seriously and advice immediately sought from the safeguarding lead; practitioners should guard against second guessing the response of the multi-agency safeguarding hub (MASH) to a referral of concern about a child; importance of early identification of vulnerability, assessment of risk and consideration of appropriate services; importance of gaining an understanding of who lives in a household and their role, not focusing solely on mothers but proactively engaging with fathers; information sharing alone does not safeguard children; be aware of the impact of professional desensitisation and cultural normalisation; importance of professional curiosity and respectful challenge; be aware that moving between areas, away from support systems, can increase a family's vulnerability. Recommendations include: ensure that the learning from this review is disseminated widely and incorporated into updates, and the development of policies and procedures; ensure that the safe sleeping policy is shared with all relevant staff; ensure that guidance on bruising to non-mobile babies is widely disseminated and embedded in practice across all agencies. Keywords: infants, bruises, physical abuse, professional curiosity, sleeping behaviour > Read the overview report

2022 – Sandwell - Child RS

Serious injuries to an infant in June 2019. Child 2 was taken to hospital with multiple injuries believed to have been caused non-accidentally. There was a history of mental health issues, criminality and substance misuse in the family. Learning includes: bruising to non-mobile babies should always be treated seriously and advice sought from a named nurse/safeguarding lead/MASH; safeguarding children and young people should be the priority for all agencies providing services to adults, with an embedded Think Family approach; the importance of practitioners engaging with fathers and not focussing solely on mothers; that practitioners should be aware that moving between areas can increase a family's vulnerability; the importance of the role of the GP and of early registration of a new baby with a GP practice; that key practitioners should have an understanding of the importance of safe sleeping; the value of multi-disciplinary meetings (MDTs) in GP practices where early concerns about the care and safety of children can be shared and a co-ordinated approach taken; the value of community health services using red flags/alerts in electronic medical records to indicate concerns regarding a child or family; and that severe staff shortages can create a 'start again approach', so that emerging patterns of concern are not identified. Recommendations include: seek assurance from the local health forum that the safe sleeping policy for hospitals is shared with all relevant staff; and ensure that the West Midlands guidance in respect of bruising to non-mobile babies is disseminated and embedded in practice across agencies. Keywords : infants, injuries, child health > Read the overview report

2022 - Sandwell - Child SD

Serious injury resulting in a permanent disability to a 17-year-old male in 2022. No suspects were identified after a thorough police investigation. At the time SD was under a youth rehabilitation order for motoring offenses and had recently become a father. Learning themes include: real-time information sharing; coordination of support among multiple agencies; the challenge of engaging with families involved in criminal activity; transitions between services as youth turn 18; and the role of education in early prevention by detecting reduced school attendance and behavioural changes. Recommendations include: reinstating read-only access to children’s case files for adult social care; ensuring visibility of involvement and interventions across agencies through the Early Help system; clarifying the lead professional's role in co-ordinating support across multiple agencies; establishing a 'learning offer' to increase understanding of 'adultification'; provide briefings on the impact of exploitation; ensure that education practitioners are trained in the use of GCP2; and subgroups should work together to evaluate the effectiveness of information sharing for exploited young people, including their national referral mechanism status. Keywords : adolescent boys, child criminal exploitation, early intervention, education, injuries, young offenders > Read the overview report

2022 – Sandwell – Child VS

Death of an infant in 2020. Learning includes: the need for a whole systems approach to safeguard unborn babies; where a child is subject to a child in need (CIN) plan due to neglect, and isolated incidents occur such as an injury, these should be managed with the same rigour as that for children not previously known to children’s services; history not always being drawn on to provide context for new assessments; all case discussion should include discussion about the legality of a child’s living arrangements; information sharing practice in CIN cases may not be robust; professionals were insufficiently curious, and they did not ask pertinent questions to better inform their plans. Recommendations include: ensure frontline workers receive clear and consistent messaging on how to refer and work with pregnant women where there are concerns for unborn babies; professionals are encouraged to challenge and take an active role in progressing cases, escalating cases where insufficient progress has been made; agencies conduct holistic assessments inclusive of all individuals linked to the subject child; information is shared with all staff groups regarding how to recognise when a child is a looked after child versus a child living within a family arrangement; information sharing in cases where children are subject to a CIN plan is timely, recorded and shared. Keywords:   infant deaths, pregnancy > Read the overview report

2022 – Sandwell – Child YS

Assault on a 7-month-old child by their father, resulting in life threatening injuries. Learning includes: understand the impact of trauma and become more trauma-informed in practice; understand the way in which different faith communities perceive domestic abuse and the difficulty in speaking openly; the importance of professional curiosity and challenge; the importance of clear and factual record keeping and interagency cooperation; create a safe space for multi-agency reflection and supervision; the importance of cultural awareness and challenging assumptions recognising that different families from the same cultural or religious group may have different views and practices. Recommendations include: ensure effective implementation of information sharing, 'think family' approach, using evidence-based tools, trauma informed practice, resolution and escalation policy; work with community groups to combat domestic violence; host training on effective safeguarding of Black, Asian and minoritised ethnic, cultural and faith groups. Keywords: infants, physical abuse, family violence, ethnic groups, religion, trauma-informed practice > Read the overview report

2022 – Sefton - Delilah

Death of a 12-week-old infant girl in October 2021 following co-sleeping with her mother and twin sibling. Delilah’s mother had consumed alcohol and cocaine the previous night and had experienced multiple incidents of domestic abuse. Learning themes include: the effect of twin births on risks associated with co-sleeping; viewing substance use in the context of domestic abuse and depression; impact of alcohol use on parenting capacity; the presence of domestic abuse in current and past relationships; limitations in the child and family assessment; effectiveness of the child in need plan; understanding family composition and functioning, including older children living with family members in other local authority areas; and disguised compliance. Recommendations include: remind partner agencies of the importance of an early referral for an assessment of risk to an unborn child; obtain assurance from partner agencies that consistent, unambiguous safe sleep advice is given to parents in respect of multiple births; develop a policy outlining action to be taken when parental consent to observe sleeping arrangements for new born children is declined; empower professionals with knowledge of alcohol risk identification; ensure the local Domestic Abuse Partnership Board address the training needs of non-specialist domestic abuse professionals, reflecting on the many ways domestic abuse may affect victims; ensure child and family assessments explore relevant issues in sufficient depth; ensure child in need plans are specific about what needs to happen and by when, and that plans are not ended prematurely; and commission a case study highlighting the challenges of professional engagement and the importance of exercising professional curiosity. Keywords : sudden infant death, sleeping behaviour, substance misuse, family violence, parents with a mental health problem, professional curiosity > Read the overview report

2022 – Southampton - Ted

Non-accidental injury to the leg of a 1-year-old boy who was identified with significant emerging health needs prior to the injury. He is developmentally delayed and was described as ‘non-mobile’. Learning includes: the importance of knowing and understanding the impact of a parent’s vulnerabilities and history on their parenting; parental substance misuse, mental health, and prescribed pain medication; working with homeless families; exploring and understanding a disabled child’s likely and actual lived experience; considering absent parents, even when domestic abuse is alleged; considering what support is required to ensure a lone, non-birthing parent acquires ‘parental responsibility’; referring/ transferring a child in need plan across local authority borders; and the need to consider if the parent requires an assessment or support due to their own needs or as a care leaver. Recommendations include: the partnership should request that agencies review their practice in respect of ensuring that the person caring for a child has parental responsibility and provide feedback on what recent progress has been made; the MASH to be asked to consider their expectations and processes regarding transfers from other local authorities in respect of children subject to a Child in Need plan; and the partnership to consider how it can promote the responsibilities of partner agencies to care leavers. Keywords : children with disabilities, injuries, fathers, housing, substance misuse, adverse childhood experiences > Read the overview report

2022 - South Ayrshire - Child P

Death of a 7-week-old boy in November 2017 following abusive head trauma. His father was convicted of his culpable homicide. Learning themes explore: child health surveillance practice – relating to the examination of the baby and support for parents; short stay paediatric assessment unit standards; child protection training – relates to the assurance arrangements and coverage of training for particular groups of clinical staff; and effective multi-agency working around child deaths. Recommendations include: need for audit of clinical standards to guide future training/supervision for child health surveillance; need for action to involve fathers by maternity and community child health services; instigation of programme of support for new parents of crying babies; discussion needed to consider amending online revalidation system to require GP refresher courses in child protection; learning needs analysis to clarify training coverage and guide future policy; need to ensure awareness/significance of multiple contacts with NHS by parents seeking help; and need to ensure Ministry of Defence understands importance of making veteran’s records available in terms of their experience in service and later possible mental health issues. Keywords : crying, infant deaths, non-accidental head injuries, infant behaviour, fathers, hospitals > Read the overview report

2022 - South East Wales - SEWSCB 2/2022

Suicide of 17-year-old girl in October 2021 while living in a supported accommodation. Learnings is embedded in the recommendations. Recommendations include: supported accommodation providers ensure there is a safeguarding training and development plan in place for all staff; the importance of acknowledging the age of the child when considering the presenting concerns, and the child’s lived experience; review internal recording tools to ensure the voice of the child is promoted and evidenced; ensure children are seen (and seen alone if appropriate) as part of an assessment; escalate concerns if parents refuse or challenge the need for a child to be seen (and seen alone if appropriate) and to record that decision; develop practice guidance on the lived experience of the child to assist practitioner insight, to ensure that the voice of the child is actively heard and to support effective action to safeguard children and young people; ensure that relevant staff are aware of the Southwark Judgement and how the key principles can be applied to assessments with homeless young people; review their assessment tools to ensure they are child focused, promote the voice of the child and record that the child has capacity to provide informed consent; ensure they have procedures in place to gather historical information from other areas where there has been known involvement with child or family and to have clear escalation policies in place if this information is not provided in a reasonable timescale; and have clear contingency plans in place for children and young people to ensure that they are seen face to face in the event of any future pandemics. Keywords : suicide, homeless adolescents, adverse childhood experiences, child sexual exploitation, mental health > Read the overview report

2022 - Staffordshire - J and K

Siblings J and K (aged 16-years-old and 12-years-old) reported missing in September 2021. The referrer expressed concerns about their safety, stating their father had taken the children from the UK and they might be entered into a forced marriage. Learning includes: practitioners’ confidence and skills in recognising the warning signs for forced marriage and how to respond; understanding how Forced Marriage Protection Orders (FMPOs) should be used and which agency should take the lead in making an application; raising awareness of both the issue and the warning signs of forced marriage with young people in a school environment; raising awareness of the support that is available from the national Forced Marriage Unit; and ensuring widespread understanding of the ‘One Chance Rule’ - that practitioners may only have one chance to speak to a potential victim and therefore one chance to safeguard the child. Learning will be developed into formal recommendations. Action taken includes: children’s social care to lead on FMPO applications related to children; training for the social care workforce to ensure all workers have an up-to-date understanding of the risks and indicators for forced marriage; a whole system transformation in the local authority to prevent multiple handovers; improved processes by police within the Force Control Centre to enhance safeguarding and ensure warning markers are accurate; education safeguarding leads to ensure warning signs of forced marriage are increased across education settings; and steps taken by the Intensive Prevention Service to disseminate national guidance on forced marriage and raise the profile of the Forced Marriage Unit. Keywords : forced marriage, culture, siblings, abusive fathers, emergency protection orders > Read the overview report

2022 – Stockport - Child A

Alleged interfamilial sexual abuse of female Child A (9-years-old in 2017) by male sibling B (11-years-old in 2017) in May 2017 and April 2021. Family history includes domestic abuse perpetrated by the birth father against the birth mother, criminal activity, and the children living with their birth father and stepmother. Learning includes: ensuring the voice of the child and understanding their experience is a focal point in education system record keeping; the importance of looking at family history within a social work assessment to avoid focusing on a single issue, and to include all adults with parental responsibility in the assessment; the need to risk assess parent safety plans to ensure sibling abuse does not re-occur; professionals understanding the complexity of the health information recording system; the impact of a criminal investigation on working with a family and delays to intervention; fully considering the role of the non-resident parent; practitioners acquiring the right skills to support young people who behave in a sexually harmful way so appropriate interventions take place; and making sure the knowledge, understanding and use of the processes and policy around sexually harmful behaviour are embedded in practice. Recommendations include: makes no recommendations but documents system changes made since 2017. Keywords : sibling abuse, harmful sexual behaviour, family violence, parental responsibility, assessment [social work], voice of the child > Read the overview report

2022 – Stockport – Child F

Sexual assault of a 17-year-old girl in October 2020 by a male while missing from care. Child F has complex needs and required 2:1 staffing 24/7. Learning includes: professional understanding of health pathways, what they mean and how to access them for children with complex needs; knowledge of processes and policy within various health systems to ensure greater co-ordination of the services working with children who are involved with several agencies; management of multiple and changing diagnoses in the context of what this means for the child and access to services or placement provision; the need to undertake risk assessments during placements when there are signs that a placement is not fulfilling its responsibilities; and professional understanding of the Dynamic Support Database (DSD) and the Care Education and Treatment Review (CETR) processes. Formal recommendations are not included, but actions include: reviews to be undertaken of the transforming care hospital discharge and DSD information to ensure processes are working effectively for children with complex needs; children's social care to receive training in relation to the DSD, CETR and related processes for children with complex needs; challenges associated with commissioning specialist placements and availability of these will be raised with the National Panel; a universal information sharing system that would benefit agencies in ensuring robust information sharing will be shared with the National Panel; and arrangements will be reviewed to ensure that external placements will provide the best possible service for children with complex needs. Keywords : runaway adolescents, children with multiple disabilities, placement breakdown, children in care, supervision orders > Read the overview report

2022 – Suffolk – Andy and Arin

Joint serious case review following two cases of filicide and maternal suicides which occurred within a two-month period between March and April 2019. Learning includes: professionals must consider the implications and risk for wider family members, especially children, when dealing with vulnerable people with mental ill-health; checks must be made by health professionals to establish if the patient or child are known to other agencies or teams in order to share relevant information; the use of information systems and good practice in sharing information must be part of any procedure and practice guidance within any health settings; practitioners should be proactive in sharing information as early as possible to help identify, assess and respond to risks or concerns about the safety and welfare of children; agencies must review their assessment processes to ensure they include mechanisms to support teenage fathers; health professionals need to be professionally curious as well as dealing with the clinical care of a patient; assessment process for health visitors and midwives must be reviewed to ensure they include professional curiosity around impact and cultural isolation; and health visitors need to consider the support needs of transient families, particularly when from communities who may be culturally isolated. Recommendations include: review assessment processes to ensure they include consideration of the impact on individuals, the subject of the assessment, and to ensure they consider the support offered to young parents; and consider the effect of parental mental health or physical needs when planning service provision. Keywords: filicide, information sharing, professional curiosity, social isolation, suicide > Read the overview report

2022 – Suffolk – Child G

Injuries and hospitalisation of a 2-and-a-half-year-old boy in 2020. Child G was found to have a depressed skull fracture, resulting in a section 47 enquiry. Learning is embedded in the recommendations. Recommendations include: decisions stated in MASH outcomes as 'necessary' need to be actioned; MASH decisions which are not the outcome of strategy discussions and require adjustment to reflect local considerations and knowledge of the family must have a clear rationale recorded; workers and agencies who are key to the understanding and progress of a case should always be kept updated; the possibility of non-accidental injury should always be considered in the case of multiple injuries and bruises and when parents' explanations for these are inconsistent; professionals should always check the history, past referrals and the social worker/social work team to ensure all relevant and significant information is gathered; social care should routinely update all agencies involved in a case; all professionals involved in a case should ask questions and get clarity about the key adults in a child's life, and these questions should be standard practice for supervisors and managers to ask at supervision; all professionals should be guided to read the Child Safeguarding Practice Review Panel’s report 'The myth of invisible men' (2021); supervision in social care must always allow for reflection by the social worker. Keywords: interagency cooperation, non-accidental head injuries, parenting capacity, supervision, unknown men > Read the overview report

2022 – Suffolk – L, M and N

Thematic review based on the rapid reviews for three young infants who were born in Suffolk in 2021. Two infants died and one infant was injured whilst in the care of their parents. Learning: N/A Recommendations include: raise the profile of safer sleeping and associated risks across partner agencies including support to increase knowledge of this area for social workers; embed recognition that house moves and temporary living arrangements are seen as situational risks for babies which need proactive plans that recognise and addresses before babies are born; closer working together between social care and health services in pre-birth assessment and child in need processes; increase recognition of the importance of the health visitor's role; parents' own life experiences are explored in depth and understood; fathers are central and must be included whether they are living with the family or not; understanding and use of family network in pre-birth assessments, parents may highlight family as support; professionals need to explore and be respectfully challenging; supervision is used effectively to explore risk and hypothesis, ensuring that information has been verified or explored; pre-birth assessment to remain open until after the baby is born and there has been time for stress-testing of plans and support; hospital discharge planning meetings to be considered for child in need cases as part of the plan for younger parents, and parents with other vulnerabilities including where there are several addresses and uncertainties; recognition of the power imbalance between agencies and parents, relationship based case work that starts with this awareness is essential. Keywords: sleeping behaviour, infant deaths, abused infants, home visiting, risk assessment > Read the overview report

2022 – Suffolk – Young People F

The sexual abuse of an 11-year-old girl, and grooming of her 8-year-old sister, by their mother and her boyfriend over a 12 month period prior to April 2020. Learning : N/A Recommendations include: schools should consider how they monitor and review the concerns logged on their child protection online management system, there should be an automatic review built in when a certain number of concerns are logged within a specific period; safeguarding leads within schools should ensure that any referral to another agency is always followed up and that the nature of the response is recorded at the time; health services need to ensure that all transfers in families where children are at risk are accompanied by appropriate documentation, management review and a visit; when a concern is raised with health services by another agency, consideration should be given to a visit being undertaken by a health visitor rather than relying on what was seen at a visit some weeks or months earlier; children and young people services should ensure that at the point of referral, any extensive history is carefully considered within the multi-agency safeguarding hub as part of effective decision making on what action to take; and children and young people services should set any retracted compliance regarding a common assessment framework within the context of the family history and consider stepping up for a social work assessment rather than simply accepting that nothing can be done as parental co-operation is withdrawn. Keywords: child sexual abuse, grooming, self harm, child abuse images, physical effects > Read the overview report

2022 – Surrey – Child Acer

Death of a 5-month-old baby in January 2021. Acer was found unresponsive in a baby bouncer having suffered a cardiac arrest. Learning themes include: assessing neglect and recognising its impact on outcomes for children; the importance of pre-birth assessments; 'start again syndrome' whereby family history was not sufficiently known or significant events in the children's lives were not considered holistically but as separate incidents; professional advice on safe sleeping; risk-factors identified in the out of routine report, which states that that the risk of SUDI should not be seen in isolation from other risks present in the home environment; the impact of the COVID-19 pandemic; and wider-systemic issues across the multi-agency system. Recommendations include: continue to roll out the Neglect Tool/Graded Care Profile (GCP2) training programme to ensure that practitioners from partner agencies utilise it to recognise and assess neglect in children; practitioners must take account of known factors concerning the premature birth of twins when considering the timing of a pre-birth assessment, and this message requires constant reinforcement in learning and development; make sure that partner agencies use single/multi-agency chronologies to inform decision making concerning families where there is chronic neglect of children and complex family dynamics; and there should be continued development of a local multi-agency framework/protocol for practitioners working with families where infants are at risk because of unsafe sleeping arrangements. Keywords: coronavirus, child neglect, assessment [social work], mental health, sleeping behaviour, sudden infant death > Read the overview report

2022 – Sutton – Child X

Death of a 3-and-a-half-month-old girl in May 2021. Child X was in the care of foster parents when she was found unresponsive in an unsafe sleeping position. Learning includes: joint working between midwives and social workers should be a core element of discharge planning for vulnerable new babies, even when they are going to foster carers; rigorous checks and assessments of foster carers taking on infants; gaps in supervision can occur when services use agency staff who might not have the appropriate knowledge and skills to undertake safe practice with vulnerable families; where there are concerns that a child has been harmed, there is a need for equivalent response when the child is in the care of foster carers as in the care of their birth parents. Recommendations include: a campaign to raise awareness of safe sleeping arrangements for infants to include 'what if' questions; to seek assurance that independent fostering agencies comply with standard 10 of 'Fostering services national minimum standards' (2011), relating to suitable physical environments; to ensure managers and supervisors are aware of the importance of following up in supervision that safer sleeping arrangements have been checked by social workers and health professionals; all services ensure that their staff are aware of the neglect toolkit and bruising of non-mobile infants guidance. Keywords:  bruises, neglect identification, parents with a mental health problem, private foster care, sleeping behaviour, sudden infant death > Read the overview report

2022 – Swindon – Babies with injuries

Reviews the assessment and safeguarding of infants prior to and following a non-accidental injury, focusing on three infants aged 7, 9 and 11-weeks-old. Learning focuses on: the need to increase awareness of the unborn baby protocol; child protection processes and case management across perinatal mental health services; the response to anonymous referrals and the scope of the resulting health checks; the need to consider and involve fathers; improving the exercise of professional curiosity; the impact of COVID across agencies; use of targeted support in pregnancy in order to prevent escalation of concerns post-birth; improved awareness of the voice of the child; need for improved information sharing and recording; understanding that parents can be persuasive and that a parent may not be protecting their child; how caring for a new baby can lead to increases in parental mental health issues and domestic abuse; how professionals providing support to families with a new born baby need to be aware of fathers' mental health. Recommendations include: ensure the attendance of the appropriate health professionals at strategy meetings, including when these take place out of hours; consider how to encourage and support all professionals to talk to each other and collaborate, so that that all information is known and considered; review systems and practice to ensure that fathers or male partners are equally considered by services. Keywords: infants, physical abuse, injuries, pregnancy, fathers, men, voice of the child > Read the overview report

2022 - Tameside - Ben and Alex

Harmful sexual behaviour and disclosure of rape by a female child in 2020, and neglect and non-accidental injuries to a young male child. Both Alex and Ben have been known to agencies since birth, with recurrent re-referrals for both children. Learning includes: professionals' knowledge of strategy meetings and recognition of their positive effects upon case progression; professionals' understanding of how and when to complete the Graded Care Profile (GCP) effectively or when to seek the advice of a manager or supervisor; including the voice and lived experiences of young, non-verbal children in assessments; concerns regarding the success of the Signs of Safety model and its use in practice; some families consider child protection plans to be intrusive and not a source of support, this reduces their level of true engagement. Recommendations include: ensure that the GCP training package is completed and evaluate whether professionals are understanding the tool and embedding it into their practice effectively; consult with general practitioners (GPs) to gain a better understanding of their roles and responsibilities, and to understand what can realistically be expected of GPs in terms of safeguarding; remind staff in partner agencies to fully explore the lived experience of a child and to include their findings in all records including assessments, alongside the voice of the child; consider developing a parent advocate scheme to support families coming to case conferences. Keywords:  harmful sexual behaviour, child sexual abuse, injuries > Read the overview report

2022 – Tameside - Craig

Allegations of rape and sexual abuse of a boy in care by another child living at the children’s home in 2019. Learning includes: the importance of having specially trained interviewers in police and social work services available to undertake forensic interviewing with a good enough understanding about helping children disclose information and being sufficiently well informed about current guidelines for interviewing; there was a belief that the risk assessment measures put in place in the care home were impenetrable which excluded the possibility of abuse taking place; a need for strategic leaders to create a context in which practitioners and front-line staff are better equipped and supported to make effective and timely responses to children in care with the most complex needs; a need to ensure that therapeutic reports and updated risk assessments are received and considered as part of on-going, overall risk assessment; and a need for professional curiosity about allegations being made and a need for a neutral and enquiring position to support further exploration of allegations. Recommendations include: provider impact assessments should have clear mitigations in place for children who exhibit harmful behaviour and are a risk to other children; ensure reviews of looked after children include a full account of any therapeutic input and how it integrates with the care plan; and ensure information sharing protocols reflect the national information sharing protocol issued by the Government and take into account immediate risk and assessed risk either identified through reports or assessment processes. Keywords: harmful sexual behaviour, residential child care, risk assessment, abuse allegations, disclosure > Read the overview report

2022 – Tameside – Dominik

Non-accidental injury to an infant boy in 2019 including eye injury, cracked ribs, and a fractured leg. Learning includes: a need to assess the impact of parental mental health on parenting capacity; a need to identify potential safeguarding concerns to a new-born baby following a family dispute; a need for information held on early help systems to be held on children's social care systems; a need for a pre-birth assessment by children's social care which could have informed part of the court proceedings; and a need to ensure GDPR guidelines are correctly applied by children's social care. Recommendations include: information sharing policy, between the multi-agency safeguarding hub (MASH) and partners, should not allow GDPR to act as a barrier to sharing information when there are safeguarding concerns; the quality of recording and decision making based on effective triage in the MASH needs to continue to be improved and monitored for consistency so that information, risks and vulnerabilities can be connected; the sharing of information between early help and children social care systems needs to be strengthened so that there is a stronger interface between them; there needs to be assurance, from children's services and midwifery, that the threshold for initiating the pre-birth protocol is being applied appropriately; and any agency that identifies that parental mental health needs are impacting on parenting capacity needs to share that with other partner agencies working with the family so that information can be triangulated and an appropriate response agreed. Keywords: injuries, infants, mental health problems, record keeping, grandparents, pregnancy > Read the overview report

2022 - Tameside - Ellie

Death of a girl in 2021. Ellie's brother, a young adult, was found guilty of manslaughter. Learning focuses on: the assessment of children and young people as young carers; procedures to address domestic abuse in families where a child is a perpetrator of abuse; how capacity to parent a child is assessed when mental ill health has been identified in a parent; how the impact of parental mental ill health on a child is assessed; recognition and response to vulnerability in an adult who has parenting capacity; availability of help and support for a person who has a diagnosis of autism. Recommendations include: adult and children's multi-agency services should address transitional care between adult and children's services; children's social care to provide evidence of robust procedures when closings cases, ensuring there is clear identification of the services continuing to support the child and family; social work assessments should include an effective consideration of history and parenting capacity that informs thorough analysis of risk; commissioners should provide assurance on improving waiting lists for neurodevelopmental pathways timescales, so that children don’t wait too long for support and diagnosis; review the availability of services and support for families who are waiting for an autism spectrum disorder (ASD) diagnosis and post diagnostic support; the safeguarding children partnership to seek assurance on the effectiveness of interventions available for children with complex and challenging behaviours. Keywords : child deaths, sibling abuse, autism, children as carers > Read the overview report

2022 – Thurrock - Serious Youth Violence

Local learning review conducted following a serious incident of youth violence. Learning includes: agencies would like clearly defined thresholds in relation to contextual safeguarding; agencies do not always feel confident on what information they should be sharing, with who, and how to escalate concerns of poor information sharing; it is difficult to evidence change where there appears to be positive engagement and possible disguised compliance; the benefits of extensive mapping, including the collection of data on gang related violence, hotspots, presentations at local hospitals, and local police intelligence data; the value of child criminal exploitation leads in agencies including children's social care. Recommendations include: the completion of a review into information sharing between local police, children's social care and youth offending services; ensure information relating to the transfer of care of vulnerable children and their families from 'out of area' is shared with relevant local health agencies; information about hospital attendances by young people related to serious youth violence, especially in hospitals outside the young person's local area, is shared with relevant agencies; ensure the inclusion of health representatives in multi-agency forums related to children who are at high risk of youth violence; develop a clear threshold and pathways document on contextual safeguarding; consider the development of a transitional safeguarding approach with the Safeguarding Adult Board. Keywords: adolescents, violence, contextual safeguarding > Read the overview report

2022 – Torbay – C92 and C93

Stabbing of a boy by his mother in December 2021 when she suffered from an acute and transient psychotic episode. Learning includes: the importance that professionals working with children have the skills and knowledge to identify parental alcohol misuse and neglect and intervene for children who are not able to voice their experiences; there tends to be an over optimism about parent’s self-reporting and that quite often substance misuse is known about but not seen as excessive; in instances where an individual smells of alcohol but there is no evidence of intoxication this may reflect that they have a tolerance for alcohol at harmful or dependent levels. Recommendations include: assurance that practitioners have sufficient training and development to enable professionals that work with children to understand the impact of parental alcohol misuse and recognise and respond to children exposed to parental alcohol misuse; assurance that local education settings have an effective policy and systems in place to ensure that information is available to inform decision making by the MASH during school holidays; and ensure that children are put on school roll immediately that a place is accepted and that this is not a systemic problem in their area. Keywords : alcohol misuse, child neglect, children missing education, professional curiosity, referral procedures > Read the overview report

2022 - Tower Hamlets - Julie

Head injuries to an infant girl, on two separate occasions due to falling off a bed, both of which required hospitalisation. Learnings is embedded in the recommendations. Recommendations include: promote learning as a public health message about the importance of avoiding co-sleeping and unsafe sleeping arrangements; explore if translated versions can be made available for online pre-birth packs; neglect tool kit to be promoted within multi agency forums and used as a tool where all agencies involved contribute; review practices to capture the voice of the infant; support for practitioners regarding professional curiosity, such as tool kit, bitesize videos or training; review how to support practitioners around the non-engagement of parents and carers to ensure cases are appropriately stepped down; review how to strengthen continuity of care when vulnerable families move to other parts of the borough; review if GP deregistration should be discussed at a multi-disciplinary team meeting for vulnerable families; review what percentage of MASH referrals are received from GPs; review the effect of the pandemic on multi-agency practice and families; investigate how agencies ensure interpretation services are used, and how the level of need of interpretation is addressed and recorded and ensure the interpretation services are easily accessed by practitioners; communications/awareness raising to be sent out to practitioners on consistent use of interpretation and cultural competence; ensure there is a multi-agency agreement and approach to a Think Family/ Think Community strategy, and this is replicated in practice; and ensure there is a trauma-informed model of support across all safeguarding agencies. Keywords: child neglect, head injuries, health visitors, home environment, infants > Read the overview report

2022 – Trafford - Teddy, Wilbur and Peter

Suicide of a 17-year-old and attempted suicides of a 16-year-old and 17-year-old, all cases occurred separately, in England. Learning includes: a need for local authorities to find suitable alternative placements and health and social care to commission appropriate placements for 16 and 17-year-olds; the impact of chronic underfunding of mental health services nationally on young people’s timely access to appropriate mental health services; the need to consider each individual in the context of their age, maturity and mental capacity at each contact; a need for professionals to maintain high levels of engagement and support throughout a young person’s admission into hospital; a need for resources to support 16-17-year-olds who do not meet the threshold to be detained under the Mental Health Act, but are deemed to require a level of care that cannot be fully met within the home or by community services; and a need for triggers for harmful behaviours to be sufficiently considered when formulating plans of care. Recommendations include: ensure appropriate services are being commissioned that can meet the needs of young people aged 16-17-years-old within the community; ensure that there is a clear record of parental responsibility that is amended if a child is placed on an interim/full care order or adopted; review discharge planning processes and ensure a multi-agency response to discharge planning that commences on admission; and strengthen trauma informed practice and safety plan intervention. Keywords: suicide, child mental health, adolescents, transgender, LGBTQ, child mental health services > Read the overview report

2022 - Wandsworth - Alsami

Death of a 14-year-old boy by suicide in June 2021. Learning includes: the importance of taking time and assertive commitment to understand the lived experience of a child; ensure that professionals are proactive in understanding and working with the religious, cultural background of children they are in contact with; the impact of adverse childhood experiences (ACEs) and childhood trauma on children whether they verbalise their concerns or not; take particular care and attention towards 'sensitive and quiet' children in a large family group, ensuring that their views, worries, concerns and lived experience are sought and assertively included in plans and any work with them; purposeful parental engagement which takes account of the parental vulnerabilities, ACEs, and childhood trauma on their parenting; have an informed view about the impact of alleged sexual abuse on all children in the family and in particular male children where the perpetrator is a male and the victims are female children; take account of research into the impact on male self-image, masculinity, and self-esteem of male abuse in families; recognition of the impact of contextual safeguarding to adolescents, especially young men who may be subject of exploitation and fear in communities. Keywords: suicide, adolescent boys, adverse childhood experiences > Read the overview report

2022 – Warwickshire - Grace

Significant and intentional overdose in January 2021 by a 13-year-old girl. Learnings include: in order to understand what a child might be communicating by their behaviour, professionals need to build a relationship with a child; ensure that they consider the cumulative impact of neglect and emotional harm on children who are struggling with their own mental health when assessing and deciding on the need for support or a plan; and the COVID-19 pandemic has had an impact on families and on the ability of professionals to respond to children and families requiring support. Recommendations include: assurance that the waiting times for autistic spectrum disorder (ASD) assessments are addressed; all relevant partner agencies to be asked to provide evidence regarding how they are ensuring that the siblings of children with complex issues receive an assessment and early help/preventative support, and that assessments and plans give due consideration to all the children who spend time in a family home; assurance from the Integrated Care Board that GPs are briefed and trained to think beyond pregnancy prevention including considering the risk of abuse when prescribing contraception to children; consider the cumulative impact of neglect and emotional harm on older children when reviewing and launching their revised neglect strategy, using this case as an example; and review the current systems and practice regarding seeking consent for information sharing, including about parental health, considering what further support is required to ensure that information is appropriately sought, provided, considered, and recorded. Keywords : suicide, drug misuse, autism, bereavement, adverse childhood experiences > Read the overview report

2022 - West Glamorgan - A

In April 2019, a 14-year-old girl went missing for five days from her foster home. She was found by police in a caravan in during which time it was alleged that she had been subject of both sexual and criminal exploitation. She was known to the local authority children’s services team since 2006. Learning is embedded in the recommendations. Recommendations include: all agencies are reminded to be child centred in their approach which includes the use of language to accurately reflect the voice of the child; all agencies are reminded of the benefit from formalising the frequency in which it undertakes holistic assessments; the profile of child information form (CIF) to be raised across the partnership to ensure practitioners, partners, children, carers and parents are clear as to the part they play in the completion of the CIF; consider adopting an approach to serve as the cornerstone of all practice – a common language - such as, trauma-informed practice; review the current arrangements for interviewing child witnesses in partnership with social services and agree best practice and compliance for interviewing children; consider extending the current use of the Child Witness Booklets to Strategy Discussions, Strategy Meetings and Section 47 Enquiries; consider children and adults within their practice in relation to proactive information sharing; send out a reminder of practice across the partnership in respect of Section 5 of the Wales Safeguarding Procedures (2019); and develop and publish guidelines for practitioners and partners on how to work the technological era and the impact social media has on safeguarding children and young people. Keywords : child criminal exploitation, child sexual exploitation, children in care, placements, voice of the child > Read the overview report

2022 – West Glamorgan – S58

Death of a three-year-old during the autumn of 2019. It was established that Child D had died of natural causes relating to their complex underlying health needs. There had been historic concerns around the four siblings and in Summer 2019 the children were placed on the child protection register under the category of neglect. Learning includes: the optimistic view of some professionals appeared to allow disguised compliance by the parents; parents used complaints and conflict to achieve changes in services they received; the importance of hearing the voice of the child; professional ability to analyse information from differing perspectives; and understanding multi agency working and the benefits of sharing information. Recommendations include: the need to be aware of disguised compliance and have strategies and methods for working with families where this is a factor; support for practitioners in dealing with conflict and complaints from families that has potential to impact on the safeguarding of children; listening to children; and multi-agency working and sharing of information. Keywords : child health, childhood illness, child neglect, siblings, disguised compliance, parent-professional relationships > Read the overview report

2022 – West Lothian – Learning Review

Presents findings from two significant case reviews involving two children from different families between 2018-2021. Child C was removed from their mother’s care after attending hospital with a fractured skull. The details of Child D are not shared. Learning includes: the interaction of child protection with adult services when parents experience mental health problems or learning difficulties; formal assessments of parents’ capacity balanced against the safety of the child; recognising adolescents as vulnerable from neglect or other harm, and not solely focussing on their presenting behaviour; male carers living in the family home; careful consideration of historical information; engaging with families and over optimism; multi-agency planning and the role of lead professional; and multiple referrals to screening groups or other services for support. Recommendations: there are no formal recommendations. Provides reflections from a survey of 128 respondents (incorporating all agencies working with children and families) and three discussion groups to obtain views of how learning is embedded into practice. Keywords : child neglect, family violence, parents with a mental health problem, parenting capacity, unknown men > Read the overview report

2022 – Wigan - George

Multiple injuries including significant subcutaneous swelling to the head of a 23-month-old boy in March 2022. George was brought to nursery by his mother and shortly after his arrival staff noticed several bruises and abrasions to his face. George’s mother was arrested on suspicion of assault. Learning themes include: supporting the transition to adulthood, especially for those approaching parenthood; considering the meaning behind missed appointments, late cancellations and rearranged appointments; the impact on young carers when their siblings are placed in care; ensuring the child’s voice and lived experience leads decision making; critical thinking, professional curiosity and over optimism; threshold application at point of closure of cases; unseen men and their relationships with vulnerable women / those with experience of abuse; development of practice approaches for those working with individuals who have experienced trauma. Recommendations include: consider whether transitional planning is aligned with the Care Act 2014 and whether the correct trigger points are in place to start that planning (in order to help support adolescents who have multiple areas of vulnerability as they transition into receiving an adult service offer); review the data infrastructure cross-agency to identify whether improvements can be made within current systems, for example, automatic chronological entry to be implemented, a possible positive outcome being the ability for practitioners to see real-time updates across agencies outside of set review timings. Keywords : abused boys, bruises, child abuse, child neglect, cycle of abuse, transition to adulthood > Read the overview report

2022 – Wiltshire - Baby Eva

Death of a 3-month-old baby girl in 2021 from injuries that suggest she had been shaken. Learning is embedded in the recommendations. Recommendations include: explore work to engage fathers in ante and post-natal care and look at ways of embedding and mainstreaming the improvements; services for young people should include awareness raising about the harmful effects of street cannabis, with an especial focus on those entering parenthood; services for adults should be constructed such that a greater focus is placed on those service users who are parents and, within that group, an even sharper focus on those who are parents of babies; ensure that there is a clear message driven that the real or suspected presence of cannabis in a family home where children are present should be regarded as a potential risk factor; commission training for front-line staff aimed particularly at exploring the impacts and effects of cannabis use; produce either practice guidance and/or an assessment template to help guide front-line staff in assessing the impact of cannabis use; review of arrangements between the police and MASH about the reviewing and sharing of untested intelligence reports; police should share information with acute hospitals in relation to substance misuse and mental health issues; and ensure a similar response to women and men who might be parents and are taken into custody. Keywords : infant deaths, drug misuse, home visiting, information sharing, mental health services > Read the overview report

2022 – Wiltshire – the long-term sexual abuse of children in care

Long-term sexual abuse of three siblings in foster care. The abuse was perpetrated by the male foster parent. Learning includes: professionals should not assume that when a child has had therapeutic interventions this will be protective in the longer term; as children with disabilities are more vulnerable to sexual abuse, professionals need to ensure that this is considered when their behaviour is being assessed; professionals need knowledge and confidence about adult behaviours that might indicate a sexual risk to children; professionals need to be able to consider the 'unthinkable' about carers they may know well and be alert to the possibility of sexual abuse; when professionals predominantly work with one carer, they need to ensure that equal professional scrutiny applies to the second carer; opportunities should always be taken by trusted professionals to have age and ability appropriate discussions about sexual abuse with children in care; schools are key in providing an environment where children know who they can talk to about sexual abuse and what will happen if they tell someone; children in care in long term placements need significant relationships with professionals and/or their carers if they are to disclose sexual abuse. Recommendations include: ensure professionals are thinking and talking about the risk of sexual abuse of children in care; learning from the review is shared with the local corporate parenting panel; training foster carers about intra-familial sexual abuse; and assurance of the local plan to include direct information from respite carers in child in care reviews. Keywords: child sexual abuse, foster care, children with learning difficulties, siblings, abusive men > Read the overview report

2022 – Wirral – Emily and Lily

Sexual abuse of two sisters by their grandmother and her partner which came to light in January 2021. Learning includes: over-optimism in family carers with an over reliance on self-reports and a lack of true understanding on the lived experience of the child in visits and assessments; the lack of a detailed re-assessment rather relying on copying forward a lot of the information already there; impact of covid on contacts and lack of school attendance meaning less visibility at a particularly vulnerable time; and dismissal of concerns raised by other family members as being malicious. Recommendations include: support the implementation of systemic practice, training and guidance about the importance of professional curiosity, especially to help with understanding the strength or weaknesses and dynamics of family and wider support networks; review findings from audits and recent reviews to identify the impact of lockdowns and reduced face-to-face contact with families, and to use the findings to inform future strategy; children's social care to review its assessment process for connected carers to assure that decisions are appropriately informed by up to date assessments; and review guidance and training about gathering the daily lived experience of children and adults and to update in light of the introduction of systemic practice. Keywords : child sexual abuse, adverse childhood experiences, foster care, sex offenders, sign language > Read the overview report

2022 – Wirral - Taylor Children

Concerns the welfare of three siblings aged 3, 5 and 7-years-old whilst living with their mother and her new partner in the family home. In December 2021, multiple bruises were found on two of the children following an anonymous referral reporting that the 5-year-old boy was being physically and verbally abused by the mother’s new partner. Learning themes include: introducing a new partner to the family; professional curiosity and disguised compliance; the impact of adverse childhood experiences (ACEs); and the impact of COVID-19. Recommendations for the partnership include: to undertake a wider review of the impact of COVID-19 on safeguarding families; for learning from this rapid review to be shared with partner agencies; to ensure that there continues to be a focus on understanding the daily lived experiences of children in its review of the local model for working with children, young people and families; to ensure guidance and training about professional curiosity, and responses to new partners are available to all professionals; and to continue to support ongoing work locally to raise awareness and response to ACEs. Keywords : physical abuse, unknown men, professional curiosity, adverse childhood experiences, coronavirus, siblings > Read the overview report

2022 – Wokingham – Aisha and Ciara

Sexual abuse of two siblings under 6-years-old by an acquaintance of their mother. Both children were also subject to neglect by their mother. Learning includes: the importance of understanding the circumstances of parents or family members who are identified as having unmet and unassessed learning needs or learning difficulties; the need for a structured approach to identify and address child neglect; ensuring professionals are equipped when working in the area of child sexual abuse and improved awareness of the importance of clarity regarding risk; professionals balance intuitive reasoning with analytical reasoning; and a need for discussion in a multi-agency context about how to facilitate communication with a child and ensure their needs and voice are brought into focus, considering issues of disability, age and language. Recommendations include: build a stronger, structured approach to neglect; and remind practitioners that verbal or written communication is adapted to ensure accessibility during contact with families where there are potential learning needs. Keywords: child sexual abuse, child neglect, family conflict, professional curiosity, children’s services, language development > Read the overview report

2022 – Wokingham - Young Person Harry

Arrest and conviction of a 13-year-old boy for a serious violent crime. Learning includes: children and young people with special educational needs and disabilities (SEND) need to be understood, and local capacity improved, so that these specialist needs can be met; the quality of information sharing when a child or young person with an education health and care plan (EHCP) changes schools is crucial; new pathways are required for young people with complex needs if exclusions from school are to be reduced; there is a need to develop a culture of safeguarding within front line staff to improve the service offered to young people by Thames Valley Police. Recommendations include: develop new procedures for the early review of EHCPs when a child or young person moves local authority area at the same time as transitioning from primary to secondary school; develop new information sharing procedures when students with an EHCP change schools, including professional meetings attended by the relevant schools, the agencies working with the young person, and the parents/ guardians; Thames Valley Police should produce new policy and guidance in relation to children and young people who are identified as suspects in a criminal investigation and develop a culture of safeguarding and partnership working, with training delivered to all police officers and police community support officers; update policy and guidance for the review of referrals and contacts that involve children and young people with SEND. Keywords: children with a learning disability, county lines, criminal child exploitation, exclusion from school, police > Read the overview report

2022 – Wolverhampton – Child R

Suspected non-accidental head injury to an 8-day-old baby. At the time of Child R’s birth all of the children in the household were the subject of child protection plans. Learning themes include: knowing and considering the parent’s history and vulnerabilities when working with a family; understanding a child’s lived experience and what they may be communicating by their behaviour; the likelihood of child neglect coexisting with other forms of abuse; the impact of ‘growing families and growing children’ on the ability of parents’ to cope; the cumulative impact of long-term neglect; awareness among professionals of control and coercion and non-violent domestic abuse; need for professionals involved with adults to be aware of plans for the children in the household; the effect of COVID-19 on families and services received; considering making older siblings aware of safe handling and careful behaviour around a new born baby; child protection procedures regarding parental contact following an injury. Recommendations include: ensuring improvement actions are taken, including seeking assurance that the learning from this review is considered by those responsible for ICON training, and that ICON recognises the need for bespoke plans about safe handling for parents with learning difficulties and where there are older children in the family; ensure that services are aware of the need to follow child protection procedures when a non-mobile child has injuries; and ensuring that when children are the subject of a plan, this is recorded on the GP record of any adults in the household. Keywords : abusive men, family violence, neglected children, non-accidental head injuries, parenting capacity, siblings > Read the overview report

2022 – Worcestershire – Baby D

Death of a 6-week-old boy in October 2020 who was found unconscious and unresponsive by his father in the early hours of the morning. Reports identified fractures to his posterior ribs that were believed to have occurred 5-10 days before the baby’s death and were unexplained. Learning includes: where new information becomes available that gives rise to safeguarding concerns, such information should be shared with all appropriate agencies in a timely manner to ensure any other children or individuals are safeguarded; a need for early consideration of the circumstances of a case to understand if abuse or neglect is suspected or whether significant concerns arise regarding potential child protection issues; and if information is received during an investigation which raises a new or additional safeguarding concern, a clear decision should be made whether this will be managed within the sudden unexpected death in childhood (SUDIC) process or whether this requires referral or strategy discussion. Recommendations include: all appropriate agencies are being invited to, attending and contributing to information sharing meetings; where abuse and/or neglect is suspected within a SUDIC joint agency response, then a decision must be made and recorded, using the levels of need guidance, as to whether there are specific risks for other children; and the partnership should seek assurance that the local and regional multi-agency procedures provide sufficient guidance on dealing with risks to children who have moved with their parents to another country. Keywords : sudden infant death, transient families, risk management, referral procedures, police, hospitals > Read the overview report

Case reviews published in 2021

A list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2021. To find all published case reviews search the national repository .

2021 – Anonymous – Anonymous Family

Chronic neglect, physical and sexual abuse of eight siblings and three older half siblings perpetrated by their parents and one sibling. Both parents and the eldest child of their relationship were convicted and sentenced for sexual offences and neglect. Learning includes: the impact of securing evidence in criminal proceedings and safeguarding children; mothers as sexual abusers of their children and the impact of disguised compliance by parents; the level of knowledge, skills and training available to practitioners on child sexual abuse within the family; the continuing need for escalation and professional challenge by practitioners; the historical and current issues around the retention of records; the central role of the Independent Reviewing Officer (IRO) needs to be recognised when there are a number of children within a family in different placements; and children “not brought” to medical appointments. Recommendations provided around the following themes: child sexual abuse investigation processes and management oversight; professional escalation and challenge; training and professional development for frontline practitioners; and information sharing. Keywords: child neglect, child sexual abuse, physical abuse, non-attendance, disguised compliance > Read the overview report

2021 – Anonymous – Anonymous victims of FC1

Sexual abuse of several children by their foster carer between 2007 and 2019. The foster carer and his wife were registered with a private fostering agency and had fostered 40 children from five different local authorities between 2007 and 2020, usually as mother and baby placements. Learning includes: while there were no obvious physical injuries to the young children victimised by the foster carer there will be potential long-term impacts on their health and wellbeing; training about the “invisible male” should also be used to consider situations where foster carers and other professionals are providing care and support in their own homes; the identification of child sexual abuse in particular with regard to children who are pre-language or have significant language or communication difficulties. Makes no recommendations but sets out actions including: regional event to be developed to share learning on: understanding and avoiding the impact of professional bias; ensuring neither foster carer is an “invisible party”; understanding perpetrator profiles; and sexual abuse of babies and pre-verbal infants. Model: Rapid review. Keywords: child sexual abuse, foster care, infants, child abuse identification, unknown men > Read the overview report

2021 – Anonymous – Baby D

Injuries to a 4-month-old baby boy in 2019 inflicted by his mother who was mentally unwell. Learning includes: inconsistent understanding regarding statutory guidance in the child protection procedures about undertaking pre-birth assessments related to mental health risk factors; coordinated work, robust information sharing and effective strategic oversight will better ensure all children are safeguarded; children are best protected when the local system of management oversight in supervision and meetings is strong, resulting in well-coordinated risk assessments, interventions, and planning; professional curiosity is best supported if there is a local culture of collaboration and professional challenge; confident and open practitioners work better with families if their professional views are challenged and practitioners at times struggle to communicate with some families; families do well when they have a good understanding of their rights and responsibilities and can make informed choices. Recommendations include: ensure that all local multi-agency pre-birth risk assessment tools and protocols and information sharing comply with child protection procedures and local guidance, and that staff are aware of, and trained, in using these; seek assurance of the quality of individual agency supervision and management oversight; consider how empowering staff and supervisors in exhibiting professional curiosity can be encouraged in training and supervision, so that staff feel confident to have challenging conversations. Keywords: physical abuse, mothers, parents with a mental health problem, mental illness, professional curiosity > Read the overview report

2021 – Anonymous – Child E

Death of a 6-year-old girl in June 2019. Cause of death is unknown. Learning: there was a need for more focus on the quality of Child E's lived experience and on her parents' refusal to consent to potentially lifesaving treatment; there was insufficient professional curiosity and response about understanding and investigating the children's experiences of living in overcrowded accommodation. Recommendations: review the process and procedure for identifying risks and harm to children when parents or carers are not complying with medical advice; professionals need to establish whether fathers have parental responsibility for children; consider the options for improving the coordination of services and information sharing to address the needs of children with disabilities. Keywords: child deaths, children with disabilities, medical care, parental responsibility, professional curiosity, voice of the child > Read the overview report

2021 – Anonymous – Child P1

Injuries to a 6-week-old child in July 2017, including a fractured skull and injuries characteristic of a shaking injury. Learning includes: there were specific areas in which awareness of honour based violence may not have sufficiently informed practice; limited use of psychological assessments to inform subsequent assessments and decision making raises the possibility that practitioners may not pay sufficient attention to historic reports when carrying out assessments; the rule of optimism appeared to be influential; the role of GP practices in safeguarding children was weakened by the father being registered at a different practice to the mother and their children, and the father's practice being unaware of his children and the prior safeguarding measures; identifies good practice including, effective multi-agency working and psychological assessments of the mother and father which proved to be insightful. Recommendations include: guidance on how the honour based violence apparent in the early years covered by this case review should be responded to; consider whether court ordered reports should be shared during and after court proceedings; request partner agencies to include the extent to which practitioners make appropriate use of historic reports and assessments in the quality assurance of case files; ensure that professional challenge becomes an integral element of safeguarding practice; ensure that pre-birth assessments are carried out in accordance with the agreed multi-agency policy; seek assurance from health providers regarding decision making on the level of service provided to families where there are safeguarding children concerns. Keywords: infants, shaking, culture, optimistic behaviour, violence, general practitioners > Read the overview report

2021 – Anonymous – Child X1

Sexual abuse and sexual exploitation of a girl whilst she was looked after by the local authority. Child X1 was one of several victims and the evidence from the disclosures resulted in the successful convictions of the perpetrators.   Learning includes: the completion of full family histories by professionals is not always given sufficient priority and that this has the potential to undermine the quality of risk assessments and associated planning for children who are looked after; a safe system in terms of placing children who cannot live with their parents will necessitate decision-making which has a clear understanding of children's needs; although resources are a challenge for all local partnerships, if these are balanced by a strong focus on the needs of a child this has the best likelihood of allowing and supporting a child to grow up with consistent carers, and helping them to reach their potential; an approach that is based on contextual safeguarding and includes proactive investigation and evidence gathering as a means of tackling child sexual exploitation is core; when children request contraception, good principles of critical thinking need to be applied to ensure that indicators of risk are clearly articulated and responded to within the multi-agency safety plan; good practice indicates that information sharing, risk assessment and transparency are key in planning for the young person within a multi-agency context. Recommendations: makes no recommendations but poses several questions to the safeguarding partnership. Keywords: child sexual abuse, child sexual exploitation, children in care, contraception > Read the overview report

2021 – Anonymous – Family H

Sexual and physical abuse of siblings over a two-and-a-half-year period by their father. Learning relates to: the home education of children and young people; identification of home educated children; ensuring a stable education; safeguarding home educated children; social, pastoral and leisure needs as the foundation of child development; and bereavement support. Recommendations: raise awareness of the importance of the identification of elected home educated children and the need for them to be registered across all agencies; make a recommendation to the National Panel to complete a thematic review of serious case reviews, rapid reviews and child safeguarding practice reviews that relate to home educated children; consider the existing pathways to bereavement support for the children of terminally ill parents. Keywords: child sexual abuse, physical abuse, siblings, abusive fathers, single parent families, bereavement > Read the overview report

2021 – Anonymous – Hatty and Jen

Sexual abuse of two sisters aged 14-years-old and 13-years-old by their father over a period of six years. Both children were placed with a foster family, and a police investigation was initiated. Learning focuses on: home education of children; working effectively to identify and address sexual abuse and exploitation; understanding adult sexual offending behaviour and evaluating the risks of likely and future harm; supporting children to seek help from professionals; children communicating that something is wrong through their behaviour; interviews with children which do not follow guidance are likely to undermine effective safeguarding, decision-making in the family courts and criminal processes; recognising and addressing the impact of domestic abuse; safeguarding children from being physically harmed, characterised as "physical chastisement or physical punishment"; delivering culturally competent practice; the importance of a structured approach to children's experience of parental neglect over time. Recommendations include: make a recommendation to the National Panel to complete a thematic review of serious case reviews, rapid reviews and child safeguarding practice reviews that relate to home educated children; scrutinise how partner agencies are equipping their staff to understand and support children's help-seeking behaviour; issue a child-centred position statement about the appropriateness of physical chastisement and provide guidance about what safeguarding responses are required; understand and scrutinise how supervision arrangements promote professional curiosity, are child-centred, and address fixed thinking across partner agencies. Keywords: child sexual abuse, home education, help-seeking behaviour, family violence > Read the overview report

2021 – Anonymous – PS

Serious assault of a child in care by an adult in 2019, resulting in life-changing injuries. The perpetrator was the son of a member of the residential unit staff where PS lived. Learning includes: it’s critical that families involved in Special Guardianship Order placements receive information, advice and training on adverse childhood experiences and the strategies they need to adopt to maintain the placement; agencies should have acted as responsible adults and asked for a previous assault of PS to be investigated; victims of crime often are fearful of retribution. Recommendations include: ensure that the ‘voice of the child’ is routinely captured during assessments; ensure that measures used to determine suitability of residential settings for placing children are fit for purpose; ensure that newly-qualified social workers and practitioners working directly with children and families receive formal monthly supervision; staff working with children such as PS should be trained to spot and respond to early signs of exploitation, such as cash in hand work; staff and managers should know and be able to apply the principles of trauma-informed practice. Keywords: children in care, child criminal exploitation, trauma-informed practice, adverse childhood experiences, violence > Read the overview report

2021 – Bexley – Baby R

Death of a 4-week-old boy in July 2020 due to non-accidental head injuries. Learning:  the family should have continued to receive the right level of support when they were transferred to another local authority; disagreements between local authorities over the transfer and status of the family caused delays in the family receiving the appropriate level of service; housing services not being aware of the neurodiversity and safeguarding needs of the family; lack of communication between mental health services and children’s services; bruises or marks observed on a non-mobile baby should have triggered a robust multi-agency response. Recommendations:  current approaches to risk assessment through child protection enquiries or child in need processes should obtain and take into account family background and previous experiences such as trauma, neurodiversity, and parental mental health difficulties; strengthening education and training on the ‘think family’ approach, as well as neurodevelopment disorders and what such difficulties mean for parents’ understanding and interpretation of information and advice; raise the role of housing services in statutory child protection processes as an issue of concern with the Child Safeguarding Practice Review Panel; ensure that practitioners understand the significance of bruising in infants and the need to act. Keywords: infant deaths, non-accidental head injuries, parenting capacity, developmental disorders > Read the overview report

2021 – Bexley – Child O

Serious and potentially life-threatening incident to a 4-year-old boy in July 2019. Child O was taken to hospital after accidentally swallowing Gamma-ButryoLactone (GBL), a Class C drug commonly known as ‘liquid ecstasy’, he found in his mother’s handbag. Learning looks at: the support offered to the family under the Special Guardianship Order (SGO) and the quality of the support plan; robustness of the communication between local authorities (LAs) including how safeguarding referrals were raised; adult mental health; domestic abuse and Multi-Agency Risk Assessment Conference (MARAC) involvement; issues arising from management oversight and supervision information. Recommendations include: review training programmes about the legislations, governing and meaning of different types of placements such as SGOs, Children Looked After (CLA) and adoptive placements that are open to LAs when considering the future of children who are unable to live with their birth parents; oversee a multi-agency review of current arrangements for children in need that are also subject to SGOs. Keywords: accidents, drug misuse, kinship foster care, placement, special guardianship orders, child neglect > Read the overview report

2021 – Birmingham – BSCB 2017-18/02

Death of a 21-month-old girl in November 2017 as a result of brain injuries following physical abuse by the partner of the child's special guardian. The perpetrator was found guilty of murder and sentenced to a minimum term of 20 years in prison. Learning includes: the importance of a close family relationship for the child with the special guardian; the importance of wider family support for the arrangement; management of contact; the importance of understanding a special guardianship order (SGO) as at the adoption end of permanence. Makes no recommendations but identifies learning points with actions: enough time should be given to assess the integration of a child placed within a family, the care of that child and the impact on all members of the family before a final SGO is made; organisations need to reflect on how the impact of a change of social worker and team in the middle of proceedings and planning can be mitigated to keep the needs of the child at the centre; there is an absence of guidance on what action to take when a child is presented with concerning bruising for frontline professionals; an absence of appropriate challenge and professional curiosity, particularly around apparently open reporting. Keywords: physical abuse, bruises, special guardianship orders, professional curiosity > Read the overview report

2021 – Birmingham – Child A

Death of an adolescent boy due to a fatal stabbing in January 2020. Learning includes: professionals tackling child criminal exploitation need to know and understand the serious youth violence strategy, engage with families, have a comprehensive knowledge of the National Referral Mechanism and be alert to a 'reachable moment' for a child; professionals need to understand the impact of adverse childhood experiences on children and how to use a trauma informed approach; professionals need to understand what 'place' means to a child and how that influences their lives; preventing school exclusion is a good preventative move because being in education is a safe place for children to be; educate children as to the dangers of knives and being involved in gangs and serious youth violence because this can prevent future exploitation; consider using a 'think family' approach; health agencies have limited occasions to intervene and so should capitalise on them where possible; children who go missing should have a return home interview. Recommendations are embedded in the learning. > Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Ava, Lucas, Harper and Chloe

Chronic neglect of four siblings over several years. In 2019, two of the siblings aged 1.5-years-old and 2.5-years-old were reported to have been injected with heroin, which was confirmed by a child protection medical examination. Learning focuses on the following themes: understanding the lived experiences of each child and impact of the parents’ and carers' behaviour and lifestyle; responding to neglect; processes around child protection, public law outline and placements; adult services' work with parents and incorporating a Think Family approach; multi-agency working and communication; and de-sensitisation and professional culture. Recommendations include: examine the current position relating to neglect in the local area; ensure that public law outline (PLO) processes are being conducted in a timely way and any delays and risks are addressed immediately; ensure a partnership approach in supporting families involved in PLO proceedings and related matters; provide training to the multi-agency workforce on working with families significantly affected by substance misuse; promote the use of the resolving professional disagreements protocol and the role of the child protection conference chair as a point of reference for any professional who is concerned about the progress of a child protection plan; provide opportunities within training for professionals to focus on desensitisation and the impact this may have on the children and families receiving support. Keywords: child neglect, substance misuse, poverty, voice of the child > Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Child CD

Death of a 13-month-old child in February 2019. Ambulance services were called but Child CD did not show signs of life and resuscitation was not attempted. The ambulance crew expressed concerns about the home environment and circumstances in which Child CD was found. Learning includes: maternity services should provide assurance that routine domestic abuse enquiry is effective, and not a widespread issue; Early Help may be indicated when families move frequently; there should be a robust assessment of family needs when women with a significant history of mental health or emotional instability are pregnant and in the post-natal period so that they can be supported in caring for their baby and other children. Recommendations include: safer sleep and the risks to mobile infants or toddlers should remain a focus of local multi-agency activity; a focused response and co-ordinated multi-agency working with adolescents with complex health and social needs on the edge of statutory intervention; assessing and working with young fathers who have or assume childcare responsibilities is crucial. Keywords: child deaths, sleeping behaviour, housing, mental health, parental involvement, prescription drugs > Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Child LO

Death of a 16-month-old child in December 2017. Child LO died due to an airway obstruction whilst sleeping unsupervised in an unsafe environment. Learning includes: seeing where babies and young children sleep (day and night) can improve assessment of safe sleeping environments and provide an opportunity for professional advice; local authorities should be aware of local holiday parks and ensure that the winter rules are adhered to; professionals need to be curious about why a mother and child is living in a holiday caravan and provide relevant advice and support to address any accommodation issues; the courts should share safeguarding concerns with front line staff; the midwifery electronic record and health visitor child health record should include full details of previous children by a mother or father, and new family members; parents are more likely to disclose their vulnerabilities if they know and trust the professional involved; multi-agency safeguarding hubs should share concerns with health professionals; better links between health visiting and nursery provision would promote better assessment and support through early help; recognising and addressing domestic abuse early has a beneficial impact on children and family life. Recommendations include: improved arrangements for: multi-agency working and information sharing, standards of domestic abuse processes, ensuring safe sleeping arrangements for babies and young children; reduce the risk of children and families living in holiday park accommodation during the cold winter months. Keywords: child death, sleeping behaviour, housing, professional curiosity, health visitors > Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Child LT

Injuries to a 3-month-old infant in June 2018 consistent with having been severely shaken and from impact with a hard surface. The father was arrested and made subject to a criminal investigation. Learning focuses on: the extent to which practitioners considered the impact of the father's mental health issues on his parenting capacity; the mother's disclosure of domestic violence and abuse and the professional response to this; the effectiveness of interpreter services; the lived experiences of the children. Recommendations include: ensure that risk assessments address the impact of parental mental ill health on children; promote awareness of the ways in which parental mental ill health can result in abuse or neglect of children and the key issues for practitioners to consider when assessing the risks to children; ensure that hospital staff fully explore a patient's presentation after suspected self-harm, make referrals for hospital mental health assessments and consider any safeguarding issues; promote the Think Family approach; consider advising the National Child Safeguarding Practice Review Panel of the interpretation challenges highlighted by this case; promote the need for practitioners to provide advice on coping with crying babies to parents for whom English is not their first language when using interpreters. Keywords: infants, shaking, parents with a mental health problem, language, communication > Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Holly

Death of an 8-month-old girl in 2016. Holly was found unconscious and not breathing in the family home and was pronounced dead at hospital. Learning: includes: professionals should encourage parents to elaborate when conversations reveal stress factors that could affect their capacity to care for their children; family members being registered with different GP surgeries could be a weakness from a safeguarding perspective; pathways for support staff in managing the risk of not being able to see children at home would enable staff to persist in their follow-up with families where increased risk factors are identified; professionals ensure that vulnerabilities identified at an early stage in work with families reduce rather than increase over time; the safeguarding risk factors associated with babies and very young children. Recommendations: ask agencies to provide evidence they have completed proposed actions and to summarise their impact. Keywords: infant deaths, adolescent parents, teenage pregnancy, siblings, child health, non-attendance > Read the overview report

2021 – Blackburn, Darwen, Blackpool and Lancashire – Mia

Death of an 8-month-old girl in July 2020 after becoming submerged in the bath whilst unsupervised by her parents. Mia was treated in a hospital intensive care until her death three weeks later. Learning:  considering the risks for a blended family of several households; identifying and responding to neglect; sex offenders spending time within a family home; whether COVID-19 restrictions affected the single or multi-agency response. Recommendations:  emphasise the importance of documenting how a child is presenting and the interaction between the child and parent or carer to better understand the child’s lived experience; the importance of understanding the lived experience of children in blended families, particularly when they are visiting or staying in different households within the blended family; ensure that situational risks such as house moves and temporary housing are highlighted in the local response to learning about sudden unexpected deaths in infancy; a robust process for information sharing between partner agencies when sex offenders are suspected of presenting a risk of sexual harm to children; work to support women who have been exploited by sex offenders should consider a range of scenarios in which women may become vulnerable to exploitation in the future. Keywords:  infant deaths, drowning, child neglect, step-families, siblings > Read the overview report

2021 – Blackburn with Darwen, Blackpool and Lancashire – Ryan, Nathan and Amelia

Serious persistent neglect of three siblings over a number of years by their mother. Learning: lack of access to the family home can prevent agencies from fully responding to child neglect. Recommendations: resolve professional differences; child protection proceedings should not preclude pre-birth assessments; staff working with children with complex and additional needs should be trained and skilled; tools such as the Graded Care Profile 2 and local strategies and procedures should be followed; health, education and care plans should be robust; parenting assessments should be repeated or updated when necessary; consider filling gaps in service provision. Keywords: child neglect, children with chronic conditions, inter-agency cooperation, children with disabilities, autism, depression > Read the overview report

2021 – Bradford – child sexual exploitation: thematic review

Review of five children, three now adults, two of whom were abused during the 2000s. Considers the impact of learning from two other case reviews carried out locally in 2015 and 2016. Most of the children in the review experienced domestic abuse, physical abuse, emotional abuse and neglect for most of their lives. Learning: the two audits of recent cases recognised that the Ofsted improvement activity resulted in more regular formalised supervision by children’s social care; the complexity of the cases and the scale of the challenges involved in the work, risks that the cases ‘run the worker’ rather than the other way around. Recommendations: recognise that drugs and alcohol are used as part of the grooming coercion and control of victims by perpetrators and that responses need to be developed to reflect this; recognise the additional vulnerability of disabled children and respond appropriately; that the outcome for children (and their children) who become pregnant as a result of sexual exploitation or abuse is better understood and responded to. Keywords: child sexual exploitation, pregnancy, family violence, emotional abuse, child neglect, children with learning difficulties > Read the overview report

2021 – Bradford – Emily

Potentially life-threatening non-accidental head injuries to a 6-week-old girl in August 2019. Learning includes: inconsistencies around attendance at meetings meant that there was never a clear, shared understanding of the children’s lived experiences; key people were missing from child in need meetings, child protection conferences and core group meetings; and possible indications of neglect were missed. Recommendations include: child in need plans should clearly describe areas of concern, actions to be taken and measures of success; changes in the composition of a household where there is a child in need or child protection plan should lead to an updated social work assessment; schools should put arrangements in place so they can contribute to conferences and meetings during school holidays. Keywords: child neglect, family violence, non-accidental head injuries, parenting capacity, physical abuse, siblings > Read the overview report

2021 - Brent - Child K

Death of 16-year-old boy in 2019 in an attack which is believed to be connected with rival criminal groups. Learning : is embedded in the recommendations. Recommendations include: ask the Safeguarding Review Panel for guidance of serious youth violence incidents; review of practices on the provision of parenting support, where there is a perceived risk of involvement in youth offending; improve information sharing with schools and colleges in relation to children who are at risk as a result of serious youth violence or child criminal exploitation; ensure that youth offending service assessments consistently seek to identify and take full account of the child's background and relevant contextual factors and take full account of information from other localities when a young person is known to have links with services in other boroughs; consider making decisions to support or enable the relocation of family the responsibility of a manager at director level who should be reassured that all alternatives and risks present in the proposed area of relocation have been considered. Keywords:  child criminal exploitation, child mental health services, gangs, homicide, interagency cooperation, information sharing > Read the overview report

2021 - Buckinghamshire - Baby N

Death of a 13-week-old girl in January 2019. Learning includes: the importance of understanding the family history; assessing the holistic needs of children; understanding the cross-border issues and how it impacted on the children's needs; assessing risks to staff whilst meeting the needs of those living in disadvantaged areas; and responding to urgent and emergency housing needs of children living in neglectful circumstances. Recommendations include: strengthen the provision of supervision for health visitors to ensure that good quality, regular supervision is offered, in line with the supervision protocol; development of a common cross-border understanding regarding the placement of vulnerable families in temporary accommodation; consider the use and effectiveness of existing tools, to support professionals in the wider children's workforce, to understand the impact of neglect on the lived experience of children; and implementing planned unconscious bias and professional curiosity training. Keywords:  early intervention, family support services, neglected children, interagency cooperation, information sharing, referral procedures > Read the overview report

2021 - Camden - Child E

Death of a newborn infant in September 2020. Child E was born with no brain activity after a breeched labour and delay in the parents accessing medical care, with their life support being switched off the day after birth. Learning includes: professionals should understand that some parents with a long history of intervention may be resistant to professional involvement; there are limitations to child protection information sharing arrangements when it comes to missing people; information sharing on missing people requires joint data to be made available on risk factors to predict the likelihood of specific harmful outcomes. Recommendations include: safeguarding practitioners use joint supervision to reflect on progress made against intervention plans when there is limited engagement and risks remains unresolved; joint agreement and understanding of a missing person incident enables action to be taken, including the most appropriate use of police powers; practice should be led by continuous assessment of need for children and families, with assessment including therapeutic input and, when appropriate, joint intervention by children and adult's services; parents who have a history of repeated removals of babies, and a history of adverse childhood experiences (ACEs), require support and joint intervention from adult and children’s services; local partnerships should explore how they can engage with providers of private baby scans to raise safeguarding standards. Keywords: infant deaths, newborn babies, adults with learning difficulties > Read the overview report

2021 – City and Hackney – Child A

Child A was born by emergency caesarean section at 27- weeks-old and was diagnosed with a condition found in premature babies.  There were concerns about suspected fabricated or induced illness, including the prescription of opioids for pain management, covering the period from birth to the age of 11-years-old. Learning: practitioners did not listen to the voice of the child; acceptance of what mother said and responding without any objective assessment led to unnecessary and inappropriate medical intervention; lack of professional challenge and curiosity culminated in ongoing medicalisation; there was an insufficient response in meeting educational needs.  Recommendations: embed the voice of the child in procedures and training and ensure that children are involved at each stage of their care; review practice guidance on fabricated and induced illness to ensure it takes account of children who are coming to harm through excessive medical intervention; training should include the potential safeguarding impact on children not being brought to health appointments; ensure escalation policy incorporates supporting professionals being able to challenge colleagues.  Keywords: fabricated or induced illness (FII), children’s rights, abusive parents, non-attendance, professional curiosity, voice of the child > Read the overview report

2021 – City and Hackney – Child B

Neglect of a 10-year-old child over a number of years. Child B was born with a disability and needed significant support from health specialists. Learning includes: children not being brought to appointments is an indicator of potential neglect; effective and child focused safeguarding practice with disabled children ensures they are seen, heard and helped; the focus on engaging parents and carers to support disabled children is key, but should not dilute professional challenge; the need for professionals to think about family and fathers. Recommendations include: ensure that all services have access to and use a ‘Was Not Brought” policy across the local health system; the Disabled Children’s Service should ensure that meetings include an analysis of a child’s attendance at appointments; ensure that recording systems are sufficient to identify repeating patterns of children not being brought to appointments; ensure that guidance for safeguarding children with disabilities sets out the importance of communication and hearing the voice of the child. Keywords: child neglect, children with a disability, non-attendance, voice of the child > Read the overview report

2021 – City and Hackney – Child I

Death of a 16-year-old child from natural causes whilst in custody at a Young Offender Institution. Review does not consider the circumstances of Child I’s death. Learning: practitioners need to recognise ‘subtle moments’ that might present clear opportunities to help and protect a child; where children are identified as needing early help, it is important that parents and carers fully understand what this involves in respect of a coordinated, multi-agency approach to help and protection. Recommendations: ensure that policy, procedure and practice relating to critical moments (both well established and those less obvious) is sufficiently robust to ensure effective safety planning; work with schools to ensure that they are able to identify children who show persistent behavioural difficulties; ensure that a multi-agency response to the persistent disruptive behaviour of children is sufficiently described in threshold tools; explore with primary and secondary schools how multi-agency involvement could be improved both prior to and at the point decisions are being made about permanent exclusions. Keywords: adolescents, death, young offenders, exclusion from school, violence > Read the overview report

2021 – City and Hackney – Child R

Extensive physical injuries to a 2-year-old boy in April 2020. Child R was found unconscious by paramedics in the family home with bruising and injuries and was later found to have a bleed on his brain. Learning:  issues around information sharing, particularly regarding arrangements for transferring community health records and the transfer of cases between local authority areas; issues around the ability and confidence of safeguarding practitioners to recognise risk and act with authority in cases involving both domestic violence and child abuse; the importance of safeguarding practitioners including relevant adult males in their assessments of risk. Recommendations:  review policies covering the transfer and receipt of community health records to ensure the timeliness of record transfer, case closure and escalation; review procedures for the transfer of children in need cases, defining the requirement for formal handover meetings; local safeguarding children partnerships to promote training and awareness raising that reinforces the seriousness of domestic abuse in the context of children’s safety; ensure that local threshold tools sufficiently describe the significance of risk associated with domestic abuse, particularly when such abuse forms a repeating pattern; improve how practitioners engage with adult males that are significant to the lives of children. Keywords:  pre-school children, injuries, physical abuse, family violence, abusive men > Read the overview report

2021 – Dudley – Children Q and R

Serious injuries to two unrelated children, Child Q aged 4-years-old and Child R aged 7-weeks-old, whilst in their parents’ care in December 2020. Learning: there was a lack of clarity about the men involved in the children’s lives; domestic abuse didn’t appear to have been considered by professionals; and there was disagreement between medical and children’s social care professionals about the cause of the injuries. Recommendations: decision making at strategy meetings should include all appropriate agencies; the children’s workforce should feel confident recognising potential non-accidental injuries; and the development of a practitioner forum should be considered, where medical and social care staff can gain an understanding of each other’s roles. Keywords: family violence, interagency cooperation, non-accidental head injuries, parents with a mental health problem, physical abuse, threshold criteria > Read the overview report

2021 – Ealing - Child C

Malnutrition of a 3-year-old girl in 2020. Learning includes: health visitors must ensure that the correct level of need is recorded on case management systems; work needs to be undertaken to ensure that all heath visiting staff understand the levels of need set out in procedures and understand how to apply in practice; there is a need to remind GP staff to contact health visitors directly regarding children that raise concerns; GPs are able to weigh children and spot a malnourished child and to recognise the need for urgent referral; professionals need to be reminded of the need to effectively coordinate and manage case transfers; hospital staff need to be trained to understand the significance of safeguarding, the processes for referral and the respective roles of agencies; processes for case handover within the hospital need to ensure that safeguarding is considered at each handover point; professionals have an active responsibility to seek information from strategy and other planning discussions to which they have been invited but didn't attend. Recommendations:  Makes no recommendations but the serious incident report and root cause analysis completed as part of this review identify actions to address concerns. > Read the overview report

2021 – Ealing - James

Death of a 10-year-old boy in August 2020. James died because of restricted airways after his mother gave him an excess dose of melatonin, prescribed to help him settle at night, and put him to bed with a sponge in his mouth. Learning includes: there was a significant level of contact between the family and agencies, services were maintained and there was multi-agency oversight; during this contact James’s mother was inconsistent in her presentation; James’s mother refused offers of support through children in need services; there was no contact between agencies and James’s father. Recommendations include: collaborate and co-produce with disabled children and their parents, information about and service delivery of child in need services; review information provided to parents about the Direct Payment System and their responsibilities to inform funders of situations where family members or partners are employed; review the approach to engagement of fathers as single agencies and as a partnership. Keywords: infanticide, children with learning difficulties, abusive mothers, family finance, mental health, coronavirus > Read the overview report​

2021 – East Sussex – Child W

Death of an 8-week-old infant girl in September 2018. The post mortem revealed non-accidental head injuries and fractures. The father was subsequently convicted of murder and mother was convicted of allowing death. Learning includes: consider predisposing risks and when deciding if a pre-birth assessment is required; the need to support children in care and care leavers who become parents as a part of corporate parenting; consider the additional support a family may require following an early birth and when a baby is in a neonatal unit; seek information from other local authority areas if a family have moved and it is believed there is historic safeguarding information; ask partner agencies to check what historic safeguarding information they hold on family members, and proactively share information when concerns emerge.  Recommendations include: alert the Department of Health and the Home Office to the need to review national guidelines so that CT scans and full skeletal surveys are carried out immediately on infants and young children who have died from unexpected or unexplained causes, and where there are siblings who may need to be safeguarded; the safeguarding partnership and partner agencies to explore how they can use multi-agency programmes to promote the safe handling of babies. Keywords: infant deaths, physical abuse, adults in care as children, information sharing, medical assessment > Read the overview report

2021 – Harrow – Child M

Death of a 12-year-old boy in 2020 due to multi-organ failure, sepsis and cerebral palsy. Concerns were identified regarding neglect. Child M had significant disabilities and complex chronic medical needs. Learning includes: a need to better understand Child M's lived experience and his family's coping mechanisms; insufficient case co-ordination and development of agreed ways to maintain health and minimise risk of harm; a need for a review of the respective roles of school nursing assistants and school nurses; a need for debate about the extent to which existing service user information systems support or constrain information exchange; a review of the extent to which education, health and care plans (EHCP) or non-school attendance policies are being applied to those in special education facilities. Recommendations include: develop child-centred guidance on the meaning and application of mechanical and physiological or medical restraint to children in the community who are vulnerable by virtue of physical or learning disabilities; ask agencies to remind professionals of the existence and importance of compliance with the existing 'was not brought' policy; review special schools to provide confirmation that non-school attendance responses are of comparable or superior standards than those applied to non-disabled pupils; children's social care disability service to discuss and agree the co-ordination role that it could play in complex cases. Keywords: children with disabilities, child neglect, non-attendance, school attendance > Read the overview report

2021 – Hertfordshire – Child L

Serious injuries to a 20-month-old boy in 2018. Child L and his half-brother were made subject to an interim care order. Learning includes: there was no shared understanding of the mother's learning needs or her emotional needs, and there were differing perceptions of her; when extended family are providing support, it is important to balance the strengths alongside the risks and to understand the nature of the relationships between family members; all behaviours must be viewed as potential trauma and the impact of this trauma on the lived experience of the child. Recommendations include: to build on the multi-agency understanding of risk for children under a child in need plan to include dynamic risk assessments and challenge from partner agencies; to explore how a list of children on a child in need plan can be shared with the multi-agency safeguarding network; ensure that private pre-schools and nurseries are meeting the required standards of safeguarding, and to consider raising the issue with Department for Education to bring private providers under the same guidance as statutory services. Keywords: physical abuse, adults with learning difficulties, risk assessment, trauma, nurseries > Read the overview report

2021 – Isle of Wight – Child I

Suicide of a teenager in 2019. Child I had a number of vulnerabilities and needs relating to challenging behaviour, substance misuse, emotional wellbeing (including suicide attempts), poor school attendance and missing episodes. Learning themes include: the need to consider early help support for adolescents; the importance of a whole family, strengths-based approach; ensuring a holistic view is taken of the child/family; and importance of full consideration of a child/family’s history. Recommendations include: managers should ensure the voice and experience of the child is taken into account in all work undertaken by partner agencies with families; ensure awareness of the ‘was not brought’ policy and procedures across health services, including CAMHS; and ensure the promotion of whole family, strengths-based approaches to support positive engagement and support. Practitioners should: ensure full consideration of Early Help assessment and planning for adolescents; recognise importance of full consideration of a child/family’s history so events are not seen or responded to in isolation and patterns in behaviour can be identified to better inform support and interventions; ensure a holistic view is taken of the child/family to try and fully understand what is going on rather than just the presenting issue; ensure that families are fully supported to follow up on signposted services. Keywords : suicide, early intervention, child mental health, family dynamics, voice of the child > Read the overview report

2021 – Kent - Jesse

Suicide attempt of a child. Jesse was taken to hospital with non-serious physical injuries. They had previously expressed that they were transgender and autistic. Learning themes include: clarity on the process of diagnosis of autism spectrum condition (ASC); the need for support and expertise to guide staff on gender dysphoria; effective multi-agency working including professional challenge where there is a concern that any partner agency is not following policy; and the importance of the voice of the child over the voice of the parent. Recommendations include: all relevant agencies to remind staff of the formal screening and referral pathway for ASC and to follow NICE guidance in the support and treatment for ASC screening and management; agencies must give definitive guidance to staff on their stance on necessity for ASC referral and diagnosis; the partnership should seek assurance that issues of waiting lists for ASC assessment and diagnosis are being addressed; the partnership are to provide training to professionals regarding gender dysphoria along with the learning for this review; assessment frameworks should give due regard to impact of culture and ethnicity; and agencies must provide evidence regarding the requirement to record ethnicity, other protected characteristics and vulnerabilities in records. Keywords : autism, child mental health, gender identity, transgender, suicide, ethnicity > Read the overview report

2021 – Medway – Baby Harris

Death of a 15-day-old boy in June 2019. Baby Harris was found dead in the family home, after having been asleep in his parents’ bed. Learning: lack of professional understanding around the lived experience of Baby Harris’ older brother, Child A, which could have alerted professionals to risks and harm; invisibility of unborn Baby Harris and Child A, partly due to inconsistent parental engagement with services; a lack of access to and understanding of the family's history by agencies resulting in parental risk factors not being identified; issues around multi-agency responses to domestic abuse, including issues with information sharing; safer sleep messages provided to the family were difficult to put into practice due to the family's living arrangements. Recommendations include: improving engagement with children and having an understanding of the lived experiences of children; improving the quality of assessments where children and unborn children are experiencing neglect; improving the understanding of the cumulative effects of neglect; ensuring that there is sufficient staff capacity in social work services to offer the conditions for good social work practice. Keywords: infant deaths, sleeping behaviour, children in violent families, child neglect, parents with a mental health problem, voice of the child > Read the overview report

2021 – Nottingham – Child R

Serious injuries to a 6-year-old child in 2018, which later required neurosurgery. The mother was charged with neglect and the mother’s partner was sentenced to nine years imprisonment for grievous bodily harm against Child R. Learning focuses on: compliance with child protection procedures and the arrangements for the child protection medical examinations; assessment of risk, the impact of confirmatory bias and misunderstanding of terminology; the transfer of cases. Recommendations include: ensure that multi-agency child protection procedures are effective in respect of strategy discussions and child protection medicals; chronologies should be completed as part of the referral to social care to highlight patterns of physical injury; consider an awareness raising campaign within the wider children’s workforce focused on physical harm in children and consider whether the terminology around non-accidental injuries should be changed. Keywords: physical abuse, bruises, non-accidental head injuries, family violence, medical assessment > Read the overview report

2021 – Oldham – Child P

Injury and mental trauma suffered by a 5-year-old child in September 2018 during a knife attack, including several family members. The father pleaded guilty to attempted murder. Learning focuses on the following themes: the potential impact of ethnic, religious and cultural influences on families; the need for a robust response to domestic abuse, including information sharing and a joined-up approach; the impact of bereavement on families; working with fathers; effective multi-agency working. Recommendations: use interpreters consistently when English is not the family’s or parents’ first language; the need for accurate family assessments, including the family’s background, culture and beliefs; ensure that the views of the multi-agency network are considered within the body and analysis of single assessments; comprehensive training to be undertaken for frontline practitioners on domestic violence and vulnerability factors, including an understanding of what partner agencies can offer; multi-agency training on bereavement and how to support bereaved families; all staff attending strategy meetings to be appropriately trained in relation to Working together to safeguard children 2018 and the actions that the police should take. Keywords: bereavement, fathers, partner violence, interpreters, information sharing, culture > Read the overview report

2021 – Oxfordshire – Jacob

Death of a 16-year-old boy who was found dead in his bedroom in April 2019. There was insufficient evidence that Jacob had intended to end his life. Learning: concerns about professional knowledge, skills and safeguarding systems for children at risk of criminal exploitation; multi-agency coordination could have identified contextual risks; there was a focus on responding to Jacob's behaviours but not enough focus on reducing risks to Jacob in the community; issues of unconscious gender bias in relation to criminal exploitation; missing education playing a significant role in levels of risk not being identified; importance of agencies responding quickly at critical times in a child's life to keep them safe. Recommendations include: a review of the effectiveness of the National Referral Mechanism (NRM); statute and guidance on schools who cannot be mandated to accept children on roll; a national review of placement sufficiency for children who need to be in care or placed under secure arrangements. Keywords: child criminal exploitation, child deaths, adolescent boys, violence, children missing education > Read the overview report

2021 – Richmond Upon Thames – Maria, Luis and Carlos

Death of 10-year-old and 7-year-old boys and their mother and father in March 2018. The children, Luis and Carlos, and their father were found dead at the foot of cliffs in Sussex and their mother was found dead at the family home in London.  Learning includes: consideration of the financial and homelessness support available to migrant families; ensuring the link between financial difficulty and suicide is incorporated into safeguarding adults and suicide prevention. Recommendations include: the London Borough of Richmond Upon Thames addresses issues of financial and homelessness difficulties for all communities; links to domestic abuse are addressed in the development of the borough's violence against women and girls strategy; the borough ensures that issues of financial difficulty and links to suicide are incorporated into public health and suicide prevention work. Keywords: filicide, murder, family violence, family finance, immigrant families > Read the overview report

2021 – Sandwell – TS

Sudden unexplained death of a 5-month-old baby. An expert witness concluded that TS’s death met the criteria for a sudden infant death syndrome, but no criminal charges were made. Learning  includes: routine questions and assessments need to consider the relationship with all significant family members who are involved in the care of the child; social workers need to consider information held by all involved health professionals; professional curiosity about the child’s lived experience, including considering the impact of living between homes on babies; the Bruises and injuries in non-mobile children policy should be followed in all cases where a non-mobile child has injuries. Recommendations include: ask the Department of Education and Department of Health to consider adding to guidance about routine questioning and assessments in domestic abuse whether any household members are experiencing domestic abuse in the child’s home; provide the opportunity for professionals to learn from research to inform practice; consider how to influence a cultural change across partner agencies regarding the role of fathers and secondary carers in families. Keywords: sudden infant death, parenting capacity, partner violence, professional curiosity, information sharing, families > Read the overview report

2021 – Somerset – Child Alex

Serious injuries to a 10-week-old infant in early 2020. Medical examinations determined that the injuries were caused by inflicted trauma. Learning: consistency of social worker to coordinate holistic and purposeful assessment of parenting capacity; robust supervision and management oversight to support social workers to reflect on progress of assessment and consider likelihood and severity of risks as well as strengths and protective factors; police officers should escalate their concerns about the action or inaction of another agency where they consider that a child remains at risk of significant harm. Learning across the partnership includes: understanding and defining levels of need or statutory threshold; embracing and resolving professional differences as an opportunity to share expertise, evaluate need or risk and promote a culture of shared accountability; need for a clear process for transferring child in need cases between local authority children's social care services; the need for professional knowledge of safeguarding legislation, guidance and procedures. Recommendations: Recommendations are embedded in the learning. Keywords: infants, injuries, physical abuse, threshold criteria > Read the overview report

2021 – Somerset – Child Charlie

Death of a 16-week-old infant in early 2020 whilst in the care of their father. The cause of death is the subject of ongoing criminal investigation. Learning: future safeguarding practice will be strengthened by: reviewing the governance of multi-agency safeguarding arrangements for responding to the needs of children living with domestic abuse; there should be a focus on safe outcomes for children living with domestic abuse as opposed to an incident focused response; develop the culture of partnership working and therefore individual and collective accountability for safeguarding children; a partnership agreement and approach to share information and analyse the needs of children living with domestic abuse. Learning identified by individual agencies will support them to safeguard children by strengthening capacity to: recognise and consider the impact of domestic abuse on babies and children; identify the needs of a child and their family; reflect on the needs of a child and their family. Recommendations: recommendations are embedded in the learning. Keywords: infant deaths, family violence, children in violent families, information sharing > Read the overview report

2021 – South Tees – Daniel

Life-changing injuries to a 17-year-old boy who was the victim of a shooting in March 2020. Daniel was a child in care at the time of the incident. Learning: where concerns about a child have been identified and statutory agencies are involved, any significant changes in education that could have an impact on a child's safety or long term outcomes should be formally scrutinised by safeguarding partners; unless professionals are skilled in building relationships, being directive, supportive and non-judgemental in their work with parents, they are more likely to face resistance, ambivalence and disengagement; early intervention to prevent or disrupt involvement in street gangs, offending behaviours and youth violence needs to involve skilled and trained facilitators to work with young people. Recommendations: urge the Department of Education to to set out a strategy for how it intends to improve residential care for looked after children in England; explore how schools and academies can be supported and challenged, but also held to account, by partner agencies when there is evidence that school exclusions or non-attendance is placing, or would place, a vulnerable child at greater risk. Keywords: children in care, education, victims, violence, weapons > Read the overview report

2021 – South Tees – Fred

Accidental overdose by an adolescent boy who subsequently recovered in June 2020. Learning: always consider the impact of domestic abuse and/or adult substance misuse or overdoses on children of all ages, especially when a child is directly affected; consider multiple incidents cumulatively as well as in isolation and any contradictions between the child's expressed wishes and their lived experience; when undertaking S47 enquiries, preparing for initial child protection conferences or conducting assessments, obtain relevant information from GP records about all adults involved in children's care; need for awareness of the legal implications of a child being subject to a Special Guardianship Order (SGO) in terms of parental responsibility and potential eligibility for support services; consider calling a strategy meeting if a child under an SGO returns to parental care; need for practitioners to discuss concerns with the young person. Recommendations: ensure that a child's perspective on what being safe physically and emotionally means to them is a starting point for any plan to safeguard them and that thought is given about how multiple plans in use for any individual child could be explicitly linked or streamlined; promote the use of evidenced- based tools to better support practitioners in understanding family dynamics and support for children, including who is best placed to do any direct work with a child or young person; raise awareness of the legal implications of a child being subject to a Special Guardianship Order in terms of parental responsibility and potential eligibility for support services; ensure relevant information about adults involved in caring for children is obtained from GP records at all stages of the child's journey; ensure that the response to neglect adequately focuses on the needs of adolescents. Keywords: adolescent boys, substance misuse, family violence, voice of the child > Read the overview report

2021 – South Tees – Kingfisher

Death of an infant girl and serious injury to a 2-year-old-girl. These were two separate cases that involved child neglect Learning includes: consideration is needed of the parent's history and ongoing vulnerabilities and the impact this can have on children; a pre-birth social work assessment should be undertaken where there are risks and vulnerabilities that warrant involvement from children's social care; clarity around the roles of all professionals involved with a family such as recognising that support for care leavers from a Pathway Worker may not extend to the care leaver's child; a need for professionals to meaningfully consider and involve fathers in assessments and plans in respect of their children; professionals need to use specific neglect tools and understand the root causes of neglect and the impact on a child over time; and there is a need for professionals to robustly challenge themselves, each other and parents/carers when it comes to managing cases of neglect. Recommendations include: ensure that professionals are aware of and use the local neglect strategy; assurance from the local authority regarding improvements in the use of the Graded Care Profile and evidence based practice in neglect cases; all plans for a child in need or for child protection need to provide a clear and detailed description of who is undertaking what work with the family, which takes their role and its limitations into consideration. Keywords : child neglect, parents with a mental health problem, risk assessment, fathers, professional curiosity, substance misuse > Read the overview report

2021 – South Tees – Liam

Hospitalisation of a 2-year-11-month-old boy due to ingesting multiple drugs Learning includes: seek assurance from partners about how and when learning from previous serious case reviews or child safeguarding practice reviews will be embedded into practice; ensure that arrangements are made to allow safe and open conversations with people who are known or suspected of being victims of domestic abuse; assessments should be multi-agency and consider all information, including historical context around all cumulative risk factors; professionals may want to consider a more interactive method of working with families to ensure appointments are attended; the impact of mental illness, domestic abuse, drugs and alcohol on parenting capacity should be routinely included in child in need and child protection plans; the voice of the child and their lived experience should be evidenced and prioritised in assessments and care plans in a way that assesses any change to parenting capacity; ensure that professional curiosity and information sharing is exercised and where necessary escalate concerns - may wish to consider Working Together 2018 and detailed expectations of how local authorities, and wider partners, should respond to extra-familial harm; assessments should recognise contextual risks, and care plans should recognise the capacity of parents in providing support or where necessary escalating statutory interventions. Keywords : voice of the child, drug misuse, maternal depression, neglected children, professional curiosity, children in violent families > Read the overview report

2021 – South Tyneside – Child J

Severe non-accidental injuries to a 3-month-old infant in August 2019 Learning includes: fathers need to be as visible in all agencies' antenatal and postnatal care and support as mothers; pro-active and tenacious attempts need to be made to involve fathers in assessment and the planning and delivery of support for children, this may require a specific approach to engage them; and when vulnerable young women stay with friends or partners in houses of multiple occupation, professionals should show curiosity about the other residents, especially males, and consider whether they pose any risk. Recommendations include: seeks assurance from all agencies that offer services to children and families that they have individually and collectively considered how best to improve arrangements to engage vulnerable young parents, especially fathers; ensure that all agencies keep fathers, as well as mothers, in mind especially during pregnancy and early babyhood; as well as assurance from Children's Social Care that pre-birth assessments are being done for all babies that need them, and that child and family assessments are shared more frequently and consistently with other agencies including GPs. Keywords : abused infants, non-accidental head injuries, adolescent parents, parenting capacity, family support services, home visiting > Read the overview report

2021 – St Helens – Charlie

Hospital admission of an adolescent girl in 2019 who was suspected to have been the subject of fabricated or induced illness (FII). Charlie’s mother was found unconscious by ambulance services after taking a drug overdose and had reportedly given Charlie tablets. Learning: learning is embedded within the review. Recommendations include: review data to benchmark the number of families with children who could be affected by parental opioid prescribing; parental substance misuse guidance should include further guidance regarding safeguarding concerns arising from parental dependence on prescribed drugs; a designated doctor to review Charlie's medical records to establish lessons on identifying and responding to indicators of FII, particularly in older children and adolescents; agencies identify how to improve practitioner engagement with fathers in safeguarding and child protection work; regular dip-sample audits of cases where child protection enquiries have concluded with substantiated concerns but where the decision was made not to proceed to a child protection conference. Keywords: adolescent girls, addicted parents, drug misuse, prescription drugs, fabricated or induced illness (FII) > Read the overview report

2021 – Surrey – Child B

Death of a 15-year-old boy in June 2017 by suicide. Learning: practitioners across the multi-agency network face challenges when charged with responsibility for safeguarding children in mid-adolescence; effective plans for risk-taking, tolerating uncertainty, risk-minimisation and promoting safety rely on robust risk analysis; the principle of understanding behaviour as communication is as relevant for children in mid-adolescence as for younger children. Recommendations: ensure that specialist mental health services engage in effective collaboration and co-working with the team around the child, the child’s parents, and the child’s informal network of care throughout their involvement with children; ensure that staff throughout the service are aware of and consider a range of potential sources of early help for children and families while waiting for specialist assessment or input. Keywords: child deaths, suicide, self-harm, child mental health services, self-poisoning, psychoses > Read the overview report

2021 – Surrey – Sudden unexpected death in infancy

Thematic review of 20 sudden unexpected deaths in infancy (SUDI) between April 2014 and March 2020 in Surrey. Learning includes: along with greater risk associated with placing a baby on the front or side to sleep, there is also a greater risk to babies who are in a room alone; co-sleeping when a particular high-risk circumstance is present increases the risk to the baby compared to co-sleeping alone; there is extensive data to show that breastfeeding has a protective factor in reducing SUDI. Recommendations include: ensure partners adopt a practice model encompassing reducing the risk of SUDI within wider strategies for promoting infant health, safety and wellbeing; fully implement the NICE guidance - Smoking: stopping in pregnancy and after childbirth; ensure that alcohol awareness training that promotes respectful, non-judgmental care is delivered to all health and social care staff who potentially work with patients or service users who misuse alcohol. Keywords: sudden infant death, sleeping behaviour, parenting education, smoking, birth weight, literature reviews > Read the overview report

2021 – Sutton – Child V

Near-fatal knife injury to a 17-year-old boy in December 2020. Child V had been subject to a child protection plan until March 2020. Learning includes: the need to view children who are not in school, especially those with education, health and care plans (EHCP), as high risk and requiring a safety network of agencies to work together; there is a need for professionals to improve their understanding of the impact of cumulative harm on an adolescent who is struggling to find a safe transition into adulthood; there is a need to ensure that the work already undertaken to develop a contextual safeguarding approach is strengthened to include a wider range of agencies. Recommendations include: ensure that there is an effective multi-agency partnership approach to identify critical indicators of the risk of extrafamilial harm by applying contextual safeguarding principles; ensure that there is a process in place for regularly reviewing children being removed from a child protection plan without the outcomes being achieved; ensure that children who are out of school are given opportunities to voice their views of their situation. Keywords: adolescent boys, injuries, weapons, transition to adulthood, school attendance > Read the overview report

2021 – Thurrock – Leo

Death of a 9-year-old boy in June 2019. Leo was found unresponsive in the family home, and taken to hospital where he was pronounced dead. Learning: social workers should take the “think wider family approach”, considering all members of the family or household to assess their impact on the whole family; professionals should be involved in multi-agency meetings, including healthcare professionals, to ensure effective plans are in place; when families are living in poverty, the focus needs to remain on the cause and impact of poverty on the children, and professionals should escalate cases where families' access to funds and services is not sufficient; children's services and partners should use specialist assessment tools in cases of neglect to quantify needs and measure perceived improvements or deteriorations; when an adult or child is recognised as a carer, the full extent of their role and its impact should be clearly articulated in assessments and shared with partners. Recommendations: makes no recommendations. Keywords: child deaths, child neglect, child health, poverty, home environment > Read the overview report

2021 – Torbay – C67 and C68

Non-accidental injuries to a 9-year-old girl in January 2018. Learning includes: parents require effective education programmes that are delivered in a timely manner to assist them in effectively coping with family life and improve the lives of their children; there is a lack of confidence that decision making will be robust in similar cases where there has been a non-disclosure by a child but sexual abuse is suspected. Recommendations: review the current process of the allocation of parental education programmes (including Triple P) to ensure that they are delivered at the earliest opportunity; review and identify all available options to improve the current provision of services for adolescents with complex behavioural issues; review training and guidance in respect of non-disclosure issues in sexual abuse cases. Keywords: injuries, parenting capacity, home environment, child neglect, child protection registers, harmful sexual behaviour > Read the overview report

2021 – Torbay – Child C80

Incidents of rape and sexual assault by a 16-year-old looked after child, referred to as C80, in the nursery where he was an apprentice. A sibling of C80 subsequently disclosed past experience of rape by C80. Learning includes: a trauma informed approach could be further developed across the partnership; a child’s experience of sexual abuse should form an integral part of care plans and assessments even where this is not the primary reason for protection or intervention; it is not deemed necessary or appropriate that a child’s experience of sexual abuse, or other ACEs should be shared with employers; therapy should form part of ongoing care planning to ensure continuity, particularly when placements are disrupted; life story work with all children in care should be mandatory and timely; practitioners should be confident to identify and respond to sexual abuse indicators and to differentiate between ‘normal’ behaviour and that of concern or risk; there should be a timely transfer of information regarding vulnerable students between pre and post 16 education and training providers; there is no statutory guidance regarding the level of suitability assessment required for students attending placements as part of childcare studies; information that may be of safeguarding concern should be shared by referees with potential employers; CCTV should not replace in person observation; need for clarification regarding the layout/ design of toilet facilities in nursery settings; when sexual abuse is suspected, a single point of contact should be established that signposts to appropriate support services. Makes recommendations to improve procedures for care experienced children and to strengthen approaches in the areas of recruitment, apprenticeship, supervision and safeguarding practice in early years settings. Includes recommendations for the Department for Education, regarding a review of the Early years foundation stage (EYFS) framework. Keywords : abusive adolescents, children in care, child sexual abuse, nurseries, rape, sibling abuse > Read the overview report

2021 – Wakefield – David

Sudden unexpected death of a 7-week-old boy in January 2020. Learning includes: safe sleeping is an issue for services broader than health visiting and midwifery; the value of providing timely early intensive help; using chronologies and enquiring into relevant history; professionals developing and using focussed and respectful curiosity; using language that reveals vivid pictures of risk and neglect; neglect in areas of high deprivation; use of tool kits and evidence-based frameworks to guide and inform the collation and analysis of information about neglect; and ensuring primary care services have effective arrangements to identify and respond to neglect. Recommendations include: development of a public information strategy that promotes safe sleeping for children under six months; substance misuse service should provide targeted lessons learnt for substance abuse practitioners; targeted lessons learnt should be provided to schools to include the importance of pupil file transfers when moving schools, the use of the neglect toolkit and oversight by designated safeguarding leads in schools; the Early Help Service should ensure that assessments are robust and timely and include information from all involved services; Early Help Assessments and plans should include specific reference to safe sleeping arrangements and incorporate the use of the neglect toolkit; and the Multi-Agency Safeguarding Hub (MASH) should ensure that the use of the neglect toolkit is being used within referrals to the service. Keywords : child neglect, home environment, safety measures, home visiting, infant deaths, substance misuse > Read the overview report

2021 – Wakefield – Jason

Death of a 3-month-old infant in August 2019. Jason had been co-sleeping with a sibling and his mother. Jason had already died when his mother contacted emergency services and he was taken to hospital. Learning includes: some parents have difficulty assimilating and consistently following advice and the circumstances under which children's needs are neglected; the way parents respond to their children's needs is influenced by their own childhood experiences; parents who have experienced unstable or adverse childhoods can learn to just focus on their own needs because they have learnt not to depend on others. Recommendations include: ensure multi-agency training includes curiosity about where children are sleeping as part of assessments; develop safe sleeping procedures emphasising the importance of ongoing risk assessment about safer sleeping for all services; consider how the use of the neglect toolkit is used routinely by services; encourage every GP practice to have a written protocol for discussing safeguarding concerns and follow-up. Keywords: sudden infant death, sleeping behaviour, parenting capacity, parent-professional relationships, adults abused as children, adverse childhood experiences > Read the overview report

2021 – Warrington – Case AB

Sexual abuse of three siblings by members of their extended family Learning includes: the impact of neglect and adverse childhood experiences (ACEs) on children's social, emotional and cognitive development; seek to make sense of and understand the lived experience of children; seek to understand the lived experiences of parents and carers who may have experienced trauma, live with domestic abuse, substance abuse or mental health issues and the impact of this; remain mindful, when working with children and young people with special educational needs and/or disabilities (SEND), of the fact that not all disabilities are visible, and that some children may present as more able than they are; ensure effective communication between agencies; professionals must be alert to "exaggerated hierarchy", whereby professional status becomes magnified and other professionals perceive themselves to have comparatively lower status; prevent closed professional systems, where one agency assumes a dominant position or view of a case and fails to pay attention to conflicting information or information that fails to support their views and hypothesis; during the planning of any assessment, it is important to determine who knows the child(ren) and family and holds information about them; consideration of the impact of domestic abuse on the child/parent relationship; consideration of the impact of parental mental health in relation to parenting and the impact this can have on the child/parent relationship; and children and young people should be carefully matched when placed in foster care, with foster carers having a clear understanding of children's lived experience, any SEND and how this impacts in terms of meeting their needs. Recommendations include: ensure information/concerns/allegations are communicated to children's social care in a timely manner; support information sharing between and within organisations, and address any barriers to information sharing, including neighbouring authorities; and ensure partner agencies are aware of the organised and complex abuse procedures and receive appropriate training and guidance. Keywords : disclosure, sexual abuse, extended families, sex ring, voice of the child > Read the overview report

2021 – Windsor and Maidenhead – Child T

Death of an 11-month-old girl in April 2020, due to asphyxiation. Child T was found by her birth mother, between the bed guard and the mattress. Learning includes: need for effective and appropriate transfer of children’s cases between safeguarding agencies; children’s cultural and ethnic backgrounds should be considered in assessments and care planning; the voluntary sector, including specialist domestic abuse services should be part of safeguarding partnership arrangements; impact of trauma experienced by parents can affect their ability to care for their own children; need for professionals to fully understand the role of absent or non-resident birth fathers; the temporary safety of a refuge should not influence decision making in relation to the significant harm experienced by the children; professionals should have an understanding about safer sleeping and be able to question arrangements. Recommendations include: families moving to refuge accommodation and making homelessness applications to a local authorities should be referred to the local children’s social care arrangements in the authority to which they are moving; survivors of domestic abuse moving from refuge, to new accommodation should be afforded a risk assessment as to its suitability; the Child Death Overview Panel, Public Health and Trading Standards should consider additional warnings regarding the safety of bed guards and their appropriate use in safer sleeping messages.  Keywords:  housing, infant deaths, local authorities, refuges, sleeping behaviour, sudden infant death > Read the overview report

2021 – Wirral – Liam

Ingestion of a potentially fatal amount of methadone by a 20-month-old boy in the autumn of 2018. Both parents were arrested on suspicion of child neglect. Learning: ensure that assessments collect and synthesise information from a range of sources; improve the quality of analysis of known risks; the importance of being tenacious about engaging fathers and understanding their role in the family; the particular challenges of working with families where children are placed with parents as an outcome of care proceedings; improve safeguarding of children living with parents when care proceedings have ended. Recommendations: revise existing multi-agency safeguarding procedures, protocols and guidance in respect of parents who misuse substances; improve levels of basic awareness of substance misuse, specific safeguarding issues and how to obtain specialist advice; undertake a multi-agency audit of cases where children are living in households where adults are known to misuse drugs or who are now being treated with opioid substitute therapy. Keywords: child neglect, fathers, substance misuse, care proceedings > Read the overview report

Case reviews published in 2020

A list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2020. To find all published case reviews search the national repository .

2020 – Anonymous – Adolescent girl BR19

Child sexual exploitation and neglect of a 15-year-old girl. The review focuses on one child, BR19. Learning: centres on the following themes: need for multi-agency planning and analysis of risk; impact of child sexual exploitation (CSE) and services for survivors of CSE who are parents; parental engagement and consent; professional challenge and escalation; professional curiosity of the child's lived experience; contextual safeguarding and perception of sexual activity between teenagers being consensual. Recommendations: include: to strengthen multi-agency decision making and practice in relation to child protection processes; understand and respond to the links between adolescent neglect, CSE and contextual safeguarding; understand the impact of traumatic adverse life experiences on parenting through partnership assessments. Keywords: child sexual exploitation, adolescent girls, child neglect, contextual safeguarding > Read the overview report

2020 – Anonymous – Baby L

Serious injuries to a 3-month-old infant in December 2018. At the time of the reported injuries, the baby and their older half-sibling had been subject to child protection plans and to a Public Law Outline (PLO) process. Learning: centres around: the effectiveness of pre-birth and post-birth multi-agency assessment, multi-agency case management, inter-agency communication and information sharing; how well practitioners considered the inherent vulnerability of babies to abuse and non-accidental injury, particularly in the context of the trilogy of risk; barriers to recognising and addressing over optimism in parents. Recommendations: include: ensure that pre-birth assessments are completed on time by social workers and include all relevant information, and parents’ accounts and views are appropriately tested and triangulated by evidence from other sources; ensure that guidance on injuries to non-mobile babies has been widely disseminated to all front-line practitioners and embedded in practice. Model: uses a Welsh model. Keywords: infants, physical abuse, injuries, information sharing > Read the overview report

2020 – Anonymous – Bilal

Serious neglect and physical and emotional abuse of a 9-year-old boy and his siblings by their parents. Learning: the role of neighbours and local communities in recognising and responding to concerns about children and young people; areas that usefully inform practitioner learning and improvements in practice include taking a child-focused approach, cultural sensitivity and professional curiosity; contact with the family at transition from health visiting to school nursing services can help determine ‘school readiness’ of a child and to identify unmet needs. Recommendations: identify how to report and share information about children who have not been seen for a significant amount of time and triangulate whether there are further concerns across agencies; ensure that children and young people who are home educated can access help and support to meet their needs via the current children and young people section of the local authority schools and learning webpage. Keywords: witchcraft, religion, Childline, children with learning difficulties, culture > Read the overview report

2020 – Anonymous – Child A and Child B

Sexual abuse of two children by a carer whilst in a long-term kinship care placement. An older sibling living in the same placement witnessed Child A being sexually abused by the carer and informed the mother and then the police. Carer received a custodial sentence for the sexual abuse of Child A and Child B. Learning: includes: importance of robust exploration during the approval process for kinship foster carers; placement reviews for looked after children in kinship care placements should identify when national minimum standards are not met to avoid children remaining long term in inadequate accommodation; without consistent, rigorous and child focussed oversight by supervising social workers, shortcomings in the parenting capacity of kinship foster carers may not be identified or challenged. Recommendations: include: ensure that social workers support children in kinship care to identify a trusted professional who will enable them to get their voice heard in the decisions which impact on their lives; ensure that social workers have access to regular supervision which provides opportunities for reflection and critical challenge with a specific focus on the effectiveness of care plans for looked after children. Model: uses the Welsh Child Practice Review model. Keywords: kinship foster care, child sexual abuse, children in care, voice of the child > Read the overview report

2020 – Anonymous – Child N

Injuries to a 4-week-old infant in 2016. Civil court found that the injuries were caused by the father and that the mother failed to protect Child N. A criminal investigation in respect of both parents and the paternal uncle concluded with no further action in 2020. Learning: includes: when one parent has mental health issues affecting their ability to care for the children, the assessment and plan needs to consider the impact on the other parent or carer; supervision for professionals needs to ensure they are focused on the child and not on the parent's histories and situations; professionals should seek to understand the nature of parenting relationships from the point of view of both parents or adults and the child, and not focus only on the mother. Recommendations: include: confirm if formal pre-birth assessments are being undertaken in cases where a new baby will be the subject of a child in need or child protection plan at birth; consider the benefits and practicalities of requesting that the information that a child is on a child in need plan is shared with all professionals working with the family. Model: uses the Significant Incident Learning Process (SILP) model. Keywords: physical abuse, infants, injuries, parents with a mental health problem > Read the overview report

2020 – Anonymous – Child Sam

Serious, non-life threatening injuries to an adolescent in a targeted attack in 2019. Learning: following any high-profile local incident, community tensions and anxiety are likely to be heightened; safeguarding partners need to be assured that they are sharing key information and that they are doing so securely in compliance with regulations; there are potential implications for children and vulnerable people who are ‘released under investigation’ especially when this is for an extended period. Recommendations: local police should review its ‘released under investigation framework’ to ensure that professionals conducting reviews take cognisance of a suspect’s age, vulnerabilities and safeguarding risks; review the ‘Step Up & Step Down’ procedure to ensure that a multi-agency approach is taken when making decisions relating to levels of need. Keywords: child criminal exploitation, substance misuse, coping behaviour, bereavement, family conflict, police > Read the overview report

2020 – Anonymous – Child Tracy

Death of a 3-month-old girl in March 2019. Tracy was found deceased at home. Criminal investigation commenced by police and care proceedings instigated for siblings. Learning  includes: it is the responsibility of any professional who is working with a child and/or family to initiate an Early Help Assessment Tool (EHAT); anonymous reports of safeguarding concerns can create a challenge for professionals in identifying the facts and responding to safeguarding concerns in a timely and evidence based approach. Recommendations includes: produce a pathway for professionals which details what support, processes and resources are available for engaging resistant families; ensure that information is available to the public on the timeliness of reporting concerns, as well as, the outcomes that are available to agencies in response to those concerns. Keywords: infant deaths, child neglect, non-attendance, parental involvement, assessment > Read the overview report

2020 – Anonymous – Child Z

Sexual assault and sexual exploitation of an adolescent girl between the ages 14-18-years-old. Findings include: resource pressures manifested in high thresholds; medical focus was necessary but an early consideration of home situation would have been appropriate; local authority transfer requests were not founded on the best interest of the child; lack of understanding of the lived experience of Child Z. Recommendations include: children who themselves have children should have their own social worker and their own separate plan for the avoidance of conflicts of interest. Model: uses a hybrid model based on the Welsh Model. Keywords: child sexual abuse, child sexual exploitation, teenage pregnancy, voice of the child > Read the overview report

2020 – Anonymous – Children’s Case C

Severe neglect and abuse of a large group of siblings by their mother and father over many years. Care proceedings concluded in 2017 and the children are no longer under parents' care. Six of the siblings are now adults. Learning: the overwhelming nature of the complexity and scale of the problems and of the oppositional, hostile behaviour of the parents; responses from all agencies to concerns and interventions were generally short-lived and episodic; children's lived experience was not fully appreciated. Recommendations: develop a model for inter-agency practitioner supervision for complex cases where working together closely and consistently is of paramount importance; ensure that the use of the Public Law Outline is being used effectively to give local authority and social workers sufficient leverage with families who are deliberately obstructive by clarifying their concerns in a 'Letter before Proceedings' or further action. Keywords: Child neglect, child abuse, hostile behaviour, disguised compliance, voice of the child > Read the overview report

2020 – Anonymous – Family D

Sexual abuse and neglect of three siblings by their father over many years. The father was convicted of sexual offences and received a substantial term of imprisonment. Learning: professionals need to act with caution when a victim makes a 'retraction' statement; professionals need to recognise when they come into possession of information concerning historical sexual abuse which should be shared with other agencies; providing the victims of domestic abuse with access to an Independent Domestic Abuse Advisor (IDVA) will help professionals recognise and respond to the impact of coercive and controlling behaviour. Recommendations: partner agencies should ensure that their records capture the detail and rationale for actions and decisions, and that they have processes for timely sharing of information about incidents; when the word 'retraction' is used in connection with an investigation, the reasoning behind that decision should be documented in police records and shared with other agencies. Model: uses Appreciative Inquiry (AI) methodology. Keywords: child sexual abuse, child neglect, partner violence, disclosure > Read the overview report

2020 – Anonymous – Family G

Chronic neglect and intrafamilial child sexual abuse of male and female children, aged between 3-to 9-years-old at the time abuse was first reported. The mother and her male partner were subsequently convicted of multiple offences of sexual abuse. Learning: includes: information exchange between professionals must be comprehensive and timely; professionals need to recognise the different indicators of possible child sexual abuse so that potential indicators are not misunderstood, dismissed or ignored; professionals need to use curiosity, hypothesising and a critical analytical mindset throughout the risk assessment process; if an agency decides not to implement an important case conference recommendation, the relevant agency professional must notify the case conference chair with reasons. Recommendations: include: professionals must have knowledge to enable them to identify and respond effectively to children who are or who may be at risk of suffering multiple categories of abuse; professionals must have knowledge of child sexual abuse, including female perpetrator behaviours; Achieving Best Evidence interviews and medical examinations must be child centred and undertaken in a timely way; effective management and multi-agency oversight must be child focused, analytical and reflective. Model: uses the Significant Incident Learning Process (SILP). Keywords: child neglect, child sexual abuse, abusive mothers, case conferences, professional curiosity > Read the overview report

2020 – Anonymous - Georgia

Life-threatening self-harm of a 15-year-old girl in May 2019. Learning: foster carers require training that is trauma-informed; when a child in care moves area it is important for all professionals to share information and for key professionals to speak to their equivalents in the new area; Independent Reviewing Officers (IROs) must focus on a child, regardless of the pressures that professionals working with the child are experiencing. Recommendations: undertake a multi-agency audit to consider practice and processes when a child in care is placed outside of area; seek assurance that professionals in partner agencies are using appropriate formal processes to challenge other professionals if they are concerned about the plan for a child, or do not receive information that is required. Keywords: self-harm, adolescent girls, foster care, information sharing > Read the overview report

2020 – Anonymous – Harry

Attempted suicide of a boy aged under 16-years-old in 2019. Harry had experienced significant neglect, trauma, emotional and mental health difficulties. Learning: the need for a greater appreciation of the impact of early childhood adversity and trauma and the importance of using this information to inform decision making and safety planning; importance of information sharing across borders and agency boundaries; the need for prompt action to secure the appropriate type of support and intervention when young people experience an acute and serious mental health episode. Identifies areas of good practice. Recommendations: to inform the Child Safeguarding Practice Review Panel about the apparent lack of explicit guidance about the transfer of school records across borders in Scotland and England; to review and amend guidance and procedures on the management and information sharing practices between local community based child mental health services, acute health settings and community health services for situations where children re-present to an acute setting. Model: Uses the SILP (Significant Incident Learning Process) methodology. Keywords: self-harm, suicide, adolescent boys, adverse childhood experiences, information sharing <> Read the overview report

2020 – Anonymous – Young Person B

Self-harm of a young female in June 2018. Young Person B took a significant overdose of her prescription medication, alongside over the counter medication, which caused a brain injury. Learning: includes the importance of ensuring representation from schools at child protection conferences and in core groups even when the child or young person is not attending school; the need to risk assess access to prescribed medication for children and young people who self-harm; importance of understanding the potential adverse impact on the young foster person and on other children in the family of private fostering arrangements not being assessed. Recommendations: ensure practitioners understand the signs of adolescent neglect and review the effectiveness of local approaches in addressing both chronic and acute factors; ensure that the voice of the child is more consistently acted upon; ensure private fostering is more effectively publicised across the partnership and children are identified, assessed and supported in their private fostering arrangement. Keywords: self-harm, adolescent neglect, informal care, private fostering,  adverse childhood experiences > Read the overview report

2020 – Birmingham – BSCB 2015-16/03

Serious injury to a 4-month-old baby consistent with shaking and an impact to the head in November 2015, resulting in permanent impairment. The mother was convicted of child cruelty to the baby and their sibling in March 2020. Learning: if families do not want or refuse early help, concerns should be escalated; intervention pathways need to be clear; new birth visitors should have all the information before the first visit; there is a need to remain focused on all family members and their needs; information should be linked, shared proportionately and well-recorded; assessments should identify risks and vulnerabilities; referrals should be seen in context; importance of engagement with fathers. Recommendations: improve provision and organisation of early help services including how new birth visits are carried out; Children’s Advice and Support Service (CASS )/ Multi-Agency Safeguarding Hub (MASH) should develop operational guidance to enable triggers where there are multiple referrals or contacts including using chronologies; there should be fast decision-making when there is an open case and another referral is made. Model: uses a blended approach based on Root Cause Analysis. Keywords: teenage pregnancy, parenting capacity, newborn babies, information sharing, head injury, bonding behaviour > Read the overview report

2020 – Blackpool - Child CE

Death of a 10-week-old infant in March 2019. Cause of death was confirmed as overlay due to unsafe sleeping arrangements. Police investigation concluded with no further action taken. Learning: being actively curious about members of the household, family dynamics and actual, or potential, risks to children is an important consideration for practitioners; contemporaneous record keeping is an essential requirement following all appointments and contacts; ensuring fathers are given the same advice and support as mothers is important; ensuring new parents think about safer sleeping arrangements for the baby is a core task for all professionals. Recommendations: to review the current strategies and initiatives around safer sleeping advice, support and promotional materials and consider any changes which may promote knowledge and understanding. Keywords: infant deaths, sleeping behaviour, fathers, professional curiosity. > Read the overview report

2020 – Bromley – Leo

Murder of a 17-year-old boy with special educational needs (SEN) from multiple stab wounds believed to have been inflicted by several other young people. Leo had severe difficulties with speech and language and at the time of his death, he was living in supported accommodation for young people. Learning is embedded in the recommendations.  Recommendations include: ensure that professionals have access to good training on the signs, symptoms and impact of speech, language and communication disorders; prioritising staff working with children at risk of offending; ask that agencies take all reasonable steps to identify and engage the fathers of children and young people with whom they are having contact; the Youth Offending Service should ensure that being charged with a violent offence triggers a multi-disciplinary assessment of need and risk. Keywords: adolescent boys, murder, children with disabilities, violence, language, weapons > Read the overview report

2020 – Buckinghamshire – Baby S

Death of a 5-month-old infant girl in April 2016 due to injuries caused by shaking. The mother stood trial in 2019 and was found not guilty of manslaughter. Learning includes: a more ‘enquiring’ approach to the familial circumstances might have highlighted a variety of additional needs and better-informed agency responses; professional curiosity is required and justified in all situations, not just troubling situations. Recommendations: GP practices should capture which adult presents a child in records and ensure that immunisations or other medical interventions have fully informed consent, from a parent or person with parental responsibility; NHS Trusts should remind staff that effective record keeping requires evaluated observations of a child’s familial circumstances, behaviours of its members and any additional support needs. Keywords: infant deaths, shaking, parenting capacity, professional curiosity > Read the overview report

2020 – Buckinghamshire – Child V

Unexplained death of a 2-year-7-month-old girl in December 2018. Child V experienced neglect and delayed development. Learning includes: when the siblings of an unborn baby are subject to a child in need plan (CIN) the multi-agency CIN meetings should discuss the likely effects and ensure there is multi-agency agreement prior to closure of the plan; conduct a parenting assessment so that practitioners have realistic expectations of parents and to minimise the vulnerability of children; need to use processes and tools to identify, assess and respond to neglect; the voices and lived experiences of children should inform all assessments and interventions; there needs to be a multi-agency assessment if there is a disclosure of sexually harmful behaviour; strained professional relationships can impact on multi-agency cooperation and safeguarding practice. Recommendations include: improve the early identification of and response to neglect; remind partner agencies about the decision making process prior to closure of a CIN or child protection plan; consider the development of pathways with adult services to assist with the assessment of parents and carers when there are concerns about their cognitive ability; identify the barriers to the effective use of tools to support the early identification, assessment and analysis of neglect, specifically, Graded Care Profile 2; robustly monitor and evidence the impact of the voice of the child in practice; identify and address barriers to the effective use of the escalation policy. Keywords: child death, child neglect, neglect identification, assessment, voice of the child > Read the overview report

2020 – Buckinghamshire – Serious youth violence: thematic serious case review

Review of the services provided for three adolescent boys following a serious knife crime in 2018 in which one of the boys was seriously injured. Considers what led to the boys’ involvement in serious youth offending and ways in which professional interventions may have safeguarded them more effectively. Learning is embedded in the recommendations.  Recommendations include: ensure that primary schools are able to identify children who show severe behavioural difficulties, respond to their needs and make an appropriate referral for additional early help services; ensure that early help interventions are family-focused and take a full account of the child's history; ensure that secondary school transfer arrangements identify any child who has shown severe behaviour problems in primary school; ensure that policies, procedures and practice reflect the best current thinking about contextual safeguarding risks; and ensure that agencies and partnerships actively engage with Black and minoritised ethnic communities over the prevention and reduction of serious youth violence. Keywords: adolescent boys, contextual safeguarding, exclusion from school, family violence, gangs, child mental health > Read the overview report​

2020 – Bury – Isabella

Death of a 14-month-old girl in August 2019. Learning: considerations should be given as to how professionals engage with fathers. If a father has not engaged, it should be clearly recorded that he remains an unassessed risk; if a parent does not consent to local authority support for a child in need, careful consideration should be given to escalating the protection provided; information about avoidant behaviour should be shared with all other professionals involved. Recommendations: ensure that the language change - 'was not brought' is reinforced across partner agencies and that practitioners are trained to realise 'medical neglect' and recognise missed appointments as an indicator. The universal use of the language term will emphasise parents’ and carers’ responsibility to take a child in their care to health appointments and will deliver a clearer marker to identify neglect. Keywords: child deaths, medical care neglect, sudden infant death, premature infants, parenting capacity, developmental disorders > Read the overview report

2020 – Cambridgeshire and Peterborough – Jack

Serious harm suffered by a 3-month-old baby boy because of multiple injuries, including fractures and bruising of the brain in May 2017. Learning: identifies lessons in relation to: effectiveness of assessments, consideration and management of risk; injuries to pre-mobile babies need to be viewed from a perspective of potential risk; consider risk of neglect where a child’s weight is varying; need to involve and support fathers; need to share information to allow robust discussion of concerns. Recommendations: ensure procedures on pre-birth assessments are consistent, contain guidance on timescales and ensure sufficient challenge; all agencies should understand legal orders and their implications; ensure child protection plans are SMART using tools to measure progress; review and reissue guidance for parents with mental health problems, on joint working, and on bruising in pre-mobile babies. Keywords: newborn babies, parenting capacity, feeding behaviour, adults with learning difficulties, information sharing, risk assessment > Read the overview report

2020 – City and Hackney – Child C

Death of a 15-year-old boy in May 2019 as a result of being stabbed. A 15-year-old boy was found guilty of Child C's murder, and a 16-year-old boy and 18-year-old male were convicted of manslaughter. Learning: exclusion from mainstream school can heighten risk; education settings need access to local intelligence; clarity is needed about interventions to mitigate extrafamilial risk; involving and supporting parents is essential to effective safety planning; inconsistent judgements about risk creates uncertainty; poor case recording can directly impact on practice. Recommendations: review processes that involve the application of risk gradings for young people at risk of serious youth violence; exhaust all kinship options as part of a safety plan for children who are at risk of serious youth violence; schools should ensure they have a detailed understanding of the potential safeguarding needs of any child at risk of permanent exclusion; ensure that policy, procedure and guidance is sufficient to ensure the active consideration of racial and cultural identity as part of the safety planning process involving extrafamilial risks. Keywords: weapons, child deaths, exclusion from school, contextual safeguarding, record keeping, child criminal exploitation > Read the overview report

2020 – Cornwall and Isles of Scilly – Child C

Death of a 16-year-old girl in 2018, assumed to be suicide. Learning: it's essential that practitioners understand parental capacity, strengths and attitudes to increase the effectiveness of interventions and avoid placing additional stress on children and their families; child sexual exploitation (CSE) requires a different focus from other forms of child abuse; adolescents can be exposed to a wider range of risks than younger children and concentrating on a single issue may lead to an over optimistic assessment of risk; assessments should include listening and responding to children's views. Recommendations  include: develop a research-based risk management strategy designed to address the specific features of adolescent risk taking and suicidal ideation; promote the concept of contextual safeguarding and ensure that it is adopted by practitioners and managers working within the child protection process. Keywords: adolescent girls, child sexual exploitation, suicide, contextual safeguarding > Read the overview report

2020 – Coventry - Serious case review of eight children

Serious sexual abuse of eight children, several of whom have disabilities including one child with serious physical and learning difficulties, by members of Family S between August 2010 and May 2016. Learning: the need to hear the voice of the child, and not the louder voice of adults; need to develop knowledge of sexual abuse in relation to disabled children and ways to provide opportunities for non-verbal children to communicate; and the impact of gender on the response of services. Recommendations: develop skills and knowledge in communicating with children who disclose sexual abuse; embed understanding of grooming and sexual offending in practice; and ensure a clear pathway is in place for identifying and working with complex intrafamilial sexual abuse. Model: uses a systems-based methodology. Keywords: child sexual abuse; children with disabilities, children with learning difficulties; extrafamilial child sexual abuse; disclosure, voice of the child; harmful sexual behaviour > Read the overview report

2020 – Cumbria – Child CH

Death of a 14-year-old girl in June 2018. Learning: risk assessments need to be holistic, shared across agencies and reviewed regularly; perceived risk can increase professional anxiety and be a barrier for access to services and placements; and when a child in care is particularly vulnerable, there should be a plan for service delivery which takes this vulnerability into consideration. Recommendations: request assurance on the commissioning arrangements for placements for children who require stable and safe care; ensure that information about looked after children is shared with a placement or hospital when a child is moved; and write to the Department for Education and Ofsted about the challenge in finding placements for children with significant risks and vulnerabilities. Model: uses the Significant Incident Learning Process (SILP) model. Keywords: child mental health, children in care, placement breakdown, runaway adolescents, self harm, suicide > Read the overview report

2020 – Dudley – Child A

Death of a boy aged under 3-months-old in June 2019. Child A was found unconscious on the sofa at home in the morning, and taken to hospital by ambulance where he was confirmed dead. Learning: includes: parents should have been challenged about their use of cannabis and they should have been offered early help; there were opportunities for professionals to have visited the family home prior to the discharge of Child A, which may have identified the need for more support. Recommendations: include: ensure that training of professionals includes the impact that cannabis use can have on parents’ ability to care for their children; promote the feasibility of conducting the antenatal and postnatal visits jointly, and ensure that the Graded Care Profile 2 (GCP2) tool is utilised where concerns are raised regarding home conditions and potential neglect. Keywords: sudden infant death, sleeping behaviour, substance misuse, drugs > Read the overview report

2020 – Dudley – Child D

Placement of a 12-year-old girl in secure accommodation in May 2019. Learning: Child D’s aggressive behaviour may have impacted professionals’ perspective and response to the case; despite being on a child protection plan, outcomes did not improve for Child D; and there appears to have been a lack of cohesion in care planning. Recommendations: analyse themes and trends from return home interviews to inform service provision; consider developing a strategy to manage highly complex and high-risk cases; review escalation around the legal gateway process. Keywords: adverse childhood experiences, child sexual exploitation, disguised compliance, family dynamics, runaway children, secure accommodation > Read the overview report

2020 – Dudley – Child L

Death of an infant girl aged under 3-months-old in September 2018. Cause of death was attributed to airways obstruction in the context of co-sleeping. Parents were cautioned for child neglect and drug possession offences. Learning includes: importance of enquiries about sleeping arrangements and the number of bedrooms in general as this can provide a clearer indication of where family members are sleeping and counteract disguised compliance when speaking with professionals; lack of professional curiosity surrounding why older sibling was living with her grandmother. Recommendations include: ensure the Graded Care Profile 2 (GCP2) tool is utilised in every case where concerns are raised regarding home conditions and potential neglect; ensure that the Clutter Image Rating Scale (CIRC) is utilised where clutter is identified as a factor; review multi-agency training to ensure that training on neglect includes professional curiosity, disguised parental compliance, and the avoidance of normalising poor conditions. Keywords: sudden infant death, sleeping behaviour, child neglect, substance misuse > Read the overview report

2020 – East Riding – Baby B

Life-changing injuries to a 10-and-a-half-month-old infant in November 2013 due to shaking. Mother’s partner was convicted of causing grievous bodily harm and was imprisoned. Mother was convicted for neglect and received a suspended sentence. Learning: concerns made anonymously should be treated as seriously as those that are not anonymous; health visitors and school nurses provide a useful link between schools and health services; where professionals have personal or professional relationships with a service user or someone closely involved with the service user, there is the potential for professionals’ boundaries to become blurred. Recommendations: practitioners must ensure that they are complying with current legislation, statutory guidance and agency polices relating to information; ensure that the minutes of strategy discussions are included within the case record of all agencies involved in the meeting and include the arrangements for review. Keywords: physical abuse, shaking, child neglect, parent-professional relationships, health visitors, school nurses > Read the overview report

2020 – Gloucestershire – Children of Family Y

Significant and chronic neglect of four siblings over many years. The eldest sibling committed intrafamilial child sexual abuse on his three younger siblings on numerous occasions from 2012 to 2016. Both parents were charged with neglect offences. Learning: includes: practitioners should improve their awareness and personal knowledge in being able to recognise and identify symptoms of child sexual abuse and neglect; risk assessments must be carried out with the rationale recorded and supervised; 'was not brought' is a more relevant term than 'did not attend' as the emphasis is placed on the parent or carer who does not bring a child to an appointment. Recommendations: include: all safeguarding partner agencies should ensure that staff are aware of the signs and symptoms of child sexual abuse and know what to do if they are seen or suspected; assure that staff complete background chronologies on their case files on children and families subject to child protection enquiries; ensure that staff capture the voice of the child in safeguarding cases and focus on the experience and impact on children. Keywords: child neglect, child sexual abuse identification, non-attendance, voice of the child > Read the overview report

2020 – Gloucestershire – Lauren

Sexual abuse, sexual exploitation and rape of an adolescent girl over many years. Lauren was placed in foster care under an emergency protection order when she was 17-years-old. Learning includes: the importance of an effective professional response to the sexual abuse and exploitation of children; the importance of recognising the specific needs of disabled children and young people and responding appropriately; recognising, assessing and responding to adolescent neglect; understanding relational and developmental trauma; dealing with professional disputes and differences of opinion in ways that put the child and young person at the centre. Recommendations include: sexual exploitation itself should be addressed directly instead of just focusing on addressing family difficulties or programmes designed to educate young people; ensure that children who are subject to a child in need or child protection plan because of sexual exploitation have a disruption plan in place which would be incorporated into these wider plans; professionals need to support young people and address their fears and reluctance, alongside recognising their capacity; consider how best to address victim blaming language; focus on restorative practice principles that foster and enhance partnership working and a culture where respectful professional challenge is productive and welcomed. Keywords: adolescent girls, child sexual exploitation, child sexual abuse, children with disabilities > Read the overview report

2020 – Gloucestershire – Liam

Sudden unexpected death of a 1-month-old boy in 2019. Learning: pre-birth planning and assessment is important in ensuring early understanding of possible risks; practitioners should be equipped to recognise possible feigned compliance and to address this in assessments and plans; record keeping was not of sufficient content or quality to know what was happening to the family and what risks were identified. Recommendations: where information is missing and reliant on another practitioner or agency to provide it, this should be addressed by practitioners through the escalation policy; practitioners should be equipped to assess the significance of substance misuse and poor maternal mental health and its impact on parenting capability and put in place an appropriate plan of support and intervention. Keywords: sudden infant death, drug misuse, sleeping behaviour, parenting capacity, adults abused as children > Read the overview report

2020 – Gloucestershire – Megan

Neglect and abuse of a 6-year-old girl over a number of years. Megan was placed in the care of her paternal grandmother in 2012 via a Special Guardianship Order (SGO). She was neglected and physically abused by her father, her paternal grandmother and her grandmother's partner. Learning: there is a need for practitioners to improve their awareness and personal knowledge in being able recognise and identify the signs and symptoms of all child abuse; agencies should have robust record keeping and management systems in place. Recommendations: develop a safeguarding pathway for the application of family members for Special Guardianship Orders. The process will include utilising a Family Group Conference and to apply for an interim Kinship Foster Placement to allow safeguarding to remain in place whilst a detailed viability assessment of the prospective guardians' capabilities is conducted. Keywords: kinship foster care, special guardianship orders, child neglect, child abuse, voice of the child, professional curiosity > Read the overview report

2020 – Greenwich – Child A

Death of a 15-year-old boy in September 2019. Child A was fatally stabbed after responding to a message on social media to meet some friends. Learning: there is a disproportionality of Black boys of African Caribbean heritage who are more likely to be susceptible to risks of criminal exploitation and this is mirrored in other national and local reviews, studies and case reviews; housing services weren’t engaged in multi-agency discussions about how agencies were seeking to reduce the risks to Child A; frequent moves between boroughs hampers and delays services to children and their families. Recommendations include: ensure practitioners in early help services are equipped to work with children and families affected by criminal exploitation; ensure staff are equipped to identify, assess and make plans for children whose learning disability increases their susceptibility to criminal exploitation, where contextual safeguarding is an issue; ensure that guidance, best practice and training around multi-agency safeguarding discussion and meetings involves housing services. Keywords: child deaths, weapons, social media, children with learning difficulties, housing, child criminal exploitation > Read the overview report

2020 – Hertfordshire – Child K

Death of a 16-year-old boy by suicide. Learning focuses on: understanding Child K as an individual - a relational approach; identifying and responding to Child K’s emotional/mental health needs and his needs arising from his autism; responding to families; family safeguarding; working with adolescents at risk. Recommendations: consider a trauma-informed relational approach; consider whether practice and service provision is sensitive to the cultural, historic and gender context of families, including those outside of the main Black and Minority Ethnic groups; and review cases of domestic abuse before closure to confirm that couples and children have been signposted to counselling or meditation services. Keywords: autism, child mental health, ethnic groups, family violence, suicide, threshold criteria > Read the overview report

2020 – Hillingdon – Child X

Death of a 7-year-old boy in December 2016. Inquest concluded Child X was unlawfully killed and his mother died by suicide. Learning: information sharing within the police did not always work well; information held by friends and family should be taken seriously and support should be given to help them share information; there was a lack of focus on the potential impact of the mother’s alcohol use and mental health on her role as a parent. Recommendations: guidance from the College of Policing should be unambiguous that, in cases of sexual assault, a victim care plan should be delivered by the police force where the victim resides; GPs should always ask patients whether they have any dependents when alcohol misuse is a problem; Local Safeguarding Partnership to consider, with national organisations, whether a helpline for families concerned that a child is at risk could be developed and publicised. Keywords: alcohol misuse, filicide, mothers, mental health problems, child protection, crisis intervention > Read the overview report

2020 – Hounslow – Sasha

Death of a 17-year-old girl by suicide in August 2017. Learning: assessing competence, resilience and emotional attachment disorder in adolescents and considering the impact of adverse childhood experiences (ACEs) and impact of cannabis use; using a holistic family approach to assessing children and young people where their parents have difficulties; recognising when young people are carers; the importance of reflective supervision. Recommendations: to work with the Safeguarding Adults Board to develop a ‘Think Family’ approach; review how practitioners are supported and trained in assessing adolescents who have complex and unresolved emotional issues, possibly coupled with drug use and impulsivity; promote awareness of and response to contextual safeguarding. Keywords: adolescents, suicide, adverse childhood experiences, drug misuse > Read the overview report

2020 – Hull – Baby B

Serious non-accidental head injury and bite marks to Baby B, a 20-week-old baby, in December 2016. Baby B’s father was found guilty of grievous bodily harm and received a 12-month prison sentence. Learning: maintain a focus on fathers of children to establish more clearly the implications of their needs and role in the family; need to ensure that the Local Safeguarding Children Board escalation policy is disseminated across the whole safeguarding partnership to ensure practitioners and managers challenge when there is a difference of opinion. Recommendations: children’s social care to ensure that multi-agency child in need plans are in place for children in need; partner agencies to brief their staff on their responsibility to ensure child in need plans are in place. Keywords: non-accidental head injuries, partner violence, teenage pregnancy, professional curiosity, premature infants, parenting capacity > Read the overview report

2020 – Hull – Child H

Death of a 9-month-old child in February 2014 as the result of a hypoxic brain injury. The mother was convicted of causing or allowing her child's death; her male partner was convicted of murder. Learning: includes: if duty officers in children’s services do not routinely communicate with the referring practitioner before making decisions about a referral, misunderstandings can occur and this leaves children vulnerable; need for agreements and plans to be monitored, reviewed, checked and shared with other agencies; all family members, especially those living in the household, should be subject to assessments, both to determine risk and to confirm and assess their ability to protect children in the family; need to engage men; unaddressed domestic abuse can leave some children vulnerable and with ineffective help. Recommendations: makes no recommendations but sets out questions and issues for the safeguarding board to consider around practice, procedures and strategies. Keywords: brain injury, disguised compliance, parenting capacity, family violence > Read the overview report

2020 – Kent – Child I: Carys

Death of a 16-year-old girl in 2017 by suicide. Learning focuses on issues around: initial responses to disclosures of child sexual abuse; use of child sexual abuse pathways and associated support; responses to the mental health needs of Carys; education settings being identified as key safeguarding partners; sharing of adult safeguarding information and concerns; accurate record-keeping by professionals; follow-up for children not brought to health appointments. Recommendations: ensure rigorous promotion of the role of the Sexual Assault Referral Centre to ensure victims of sexual abuse, including non-recent abuse, are being offered holistic support; explore ways to widely promote existing pathways and opportunities to respond to mental health issues in children and young people, including the policy to manage self-harming and suicidal behaviour; request assurance from Health partners that missed health appointments for children are subject to robust and consistent follow up. Keywords: suicide, disclosure, child sexual abuse, adolescents, non-attendance > Read the overview report

2020 – Kent – Suicide: thematic analysis

Thematic review of adolescent suicides, analysing five reports relating to the suspected suicides of young people between May 2014 and June 2018. Learning:  the interface between different specialist health services and other organisations is a vital, but vulnerable, line of demarcation and may be decisive in determining effective service response; suicidal ideations and suicidal plans may not be a reliable indicator of intent to commit suicide, therefore a comprehensive assessment is required; consideration should be given to a 'trigger event phase' that may capture deterioration in presentation; consideration should be given to how to support family survivors of suicide. Recommendations:  GPs and school teaching staff should be an integral part of the inter-professional holding network and receive training commensurate with this role; professionals need to have greater awareness of young people's use of online activity and social media; professionals need to respond with a comprehensive and immediate psychosocial assessment of the young person and their engagement in a therapeutic relationship; ensure that there is timely and proportionate access to mental health services with emphasis on direct positive engagement, comprehensive assessment and necessary treatments; listening to and learning from young people and their families must be used in creating preventative suicide strategies. Keywords:  adolescents, suicide, children with a mental health problem, health services, assessment, interagency cooperation > Read the overview report

2020 – Luton – Child G

Neglect and sexual abuse of a secondary school aged child. Legal proceedings took several years and Child G is now an adult. Learning: missed opportunities for a holistic and multi-agency assessment and response to Child G’s emotional needs; no evidence of chronologies being maintained or information being collated to enable a wider understanding of Child G’s history; there was a need for better management and supervision; ensure appropriate use of specialists to provide advice on how to engage with the child or adult if they have learning needs; practitioners need to be curious about the causal nature of behaviour and seek to explore alternative reasons. Recommendations: ensure that agencies have in place and follow effective safeguarding supervision and management oversight procedures, and remind agencies of the importance of appropriate challenge and escalation; establish clear self-harm procedures and pathways; ensure that effective support is provided to disabled children and their families to enable them to communicate and effectively participate in plans; ensure compliance with the procedures for child protection medicals and the inclusion of consultant paediatricians in strategy discussions or meetings. Keywords: child neglect, child sexual abuse, children with disabilities, behaviour, supervision > Read the overview report

2020 – Manchester – Child U1

Death of child under 3-years-old in January 2018. Partner of Child U1's childminder was found guilty of the child's murder, and the childminder was found guilty of causing or allowing the death of a child. Both received prison sentences. Learning: a decision that the injuries were due to a medical cause rather than non-accidental injury meant that professionals did not query an alternative diagnosis; deference to the medical clinicians involved made challenging medical professionals difficult. Recommendations: highlight the need for: professional curiosity, professional challenge and information sharing within and between agencies; assessments to include an understanding of care arrangements and an assessment of the carers; and an understanding of differential diagnosis and when bruising is present where non-accidental injury should be considered.  Keywords:  child deaths, child minding, physical abuse identification, professional curiosity , unknown men, information sharing > Read the overview report

2020 – Manchester – Child W

Non-accidental injury to a 4-month-old child in 2018, attributed to shaking. The mother received a custodial sentence. Learning includes: provide child impact chronologies to understand the daily lived experience of children; the views, wishes and feelings of children are critical to effective interventions; a trauma-informed approach to assessment, incorporating a strengths-based methodology, can be invaluable when adverse experiences in childhood have been identified; cannabis use, particularly if prolonged, is a significant feature contributing to poor mental health and compromised parenting; family engagement is critical to keeping children safe; consider the possibility of abusive head trauma in cases where there are young babies and children and domestic abuse is present. Recommendations include: planning and interventions should be informed by a conceptual model of change, particularly when working with families struggling with interrelated mental health issues, alcohol or substance misuse; ensure that a trauma-informed approach to planning and interventions is embedded into practice, particularly where adverse childhood experiences have been identified. Keywords: shaking, infants, substance misuse, trauma-informed practice, assessment > Read the overview report

2020 – Medway – Faith

Historical sexual abuse of an adolescent girl. In 2016, prior to Faith's 18th birthday, Faith disclosed that she had been sexually abused for several years by a neighbour, and that her mother had been aware this was happening. Learning includes: over many years the signs and indicators that Faith had been sexually abused were not recognised and acted upon and her voice was not heard; assessments and plans were limited in their analysis of the history of both parents, the dynamics of relationships within the family and relevant health information; there was no clear plan to give Faith a permanent safe home and the legal framework was not used effectively. Recommendations include: develop a multi-agency whole family approach to work with complex families; seek evidence from children’s services that the cause of placement breakdown is analysed and that findings are incorporated into ongoing planning for the child; ensure that all practitioners have the required knowledge and skills and confidence to recognise and respond to child sexual abuse within the family including hearing the “voice” and lived experience of the child. Keywords: child sexual abuse, child abuse identification, exclusion from school, family violence, placement breakdown, voice of the child > Read the overview report

2020 – Medway – George

Death of a 3-year-old boy in February 2018 in Croydon. George had been in the rear passenger foot well of a car when the front passenger (the mother's partner, 'A') pushed his seat back twice and crushed George. Learning: the impact on George of witnessing domestic abuse and unpredictable changes of residence was underestimated; George's presence was not adequately recorded during some incidents; the need for professionals to record and assess incidents considering information on all individuals present; the need for professionals to define demonstrable change in the situation of a child at risk or vulnerable adult before concluding sufficient improvement. Recommendations: Medway agencies to improve methods of reporting and responding to incidents involving safeguarding issues and vulnerable adults. Keywords: child neglect, transient families, parenting capacity, family violence, mothers, abusive men > Read the overview report

2020 – Merton – Child D

Death of a 7-year-old girl in November 2017. Child D was murdered by her father in the family home. Learning points relate to: mental health risk assessments; multi-agency assessments; thresholds and ‘step-up’ and ‘step-down’; the use of interpreters and cultural sensitivity in assessments where English is not the first language; considering and assessing coercive control and disguised compliance; information sharing; and sexual abuse. Recommendations include: seek assurance that in mental health assessments following attempted suicide where the adult has responsibility for children, that risks to them and partners are considered, including where the dependent is seen as part of the patient’s perceived ‘problem’ or ‘protective element’; review multi-agency approaches to assessing for the possibility of sexual abuse of children. Keywords: child deaths, abusive fathers, deception, disguised compliance, suicide, partner relations > Read the overview report

2020 – Newcastle – Laura

Sexual abuse of a girl aged between 11- and 19-years-old who has ADHD, a learning disability, speech and language difficulties and behavioural difficulties. Laura disclosed a history of sexual abuse by her mother's partner in 2017 when she was 19-years-old. Learning includes: there was a lack of professional awareness of Laura being at heightened risk of sexual abuse due to her learning difficulties and disabilities; unchecked assumptions can inhibit professionals from exploring what may be happening to a child in their family; professionals in contact with children should regularly update records about family members and seek out information about significant males in a child's life; professionals may not always consider the possibility of child sexual abuse, unless there is a disclosure or the presence of recognisable signs and symptoms. Recommendations include: an authority wide, multi-disciplinary strategy for prevention, identification and response to familial child sexual abuse; ensure that professionals understand that concerns about the behaviour, health, wellbeing or safety of children with disabilities may be attributable to familial sexual abuse, even if this is later discounted. Model: uses a systems methodology. Keywords: child sexual abuse, children with learning difficulties, children with disabilities, abusive men, unknown men > Read the overview report

2020 – Norfolk – Child AG

Neglect of a 2-year-old boy in 2018 who presented at hospital severely malnourished and had fractures of varying ages. Learning includes: issues around the assessment of risk and impact of domestic abuse on the mother and children; issues around how the parents' learning difficulties were understood in relation to their parenting; issues concerning how child neglect is understood by practitioners and the ability of services to identify and recognise malnutrition; assessments by medical practitioners should not take precedence over concerns raised by other professionals within a safeguarding network; issues around professionals’ competence in working with and understanding the culture of a Traveller family. Recommendations include: review the ability of partners to deliver the neglect strategy; equip practitioners with the confidence and skills to work with clients from diverse cultural backgrounds, including Gypsy, Traveller and Roma communities; local health agencies to review the effectiveness of faltering child growth management. Keywords: child neglect, nutrition, adults with learning difficulties, medical assessment, culture > Read the overview report

2020 – Norfolk – Child AI

Significant burns to a 5-and-a-half-year-old child in August 2019. Learning includes: staff should consider when families use emergency departments whether it’s because they don’t want professionals to visit the family home; anti-social behaviour (ASB) officers should consider the impact of ASB in a safeguarding context when a child is present and share this with appropriate agencies; the number of perceived minor injuries to a child should be viewed in relation to parenting capacity and the ability to keep children safe. Recommendations include: equip frontline staff with the skills to work with clients who may have a learning difficulty; promote the Family Network programme to build relationships with the wider family and support families when services are no longer needed; develop guidance for transferring safeguarding records from early years to schools to facilitate appropriate information sharing at the point of transition. Keywords: burns, anti-social behaviour, parenting capacity, people with learning difficulties, information sharing, unknown men > Read the overview report

2020 — Nottinghamshire — Child RN19

Death of a 15-year-old child in 2019 who was found to be emaciated but otherwise well cared for. Learning: parents and professionals should remain curious about what their children are thinking, feeling and accessing on mobile devices; social isolation can have a negative impact on emotional and psychological health; school staff should act on healthcare concerns by offering referral to appropriate services; GPs should use tools to recognise faltering growth and eating disorders are part of the differential diagnosis for this. Recommendations: review material available to parents to help them recognise the signs of anorexia nervosa and the importance of early diagnosis in children; consider requesting a national review on elective home education (EHE), changing non-statutory guidance to improve opportunities for promoting the welfare of children receiving EHE; raise awareness of early recognition of children with eating disorders and professional curiosity and how to promote this within systems. Keywords: child deaths, anorexia nervosa, body image, eating disorders, home education, help-seeking behaviour > Read the overview report

2020 – Plymouth – Baby F

Life-changing head injury of an 11-week-old boy in September 2016. Baby F was seen at hospital twice prior to his life-changing injuries. His parents were subsequently charged in connection to the injuries. Learning includes: it is important to seek engagement with both parents to assess their mental health; supervisors need to be vigilant to ensure the most vulnerable families are discussed at supervision; and when parents have their own needs, there is a risk that the focus on the child will be lost. Recommendations include: guidance on the detection and management of unusual medical presentations in non-mobile babies should be applied consistently by all agencies and counsellors should follow guidelines on safeguarding children. Model: uses Partnership Learning Review. Keywords: bonding behaviour, family dynamics, non-accidental head injuries, physical abuse identification, postnatal depression, unknown men > Read the overview report

2020 – Plymouth – Baby G

Death of a 6-month-old baby boy due to a significant head injury attributed to shaking in May 2017. Father was charged with manslaughter and received a prison sentence. Learning includes: the need for clear and accurate information sharing and for all agencies to seek information if they believe an assessment is being conducted; importance of professional curiosity for clinicians when presented with unusual signs and symptoms. Recommendations include: ensure that partner agencies recognise that minor presentations can represent injuries which may be a sign of serious abusive trauma; promote awareness among parents and professionals of the “crying curve” (“purple crying”) and the impact on parents of coping with inconsolable crying; reflect on the diagnosis and treatment of depression in new and prospective parents and how this can impact on parenting capacity; develop a programme of intervention to engage fathers and prospective fathers; engage, reassure and educate parents about infant crying and strategies for coping and impulse control. Keywords: infant deaths, shaking, crying, fathers, professional curiosity > Read the overview report

2020 – Portsmouth – Child H

Death of a 9-year-old boy in August 2018. Child H was found unresponsive in the family home and later pronounced dead. Learning: there should have been a professional focus on managing Child H's disabilities rather than seeing a child who was disabled and neglected; the need for information sharing between appropriate agencies when a child has a child in need plan; importance of professionals escalating concerns about parental capacity in a timely manner, particularly when a child has complex needs; family medicine management should be checked by professionals on a regular basis when prescribed medicines form part of a child's health and safety plan. Recommendations include: increasing knowledge across services on how concerns about a child's welfare might be managed; children's social care to review their local policy on child in need cases to ensure the policy clearly reflects the need to involve partner agencies, particularly in cases involving children with disabilities; local NHS Trusts to review their policies and procedures on recognising and responding to medical neglect. Model: uses a model of learning based on a Soft Systems Methodology. Keywords: children with disabilities, child neglect, medical care neglect, drug misuse, child health services, information sharing. > Read the overview report

2020 – Portsmouth – Child I

Death of a 9-week-old infant in 2018. Learning: practitioners working with families should take every opportunity to remind parents of key safe sleeping messages tailored to their needs; health practitioners are in a key position to identify domestic abuse and to initiate support and safety for victims; good practice was shown by the neonatal doctor in following up after Child I was not brought for a repeat blood test. Recommendations: support professionals working with universal and high risk families to identify safe sleep risks, emphasising ‘out of routine’ events such as going to a party or on holiday; support professionals in discussing alcohol consumption with parents and highlighting what happens on those occasions when they may binge or drink more than usual; Portsmouth hospital should review and improve continuity of carer arrangements, especially when there is staff sickness. Keywords: alcohol, sleeping behaviour, infant deaths, child neglect, parenting education, hospitals > Read the overview report

2020 – Redbridge – Baby T

Death of an 11-month-old girl in October 2017. Learning themes include: decisions made by Home Office about Mother’s claim for asylum and asylum support; effectiveness of Home Office asylum seeker support services and ‘mainstream’ health and social care services; impact of frequent moves of Mother and Baby T; use of interpreting services in supporting Mother and Baby T; ‘lived’ experience of Baby T; indications of trafficking or exploitation concerns and agency responses; ‘unseen males’. Recommendations: remind practitioners about policy and practice in respect of modern slavery; ensure that advice to parents on caring for crying and sleepless babies is accessible in all community languages; Home Office to ensure pregnant asylum seekers and asylum seekers with young children are referred to local primary care service at the point of first contact. Keywords: asylum seekers, babysitters, interpreters, language, maternal health services, temporary accommodation > Read the overview report

2020 – Richmond – St Paul’s School

Review commissioned in April 2017 following five convictions for sexual offences of adults who had previously worked at St Paul’s School London. Learning: accepting responsibility for past abuse must be a foundation for moving forward and developing an effective safeguarding culture; schools face difficulties in balancing a response to allegations of abuse that takes account of employment law, education legislation and good safeguarding practice; there are gaps in the national safeguarding system in relation to the recruitment and regulation of teachers, the Disclosure and Barring Service and the way in which information is shared across national organisations. Recommendations: Charity Commission should make explicit their expectations regarding best practice at times of crisis and specifically that protecting the reputation of the charity includes openness and honesty about any poor practice; Home Office should establish a system of advocacy and support for complainants in child sexual abuse cases both pre- and post-trial to ensure consistency between areas. Keywords: teachers, institutional child abuse, adults sexually abused as children, abused men, media coverage, recruitment > Read the overview report

2020 – Rochdale – Child A1

Death of a 4-month-old infant in May 2018 whilst in the care of a family member overnight. Police initiated an investigation but no charges were made.  Learning: is embedded in the recommendations. Recommendations: ensure that Special Circumstances Forms generated by midwifery services are shared by key agencies, such as general practitioners (GPs) and health visitors; ensure that information sharing and discussion take place routinely between midwifery and GP practices where issues are identified, and concerns are raised in order to understand the holistic family circumstances; where parental alcohol and substance misuse are risk factors, practitioners are able to consider any other caring responsibilities for children including babysitting arrangements. Keywords: infant deaths, alcohol misuse, sleeping arrangements, extended family > Read the overview report

2020 – Salford – Baby MD

Death of a 5-week-old infant in August 2018. Baby MD had been placed by mother in the parental bed to sleep during the night and was found lifeless the following morning. Learning: trauma-informed practice can support service users in forming effective working relationships with practitioners; case transfers should ensure all relevant information, including significant historical risk factors and parental adverse childhood experiences (ACEs) is shared; there is a need to explore more effective safe sleep interventions for vulnerable families. Recommendations: ensure that multi-agency partners have considered the relevant learning points and developed implementation plans in order to support safeguarding practice when working with complex families with multiple risk factors. Keywords: sudden infant death, sleeping behaviour, trauma, adverse childhood experiences > Read the overview report

2020 – Salford – Helen

Delay in responding to potential trafficking of a female child in 2019. Learning: immigration identification documents are not evidenced-based; need for professional curiosity; need for professional advice in a timely manner and to escalate concerns to enable a multi-agency approach; need for a multi-agency approach to age assessment and to have a pathway to resolve disputes on the presenting age of an individual; consider the child’s views at all times. Recommendations: Local Safeguarding Partnership should ensure that a local, multi-agency, effective pathway is developed and embedded to address concerns that a presenting adult may be a child and that the risk of trafficking may be present; UK Visas and Immigration should ensure robust identification procedures and have a consistent approach to directing practitioners with concerns if someone with an adult ID is thought to be a child. Keywords: child criminal exploitation, child trafficking, homelessness, interagency cooperation, interpreters, voice of the child > Read the overview report

2020 – Sandwell – JS

Minnesota Stands Out for Its Moderately Progressive Tax Code

August 6, 2024

Carl Davis Research Director

Most state tax systems fall short of the public’s perception of fairness by charging the rich lower tax rates than everyone else. Minnesota is among a small group of states that has chosen a different path. In Who Pays? , our comprehensive study of state and local taxes, Minnesota stands apart from the pack with a moderately progressive tax system that asks slightly more of the rich than of low- and middle-income families.  

Recent reforms signed by Gov. Tim Walz, the Democratic Party’s presumptive Vice-Presidential nominee, have contributed to this reality. Our analysis shows that taxes on working-class families declined markedly over the last few years in Minnesota, while taxes on high-income people went up slightly over this same period.  

The most notable changes were signed into law by Gov. Walz in 2023 as part of a sweeping tax reform package. Some changes were temporary, like taxpayer rebate checks and expanded property tax credits. But the bill also included a host of important, permanent reforms.  

Chief among those was a new Child Tax Credit that is expected to slash child poverty in Minnesota by one-third, according to Columbia University’s Center on Poverty and Social Policy. The link between Child Tax Credits and child wellbeing is well established, as the financial security afforded by these credits is associated with improved child and maternal health, better educational achievement, and stronger future economic outcomes.  

Other tax cuts signed by Gov. Walz include expanded exemptions for Social Security income and for student loan forgiveness, plus an extension of the Child Care Tax Credit to newborn children.  

To help pay for these and other substantial tax cuts, the 2023 bill included a variety of well-targeted tax increases on high-income people and profitable corporations. Certain tax deductions claimed by high-income filers have been scaled back. Capital gains, dividends, and other investment income over $1 million per year is now subject to a modest 1 percent surtax. And multinational corporations reporting income overseas now face higher taxes as well, as the state opted to piggyback on a law written by Congressional Republicans targeting companies’ “low-taxed income.”  

While the Minnesota tax code is somewhat progressive, it is far from radical. The state has embraced practical, administrable reforms that have lowered taxes for working-class families, reduced child poverty, and addressed the public’s frustrations with the tax treatment of multinational companies and wealthy people. At the end of the day, Minnesota does better than most states in living up to what most people would consider to be a bare minimum standard of tax fairness: the idea that wealthy people should not pay lower tax rates than everyone else.  

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Harris Chooses Walz

A guide to the career, politics and sudden stardom of gov. tim walz of minnesota, now vice president kamala harris’s running mate..

This transcript was created using speech recognition software. While it has been reviewed by human transcribers, it may contain errors. Please review the episode audio before quoting from this transcript and email [email protected] with any questions.

Hey, it’s Michael. Before we get started, I want to tell you about another show made by “The New York Times” that pairs perfectly with “The Daily.” It’s called “The Headlines.” It’s a show hosted by my colleague, Tracy Mumford, that quickly catches you up on the day’s top stories and features insights from “The Times” reporters who are covering them, all in about 10 minutes or less.

So if you like “The Daily”— and if you’re listening, I have to assume you do — I hope that means you’re going to “The Headlines” as well. You can now find “The Headlines” wherever you get your podcasts. So find it, subscribe to it, and thank you. And now, here’s today’s “Daily.”

From “The New York Times,” I’m Michael Barbaro. This is “The Daily.”

[MUSIC PLAYING]

Today, the story of how a little known Midwestern governor became Kamala Harris’s choice for a running mate. My colleague Ernesto Londoño walks us through the career, politics, and sudden stardom of Governor Tim Walz of Minnesota.

It’s Wednesday, August 7.

Ernesto, over the past few days, we watched Vice President Harris bring the final three contenders for her running mate to her house in Washington, DC, for a set of in-person interviews. And then we watched as she seemed to narrow her pool of choices down to a final two — the governor of Pennsylvania, Josh Shapiro, and the governor of Minnesota, Tim Walz. And now, of course, we know that she has made her choice. What has she told us about her campaign strategy, the way she views this race, in ultimately choosing Tim Walz?

Michael, I think what the choice tells us is that Kamala Harris was drawn to two qualities that Governor Walz brings to the table. And what’s interesting is they may seem to be in tension. For starters, here’s the ultimate everyday man, somebody who grew up in a small town in Middle America, served in the National Guard, was a high school teacher, a football coach, very plain-spoken, goes to campaign events wearing T-shirts and baseball caps, is a gun owner and very proud about it. He sort of embodies the Midwest.

And she clearly thinks that that is going to bring the kind of moderate, white, working class voters that the campaign needs in swing states to come to them, to make this feel like a balanced ticket and something that will give her enough of the crucial votes to defeat Donald Trump in the fall.

On the other hand, as governor, he passed a slew of pretty progressive legislation in the past couple of years, everything from abortion rights to gun control. So these things are likely to appeal to bread and butter Democrats.

But the question is, when voters have examined these two facets of Tim Walz, may it bring them enough enthusiasm from the base and enough undecided voters that the campaign desperately needs, or at some point, do these two aspects of him start canceling each other out?

Right. In short, you’re saying Harris is betting on a dual appeal from Walz to two essential constituencies, but the risk is that the appeal to one of them is just much, much greater than to the other.

Right. You could definitely see a scenario where voters, once they’ve examined Tim Walz’s story and legacy, may conclude that both of these candidates are quite liberal.

OK, so tell us the story of Tim Walz, a story that I think a lot of us don’t know because we really don’t know Walz all that well, and how he has come to embody these two qualities and that tension that you just described.

Michael, the origin story of Tim Walz’s political career is quite fascinating.

He and his wife were teachers in a small city south of Minneapolis. And in 2004, when George W. Bush was running for re-election, Walz took a group of his students to a political rally in his hometown. They wanted to just see the president make his case. And a strange scuffle happened when they were trying to get in.

Well, one of the kids had a John Kerry sticker on his wallet. And this is where the individual says, well, you’re not going to be allowed to enter. You’ve been deemed a threat.

Apparently, one of the students had a sticker for Bush’s rival, John Kerry, on his wallet. And security officials at the rally didn’t want to let them in.

And I said, oh, it’s OK. They’re with me. And who are you? And I said, I’m Tim Walz. I’m their teacher here, and showed them my ID. And they said, well, you two have been deemed a threat to the president. And I said, well, that’s not true. And it kind of escalated.

And this really ticked off Tim Walz. He was really upset. There was a fight and a confrontation at the rally.

At this point in time, I’m kind of nervous. I’m getting arrested. So I’m like saying, well, I’m Teacher of the Year in Mankato. And they didn’t care about that. And it was kind of a sad epiphany moment, how it felt for people to be looked right through by people. These people didn’t see me. And this is happening.

And ultimately, he sort of walks away from this moment feeling really sick of the Bush administration, the politics of the day. And he turns around and volunteers for the Kerry campaign.

And then the more interested he becomes in politics in this era, he starts looking around his congressional district, and there’s a Republican who’s held the seat for many, many years. This was a largely rural district in southern Minnesota. And there’s no reason to believe that a newcomer to politics, somebody without a donor base, could make a run for this seat and win.

But Walz signs up for this weekend boot camp, where expert campaigners train newcomers who want to run for office. And he gets really enthused by the idea that he can pull it off. So he starts raising money with the support of an army of students who become so thrilled and energized by the prospect that their nerdy and kind geography teacher is making this uphill bid for a congressional race.

So his campaign staff is basically his former students.

That’s right. And he proves to be a formidable candidate. He draws a lot of attention to his experience in the classroom and as a coach.

When I coached football, these stands held about 3,000 people. That’s a lot. It’s also the number of American soldiers who have died fighting in Iraq.

He’s a very strong advocate for pulling out of the war in Iraq.

Serving right now are kids that I taught, coached, and trained to be soldiers. They deserve a plan for Iraq to govern itself, so they can come home.

And one thing that happens in the campaign that is really surprising to people is he comes out as being in favor of same-sex marriage. Now, it’s useful to remember that this is 2006, when the vast majority of Democrats, Democrats running for most elected office, were not ready to come out in favor of same-sex marriage.

And here’s a guy who’s new to politics, who’s trying to unseat a Republican who’s held on to his seat for more than 12 years, taking what appeared to be a reckless position on something. And when he was asked about it at the time, Tim Walz told a supporter, this just happens to be what I believe in. And I’d rather lose a race that I’ve ran being true and consistent to my values than try to run as somebody I’m not.

And of course, he wins.

Yes. To everybody’s surprise, he pulled it off.

So from the get-go, he shows a kind of maverick, “politics be damned” quality, taking stands that he knows may be unpopular among the voters he’s trying to win over. But he’s got some innate political gifts that are all making it work.

Yeah, I think that first campaign showed us that Tim Walz had real political chops. He was a very effective campaigner. And people really liked him. When he was knocking on doors, when he was introducing himself to voters, they saw him as somebody who was very genuine and who was admirable.

So once he gets elected in this conservative leaning district in Minnesota, what does he actually do in Congress?

In Congress, he develops a reputation for being somebody who can work across the aisle. And this is a period where Democrats and Republicans were deeply polarized over the Iraq War. He spends a lot of his time lobbying to expand benefits for veterans, so it’s easier for them to go to college after their service, and also becomes a leading voice in the quest to repeal Don’t Ask, Don’t Tell, the policy that prohibited openly gay servicemen from serving in uniform.

And he remained really popular. He easily won re-election five times. The last time he runs for his seat happens to be 2016, when President Trump wins his district by about 15 points.

And still, voters kept Tim Walz in office.

I think it’s important to note what you just said. Walz is distinguishing himself as a Democrat who can take some pretty progressive positions, as he did in that first campaign on gay rights, as he did with Don’t Ask, Don’t Tell, and keep winning in very Trump-friendly districts of his state.

That’s right. And as he’s serving his sixth term in office, he sets his sights on the governor’s mansion and decides to run for office in 2018. He wins that race easily. And early on, during his time as governor, the eyes of the world are on Minnesota after a police officer kills George Floyd. And what we see is massive looting and protests in Minneapolis.

Right, and remind us how Governor Walz handles that violence, those protests.

Yeah, I think that’s a crucial chapter in Tim Walz’s political career and one that will come under scrutiny in the days ahead.

After George Floyd was killed on a Monday —

People are upset, and they’re tired. And being Black in Minnesota already has a stigma and a mark on your back.

— protests took root in Minneapolis.

Y’all want to sit out here and shoot off your rubber bullets and tear gas.

And they got progressively larger and more violent.

There comes a point where the mayor and the police chief in Minneapolis plead for help. They ask the governor to send in the National Guard. And crucially, that request was not immediately heeded.

This is the third precinct here. There are fires burning to the left of it at the —

And at the height of the crisis, a police precinct building was abandoned.

There’s someone climbing up the wall right now, kicking the window in, trying to climb up the wall.

Because city officials grew concerned that protesters were about to overrun it and may attack the cops inside their own turf.

[EXPLOSIONS]

And the building is set on fire.

Right, a very memorable image. I can recall it happening in real-time.

Yeah, and in the days that followed, I think there were a lot of questions of why the governor didn’t send in troops earlier and whether a more muscular, decisive response could have averted some of the destruction that spread through the city.

And how does Walz end up explaining his decision not to send in the National Guard more quickly?

The governor and his administration have said that they were really, really dealing with an unprecedented challenge. And I think there was a concern that sending in troops into this really, really tense situation could have done more to escalate rather than pacify things on the street.

But in the weeks and months that followed, there were a lot of questions about Governor Walz’s leadership. And there were critics who said, during what may have been the most challenging week of his life, we saw a governor who was indecisive and who waited too long to send in resources that ultimately allowed the city to get to a semblance of order.

Right, and it feels like this is a moment that will almost assuredly be used against him by Donald Trump and JD Vance, the Republican ticket, which has made law and order so central to their message in this campaign.

Yeah, absolutely. And here in Minnesota, that was certainly a liability for him when he ran for re-election in 2022. But voters kept him in office, and he won that race handily. And not only did he win, but Democrats managed to flip the Senate and have full control of the legislature on his watch.

And that sets in motion one of the most productive legislative sessions in Minnesota history, where Tim Walz and his allies in the House and the Senate managed to pass a trove of really progressive legislation, oftentimes on a party vote.

Tell us about some of that legislation.

Well, Minnesota becomes the first state in the wake of the Supreme Court ending the constitutional right to abortion to actually codify this right under state statute. And they did a lot more stuff. They had a huge budget surplus, and they used that, for instance, to fund meals for all school children.

They managed to pass a couple of gun control laws that were very contentious. They gave the right to undocumented immigrants to get driver’s licenses. They legalized recreational marijuana. And finally, the governor takes a pretty bold stance on this issue of gender affirming care for transgender kids and teenagers, and says that Minnesota will be a safe haven for people who want that health care.

So, Ernesto, so how should we think about that blitz of legislation and the largely progressive tone of it, given the way that Walz had campaigned and succeeded up to that moment as somebody with such broad appeal across the political spectrum?

When the governor was asked whether this had been too much too quickly in terms of progressive legislation, his answer was that these were broadly popular policies, that these are issues Democrats had campaigned on. And here, Democrats had a window of opportunity where they were in control of the governor’s mansion and control of the House, the Senate, and that when you have political capital, you spend it.

But when you start listening to Republicans in Minnesota, they say, here’s a guy who campaigned on this mantra of “One Minnesota.” That was his campaign slogan. And he sort of came into office with this promise that he would govern in a bipartisan way, reach across the aisle.

But when they had all the votes they needed to pass their policies, Republicans felt that Walz was not bothering to bring them into the fold and to pass legislation that was going to be palatable to conservatives in the state. So I think people who once regarded him as a moderate now start seeing him as somebody who, when he had the power, acted in ways that were really progressive and liberal.

So at the height of his power, Governor Walz emerges as somebody who, when given a shot at getting done what he really wants to get done with a Democratic legislature, is a pretty progressive leader, even at the risk of being somewhat at odds with his earlier image as more moderate, because in his mind, enough people in the state are behind these policies.

Yeah, and I think he assumed that he had banked enough goodwill and that people across the state liked him enough to tolerate policies they may have disagreed with. And I think it’s safe to say, among the people who cover him here regularly, there was never any real hint that Tim Walz was eyeing a run for higher office. He’s not somebody who has written the kind of political memoir that oftentimes serves as a case of what you would bring to a national ticket or to the White House. And he seems pretty happy with a state job.

So it was a huge surprise when Tim Walz starts going viral through a string of cable news appearances right after President Biden drops out of the race, and the Democrats are scrambling to put Harris at the top of the ticket. And what becomes clear is that Walz is very forcefully auditioning for the role of vice president, and Vice President. Harris starts taking him very seriously.

We’ll be right back.

So, Ernesto, tell us about this cable news audition that Governor Walz undertakes over the past few weeks and how, ultimately, it seemed to help him land this job of being Harris’s running mate.

I think Walz does something really interesting, and that is that he says that Democrats shouldn’t be talking about Trump and Vance as existential threats. He kind of makes the case that Democrats have been in this state of fear and paralysis for too long, and that it’s not serving them well. So the word he latches onto is “weird.”

Well, it’s true. These guys are just weird.

It is. It is.

And they’re running for he-man women hater’s club or something. That’s what they go at. That’s not what people are interested in.

And I think one other thing we see in Walz is somebody who’s putting himself out there as a foil to JD Vance.

That angst that JD Vance talks about in “Hillbilly Elegy,” none of my hillbilly cousins went to Yale, and none of them went on to be venture capitalists or whatever. It’s not —

I think the case he’s making is that Tim Walz is a more authentic embodiment of small town values.

What I know is, is that people like JD Vance know nothing about small town America. My town had 400 people in it, 24 kids in my graduating class. 12 were cousins. And he gets it all wrong. It’s not about hate.

And behind the scenes, people from Tim Walz’s days on Capitol Hill start calling everybody they know in the Harris campaign and the Harris orbit and saying, here’s a guy who has executive experience as governor, but also somebody who has a really impressive record from his time on Capitol Hill and somebody who could be an asset in helping a Harris administration pass tough legislation. So you should take a hard look at this guy.

Which is, of course, exactly what Harris ends up doing. And I want to talk for a moment about how Harris announces Walz as her running mate on Tuesday morning. She did it in an Instagram message. And it felt like the way she did it very much embraced this idea that you raised earlier, Ernesto, that Walz contains these two appeals, one to the Democratic base, one to the white working class.

Harris specifically cites the work that Walz did with Republicans on infrastructure and then cites his work on gun control. She mentions that he was a football coach and the founder of the high school Gay Straight Alliance. She’s straddling these two versions of Walz.

But I want to linger on the idea for a moment of Walz’s vulnerabilities, because once he becomes Harris’s running mate, Harris and Walz are going to lose a fair amount of control over how they present him to the country, because he’s going to become the subject of very fierce attacks from the Republicans in this race. So talk about that for just a moment.

Yeah, I mean, it’s important to keep in mind that Governor Walz has never endured the scrutiny of a presidential race. So the questions he’s going to be asked and the way his record is going to be looked at is going to be different and sharper. I think the Harris campaign is billing him as, first and foremost, a fighter for the middle class. And I think that certainly will have some appeal.

But I think in coming days, there’s going to be a lot of attention drawn to parts of his record that may be unpopular with many voters. For instance, giving undocumented immigrants driver’s licenses, which Governor Walz championed. It’s likely to provide fodder for an attack ad.

The very dramatic footage of Minneapolis burning in 2020 is also something that I think people will be drawn to. And there’s going to be interest in reexamining what the governor did and what he could have done differently to avert the chaos.

And on Tuesday, we saw that the Trump campaign wasted no time in trying to define Tim Walz as soft on crime, permissive on immigration policy. And they also made clear they wanted to relitigate the era of George Floyd’s killing. And specifically, they want to try to tie him to the effort at the time to defund the police, which is a movement that Walz personally never endorsed.

So the Republican attack here will be pretty simple. Walz is liberal. Harris is liberal. So, in their efforts to speak to especially white working class and rural voters in swing states, the Trump campaign is going to say this is not the ticket for that group of voters. This is the ticket of burning police precincts and gun control. And of course, that may not be fair, but that’s very likely going to be the message over the next couple of months.

Right. I think there’s going to be effort to portray him as a radical liberal who has used his small town roots to put on this sort of veneer of being a moderate and a really sort of understanding and being part of the segments of the electorate that I think are critical in this election.

I want to speak for just a moment about the person Harris did not pick when she chose Walz because many Democrats had felt that Walz was a potentially too liberal seeming running mate for a candidate, Kamala Harris, who herself comes from a blue state and is caricatured by the Republicans as liberal herself.

And the person she didn’t choose was Governor Josh Shapiro of Pennsylvania, who was seen as having a huge appeal in that particular key swing state, but also presented risks of his own of alienating parts of the Democratic base with his well-documented support for Israel and his criticism of campus protesters. How should we think about the fact that, ultimately, Harris chose Walz over Shapiro?

Yeah, I think in the final stretch of this campaign to be the vice presidential pick, we started seeing a lot of acrimony in pockets of the Democratic base, drawing attention to the fact that Governor Shapiro could be divisive on Gaza, which has really sort of split the party in recent months.

So I think at the end of the day, they made a calculation that Tim Walz would be more of a unifying figure and would be somebody who would inspire and energize enough pockets of the electorate that they need, particularly in the Midwest, to make him the stronger and more exciting pick and somebody who wouldn’t force them to go back to defending and relitigating the Biden administration’s record on Israel and on the war in Gaza.

Right, and then, on Tuesday night, we got our first glimpse of Harris and Walz together on stage for the first time at a campaign rally. I’m curious, what struck you about their debut together.

Good evening, Philadelphia.

I think everybody was watching the opening scene of this rally to see what the chemistry between these two people was going to be like. And they both seemed giddy. They were literally, at times, bouncing with enthusiasm.

Since the day that I announced my candidacy, I set out to find a partner who can help build this brighter future.

So Pennsylvania, I’m here today because I found such a leader.

Governor Tim Walz of the great state of Minnesota.

They soon got down to business. And that business was how to define Tim Waltz for voters who don’t know him well.

To those who know him best, Tim is more than a governor.

And right off the bat, we saw that Kamala Harris really highlighted a lot of pieces of his pre-political career.

To his former high school football players, he was Coach.

She repeatedly called him Coach Walz, Mr. Walz, evoking his time in the classroom, and even used his military title from his days in the Army.

To his fellow veterans, he is Sergeant Major Walz.

And then when it came time for Tim Walz to introduce himself on this massive stage —

Welcome the next vice president of the United States, Tim Walz.

— he drew a lot of attention to his small town roots.

I was born in West Point, Nebraska. I lived in Butte, a small town of 400.

He said something that he said repeatedly recently in campaign appearances, which is —

In Minnesota, we respect our neighbors and their personal choices that they make. Even if we wouldn’t make the same choice for ourselves, there’s a golden rule — mind your own damn business.

The golden rule of small towns is you mind your own damn business, which is something he said in the context of his argument that Republicans have been limiting, rather than expanding, people’s rights. But he also drew attention to the fact that he’s a gun owner.

By the way, as you heard, I was one of the best shots in Congress. But in Minnesota, we believe in the Second Amendment, but we also believe in common sense gun violence laws.

And then when it came time to draw a sharp contrast with their opponents, Tim Walz said, these guys are phonies.

Donald Trump is not fighting for you or your family. He never sat at that kitchen table like the one I grew up at, wondering how we were going to pay the bills. He sat at his country club in Mar-a-Lago, wondering how he can cut taxes for his rich friends.

He said it’s actually people like me and Kamala Harris who come from humble origins and showed what is possible in America when you hail from a working class background, and you seize opportunities that were available to you.

Thank you, Philadelphia. Thank you, Vice President. God bless America.

So when it comes to this question of Walz’s dual identities and dual appeals, what did we learn on day one of this new Democratic ticket, do you think?

I think the campaign is trying to convey that these two facets of Tim Walz’s life are not mutually exclusive, that they don’t need to be in tension. They don’t cancel each other out. They’re both part of Tim Walz’s story. And I think that’s how they’re going to present him from now until Election Day.

Ernesto, thank you very much. We appreciate it.

It’s my pleasure, Michael.

Here’s what else you need to know today. On Tuesday, Hamas said that Yahya Sinwar, one of the masterminds behind the deadly October 7 attacks on Israel, had consolidated his power over the entire organization. Until now, Sinwar had held the title of Hamas’s leader in Gaza. But with the assassination of Hamas’s top political leader by Israel last week, Hamas said that Sinwar would take on that title as well. Sinwar remains a major target of Israel and is believed to have been hiding in tunnels underneath Gaza since October 7.

And the US Department of Justice has charged a Pakistani man with ties to Iran with trying to hire a hitman to assassinate political figures in the United States. The man recently traveled to the US and was arrested in New York last month. American authorities believe that his potential targets likely included former President Trump.

Today’s episode was produced by Alex Stern, Eric Krupke, and Olivia Natt. It was edited by Lisa Chow and Patricia Willens, contains original music by Pat McCusker and Marion Lozano, and was engineered by Alyssa Moxley. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly. Special thanks to Nick Pittman and Minnesota Public Radio.

That’s it for “The Daily.” I’m Michael Barbaro. See you tomorrow.

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Earlier this summer, few Democrats could have identified Gov. Tim Walz of Minnesota.

But, in a matter of weeks, Mr. Walz has garnered an enthusiastic following in his party, particularly among the liberals who cheer on his progressive policies. On Tuesday, Vice President Kamala Harris named him as her running mate. Ernesto Londoño, who reports for The Times from Minnesota, walks us through Mr. Walz’s career, politics and sudden stardom.

On today’s episode

Ernesto Londoño , a reporter for The Times based in Minnesota, covering news in the Midwest.

Background reading

Who is Tim Walz , Kamala Harris’s running mate?

Mr. Walz has faced criticism for his response to the George Floyd protests.

There are a lot of ways to listen to The Daily. Here’s how.

We aim to make transcripts available the next workday after an episode’s publication. You can find them at the top of the page.

The Daily is made by Rachel Quester, Lynsea Garrison, Clare Toeniskoetter, Paige Cowett, Michael Simon Johnson, Brad Fisher, Chris Wood, Jessica Cheung, Stella Tan, Alexandra Leigh Young, Lisa Chow, Eric Krupke, Marc Georges, Luke Vander Ploeg, M.J. Davis Lin, Dan Powell, Sydney Harper, Michael Benoist, Liz O. Baylen, Asthaa Chaturvedi, Rachelle Bonja, Diana Nguyen, Marion Lozano, Corey Schreppel, Rob Szypko, Elisheba Ittoop, Mooj Zadie, Patricia Willens, Rowan Niemisto, Jody Becker, Rikki Novetsky, Nina Feldman, Will Reid, Carlos Prieto, Ben Calhoun, Susan Lee, Lexie Diao, Mary Wilson, Alex Stern, Sophia Lanman, Shannon Lin, Diane Wong, Devon Taylor, Alyssa Moxley, Olivia Natt, Daniel Ramirez and Brendan Klinkenberg.

Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly. Special thanks to Sam Dolnick, Paula Szuchman, Lisa Tobin, Larissa Anderson, Julia Simon, Sofia Milan, Mahima Chablani, Elizabeth Davis-Moorer, Jeffrey Miranda, Maddy Masiello, Isabella Anderson, Nina Lassam and Nick Pitman.

An earlier version of this episode misstated the subject that Walz’s wife taught. She taught English, not Social Studies.

How we handle corrections

Ernesto Londoño is a Times reporter based in Minnesota, covering news in the Midwest and drug use and counternarcotics policy. More about Ernesto Londoño

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