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Description of Assignment

During your time at Manor, you will need to conduct a child case study. To do well, you will need to plan ahead and keep a schedule for observing the child. A case study at Manor typically includes the following components: 

• Three observations of the child: one qualitative, one quantitative, and one of your choice. 
• Three artifact collections and review: one qualitative, one quantitative, and one of your choice. 
• A Narrative

Within this tab, we will discuss how to complete all portions of the case study.  A copy of the rubric for the assignment is attached. 

• Case Study Rubric (Online)
• Case Study Rubric (Hybrid/F2F)

Qualitative and Quantitative Observation Tips

Remember your observation notes should provide the following detailed information about the child:

• child’s age,
• physical appearance,
• the setting, and
• any other important background information.

You should observe the child a minimum of 5 hours. Make sure you DO NOT use the child's real name in your observations. Always use a pseudo name for course assignments. 

You will use your observations to help write your narrative. When submitting your observations for the course please make sure they are typed so that they are legible for your instructor. This will help them provide feedback to you. 

Qualitative Observations

A qualitative observation is one in which you simply write down what you see using the anecdotal note format listed below. 

Quantitative Observations

A quantitative observation is one in which you will use some type of checklist to assess a child's skills. This can be a checklist that you create and/or one that you find on the web. A great choice of a checklist would be an Ounce Assessment and/or work sampling assessment depending on the age of the child. Below you will find some resources on finding checklists for this portion of the case study. If you are interested in using Ounce or Work Sampling, please see your program director for a copy. 

Remaining Objective 

For both qualitative and quantitative observations, you will only write down what your see and hear. Do not interpret your observation notes. Remain objective versus being subjective.

An example of an objective statement would be the following: "Johnny stacked three blocks vertically on top of a classroom table." or "When prompted by his teacher Johnny wrote his name but omitted the two N's in his name." 

An example of a subjective statement would be the following: "Johnny is happy because he was able to play with the block." or "Johnny omitted the two N's in his name on purpose." 

• Anecdotal Notes Form Form to use to record your observations.
• Guidelines for Writing Your Observations
• Tips for Writing Objective Observations
• Objective vs. Subjective

Qualitative and Quantitative Artifact Collection and Review Tips

For this section, you will collect artifacts from and/or on the child during the time you observe the child. Here is a list of the different types of artifacts you might collect: 

Potential Qualitative Artifacts 

• Photos of a child completing a task, during free play, and/or outdoors. 
• Samples of Artwork 
• Samples of writing 
• Products of child-led activities 

Potential Quantitative Artifacts 

• Checklist 
• Rating Scales
• Product Teacher-led activities 

Examples of Components of the Case Study

Here you will find a number of examples of components of the Case Study. Please use them as a guide as best practice for completing your Case Study assignment. 

• Qualitatitive Example 1
• Qualitatitive Example 2
• Quantitative Photo 1
• Qualitatitive Photo 1
• Quantitative Observation Example 1
• Artifact Photo 1
• Artifact Photo 2
• Artifact Photo 3
• Artifact Photo 4
• Artifact Sample Write-Up
• Case Study Narrative Example Although we do not expect you to have this many pages for your case study, pay close attention to how this case study is organized and written. The is an example of best practice.

Narrative Tips

The Narrative portion of your case study assignment should be written in APA style, double-spaced, and follow the format below:

• Introduction : Background information about the child (if any is known), setting, age, physical appearance, and other relevant details. There should be an overall feel for what this child and his/her family is like. Remember that the child’s neighborhood, school, community, etc all play a role in development, so make sure you accurately and fully describe this setting! --- 1 page
• Observations of Development :   The main body of your observations coupled with course material supporting whether or not the observed behavior was typical of the child’s age or not. Report behaviors and statements from both the child observation and from the parent/guardian interview— 1.5  pages
• Comment on Development: This is the portion of the paper where your professional analysis of your observations are shared. Based on your evidence, what can you generally state regarding the cognitive, social and emotional, and physical development of this child? Include both information from your observations and from your interview— 1.5 pages
• Conclusion: What are the relative strengths and weaknesses of the family, the child? What could this child benefit from? Make any final remarks regarding the child’s overall development in this section.— 1page
• Your Case Study Narrative should be a minimum of 5 pages.

Make sure to NOT to use the child’s real name in the Narrative Report. You should make reference to course material, information from your textbook, and class supplemental materials throughout the paper . 

Same rules apply in terms of writing in objective language and only using subjective minimally. REMEMBER to CHECK your grammar, spelling, and APA formatting before submitting to your instructor. It is imperative that you review the rubric of this assignment as well before completing it. 

Biggest Mistakes Students Make on this Assignment

Here is a list of the biggest mistakes that students make on this assignment: 

• Failing to start early . The case study assignment is one that you will submit in parts throughout the semester. It is important that you begin your observations on the case study before the first assignment is due. Waiting to the last minute will lead to a poor grade on this assignment, which historically has been the case for students who have completed this assignment. 
• Failing to utilize the rubrics. The rubrics provide students with guidelines on what components are necessary for the assignment. Often students will lose points because they simply read the descriptions of the assignment but did not pay attention to rubric portions of the assignment. 
• Failing to use APA formatting and proper grammar and spelling. It is imperative that you use spell check and/or other grammar checking software to ensure that your narrative is written well. Remember it must be in APA formatting so make sure that you review the tutorials available for you on our Lib Guide that will assess you in this area. 
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• Case report
• Open access
• Published: 11 September 2017

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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We are also grateful to patient’s legal guardian for their support in writing this manuscript.

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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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Correspondence to Magdalena Romanowicz .

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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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DOI : https://doi.org/10.1186/s12888-017-1492-y

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Scenarios are snapshots of experiences in the professional practice of a Registered Early Childhood Educator. Each scenario includes a series of questions meant to help RECEs reflect on the situation.

Case Study 1: Sara’s Confusing Behaviour

Case study 2: getting bumps and taking lumps, case study 3: no qualified staff, case study 4: denton’s birthday cupcakes, case study 5: new kid on the block, case study 6: new responsibilities and challenges, case study 7: valuing inclusivity and privacy, case study 8: balancing supervisory responsibilities, case study 9: once we were friends, ​​​​scenarios​​, communication and collaboration.

Barbara, an RECE, is working as a supply staff at various centres across the city. During her week at a centre where she helps out in two different rooms each day, she finds that her experience in the school-age program isn’t as straightforward as when she was in the toddler room. Barbara feels completely lost in this program.

Do You Really Know Who Your Friends Are?

Joe is an RECE at an elementary school and works with children between the ages of nine and 12 years old. One afternoon, he finds a group of children huddled around the computer giggling and whispering. Joe quickly discovers they’re going through his party photos on Facebook as one of the children’s parents recently added him as a friend.

Conflicting Approaches

Amina, an experienced RECE, has recently started a new position with a child care centre. She’s assigned to work in the infant room with two colleagues who have worked in the room together for ten years. As Amina settles into her new role, she is taken aback by some of the child care approaches taken by her colleagues.

What to do about Lisa?

Shane, an experienced supervisor at a child care centre, receives a complaint about an RECE who had roughly handled a child earlier that day. The interaction had been witnessed by a parent who confronted the RECE. After some words were exchanged, the RECE left in tears.

Duty to Report

Zoë works as an RECE in a drop-in program at a family support centre. She has a great rapport for a family over a 10-month period and beings to notice a change in the mom and child. One day, as the child is getting dressed to go home for the day, she notices something alarming and brings it to the attention of her supervisor.

Posting on Social Media

Allie, an RECE who has worked at the same child care centre for the last three years, recently started a private social media group to collaborate and discuss programming ideas. As the group takes a negative turn with rude and offensive comments, it’s brought to her supervisor’s attention.

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Casebook: Developmentally Appropriate Practice in Early Childhood Programs Serving Children from Birth Through Age 8

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About the book.

• Make connections to the fourth edition of Developmentally Appropriate Practice in Early Childhood Programs 
• Think critically about the influence of context on educator, child, and family actions 
• Discuss the effectiveness of the teaching practices and how they might be improved 
• Support your responses with evidence from the DAP position statement and book 
• Explore next steps beyond the case details 
• Apply the learning to your own situation 

Table of Contents

• Editors, Contributors, and Reviewers
• Introduction and Book Overview | Jennifer J. Chen and Dana Battaglia
• 1.1 Missed Opportunities: Relationship Building in Inclusive Classrooms | Julia Torquati
• 1.2 “My Name Is Not a Shame” | Kevin McGowan
• 1.3 Fostering Developmentally Appropriate Practice Through Virtual Family Connections | Lea Ann Christenson
• 1.4 Counting Collections in Community | Amy Schmidtke
• 1.5 The Joy Jar: Celebrating Kindness | Leah Schoenberg Muccio
• 1.6 Prioritizing Listening to and Learning from Families | Amy Schmidtke 
• 2.1 Julio’s Village: Early Childhood Education Supports for Teen Parents | Donna Kirkwood
• 2.2 Healthy Boundaries: Listening to Children and Learning from Families | Jovanna Archuleta
• 2.3 Roadmap of Family Engagement to Kindergarten: An Ecological Systems Approach | Marcela Andrés
• 2.4 Taking Trust for Granted? The Importance of Communication and Outreach in Family Partnerships | Suzanna Ewert
• 2.5 Book Reading: Learning About Migration and Our Family Stories | Sarah Rendón García 
• 3.1 Pairing Standardized Scale with Observation | Megan Schumaker-Murphy
• 3.2 The Power of Observing Jordan | Marsha Shigeyo Hawley and Barbara Abel
• 3.3 “But What Is My Child Learning?” | Janet Thompson and Jennifer Gonzalez
• 3.4 Drawing and Dialogue: Using Authentic Assessment to Understand Children’s Sense of Self and Observe Early Literacy Skills | Brandon L. Gilbert
• 3.5 The ABCs of Kindergarten Registration: Assessment, Background, and Collaboration Between Home and School | Bridget Amory
• 3.6 Creating Opportunities for Individualized Assessment Activities for Biliteracy Development | Esther Garza
• 3.7 Observing Second-Graders’ Vocabulary Development | Marie Ann Donovan
• 3.8 Writing Isn’t the Only Way! Multiple Means of Expressing Learning | Lee Ann Jungiv 
• 4.1 Engaging with Families to Individualize Teaching | Marie L. Masterson 
• 4.2 Tumbling Towers with Toddlers: Intention and Decision Making Over Blocks | Ron Grady  
• 4.3 What My Heart Holds: Exploring Identity with Preschool Learners | Cierra Kaler-Jones 
• 4.4 “I See a Really Big Gecko!” When Background Knowledge and Teaching Materials Don’t Match | Germaine Kaleilehua Tauati and Colleen E. Whittingham 
• 4.5 Using a Humanizing and Restorative Approach for Young Children to Develop Responsibility and Self-Regulation | Saili S. Kulkarni, Sunyoung Kim, and Nicola Holdman 
• 4.6 Joyful, Developmentally Appropriate Learning Environments for African American Youth | Lauren C. Mims, Addison Duane, LaKenya Johnson, and Erika Bocknek 
• 5.1 Using the Environment and Materials as Curriculum for Promoting Infants’ and Toddlers’ Exploration of Basic Cause-and-Effect Principles | Guadalupe Rivas 
• 5.2 Social Play Connections Among a Small Group of Preschoolers | Leah Catching 
• 5.3 Can Preschoolers Code? A Sneak Peek into a Developmentally Appropriate Coding Lesson | Olabisi Adesuyi-Fasuyi 
• 5.4 Everyday Gifts: Children Show Us the Path—We Observe and Scaffold | Martha Melgoza 
• 5.5 Learning to Conquer the Slide Through Persistence and Engaging in Social Interaction | Sueli Nunes 
• 5.6 “Sabes que todos los caracoles pueden tener bebés? Do You Know that All Snails Can Have Babies?” Supporting Children’s Emerging Interests in a Dual Language Preschool Classroom | Isauro M. Escamilla 
• 5.7 “Can We Read this One?” A Conversation About Book Selection in Kindergarten | Larissa Hsia-Wong  
• 6.1 Take a Chance on Coaching: It’s Worth It! | Lauren Bond 
• 6.2 It Started with a Friendship Parade | Angela Vargas 
• 6.3 The World Outside of the Classroom: Letting Your Voice Be Heard | Meghann Hickey 
• 7.1 Communication as a Two-Way Street? Creating Opportunities for Engagement During Meaningful Language Routines | Kameron C. Cardenv 
• 7.2 Eli Goes to Preschool: Inclusion for a Child with Autism Spectrum Disorder | Abby Hodges
• 7.3 Preschool Classroom Supports and Embedded Interventions with Coteaching | Racheal Kuperus and Desarae Orgo
• 7.4 Addressing Challenging Behavior Using the Pyramid Model | Ellie Bold
• 7.5 Dual Language or Disability? How Teachers Can Be the First to Help | Alyssa Brillante
• 7.6 Adapting and Modifying Instruction Using Reader’s Theater | Michelle Gonzalez
• 7.7 Supporting Children with Learning Disabilities in Mathematics: The Importance of Observation, Content Knowledge, and Context | Renee B. Whelan 
• 8.1 Facilitating a Child’s Transition from Home to Group Care Through the Use of Cultural Caring Routines | Josephine Ahmadein
• 8.2 Engaging Dual Language Learners in Conversation to Support Translanguaging During a Small Group Activity | Valeria Erdosi and Jennifer J. Chen
• 8.3 Incorporating Children’s Cultures and Languages in Learning Activities | Eleni Zgourou
• 8.4 Adapting Teaching Materials for Dual Language Learners to Reflect Their Home Languages and Cultures in a Math Lesson | Karen Nemeth
• 8.5 Studying Celestial Bodies: Science and Cultural Stories | Zeynep Isik-Ercan
• 8.6 Respecting Diverse Cultures and Languages by Sharing and Learning About Cultural Poems, Songs, and Stories From Others | Janis Strasser

Book Details

Faculty resources.

To access tips and resources for teaching the cases, please complete this brief form.  You’ll be able to download the items after you complete the form. 

Teacher Inquiry Group Resources

To access reflection questions to deepen your learning, please click here.

More DAP Resources

To read the position statement, access related resources, and stay up-to-the-minute on all things DAP, visit  NAEYC.org/resources/developmentally-appropriate-practice .

Pamela Brillante,  EdD, is professor in the Department of Special Education, Professional Counseling and Disability Studies, at William Paterson University. She has worked as an early childhood special educator, administrator, and New Jersey state specialist in early childhood special education. She is the author of the NAEYC book The Essentials: Supporting Young Children with Disabilities in the Classroom. Dr. Brillante continues to work with schools to develop high-quality inclusive early childhood programs. 

Jennifer J. Chen, EdD, is professor of early childhood and family studies at Kean University. She earned her doctorate from Harvard University. She has authored or coauthored more than 60 publications in early childhood education. Dr. Chen has received several awards, including the 2020 NAECTE Foundation Established Career Award for Research on ECTE, the 2021 Kean Presidential Excellence Award for Distinguished Scholarship, and the 2022 NJAECTE’s Distinguished Scholarship in ECTE/ECE Award. 

Stephany Cuevas, EdD, is assistant professor of education in the Attallah College of Educational Studies at Chapman University. Dr. Cuevas is an interdisciplinary education scholar whose research focuses on family engagement, Latinx families, and the postsecondary trajectories of first-generation students. She is the author of Apoyo Sacrifical, Sacrificial Support: How Undocumented Parents Get Their Children to College (Teachers College Press). 

Christyn Dundorf, PhD, has more than 30 years of experience in the early learning field as a teacher, administrator, and adult educator. She serves as codirector of Teaching Preschool Partners, a nonprofit organization working to grow playful learning and inquiry practices in school-based pre-K programs and infuse those practices up into the early grades.

Emily Brown Hoffman, PhD, is assistant professor in early childhood education at National Louis University in Chicago. She received her PhD from the University of Illinois at Chicago in Curriculum & Instruction, Literacy, Language, & Culture. Her focuses include emergent literacy, leadership, play and creativity, and school, family, and community partnerships. 

Daniel R. Meier, PhD, is professor of elementary education at San Francisco State University. His publications include Critical Issues in Infant-Toddler Language Development: Connecting Theory to Practice (editor), Supporting Literacies for Children of Color: A Strength-Based Approach to Preschool Literacy (author), and Learning Stories and Teacher Inquiry Groups: Reimagining Teaching and Assessment in Early Childhood Education (coauthor). 

Gayle Mindes, EdD, is professor emerita, DePaul University. She is the author of Assessing Young Children , fifth edition (with Lee Ann Jung), and Social Studies for Young Children: Preschool and Primary Curriculum Anchor, third edition (with Mark Newman). Dr. Mindes is also the editor of Teaching Young Children with Challenging Behaviors: Practical Strategies for Early Childhood Educators and Contemporary Challenges in Teaching Young Children: Meeting the Needs of All Students . 

Lisa R. Roy, EdD, is executive director for the Colorado Department of Early Childhood. Dr. Roy has supported families with young children for over 30 years, serving as the director of program development for the Buffett Early Childhood Institute, as the executive director of early childhood education for Denver Public Schools, and in various nonprofit and government roles.

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Article Contents

Literature review, alive program, implications for school social work practice.

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Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program

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Jason Scott Frydman, Christine Mayor, Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program, Children & Schools , Volume 39, Issue 4, October 2017, Pages 238–247, https://doi.org/10.1093/cs/cdx017

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Middle-school-age children are faced with a variety of developmental tasks, including the beginning phases of individuation from the family, building peer groups, social and emotional transitions, and cognitive shifts associated with the maturation process. This article summarizes how traumatic events impair and complicate these developmental tasks, which can lead to disruptive behaviors in the school setting. Following the call by Walkley and Cox for more attention to be given to trauma-informed schools, this article provides detailed information about the Animating Learning by Integrating and Validating Experience program: a school-based, trauma-informed intervention for middle school students. This public health model uses psychoeducation, cognitive differentiation, and brief stress reduction counseling sessions to facilitate socioemotional development and academic progress. Case examples from the authors’ clinical work in the New Haven, Connecticut, urban public school system are provided.

Within the U.S. school system there is growing awareness of how traumatic experience negatively affects early adolescent development and functioning ( Chanmugam & Teasley, 2014 ; Perfect, Turley, Carlson, Yohannan, & Gilles, 2016 ; Porche, Costello, & Rosen-Reynoso, 2016 ; Sibinga, Webb, Ghazarian, & Ellen, 2016 ; Turner, Shattuck, Finkelhor, & Hamby, 2017 ; Woodbridge et al., 2016 ). The manifested trauma symptoms of these students have been widely documented and include self-isolation, aggression, and attentional deficit and hyperactivity, producing individual and schoolwide difficulties ( Cook et al., 2005 ; Iachini, Petiwala, & DeHart, 2016 ; Oehlberg, 2008 ; Sajnani, Jewers-Dailley, Brillante, Puglisi, & Johnson, 2014 ). To address this vulnerability, school social workers should be aware of public health models promoting prevention, data-driven investigation, and broad-based trauma interventions ( Chafouleas, Johnson, Overstreet, & Santos, 2016 ; Johnson, 2012 ; Moon, Williford, & Mendenhall, 2017 ; Overstreet & Chafouleas, 2016 ; Overstreet & Matthews, 2011 ). Without comprehensive and effective interventions in the school setting, seminal adolescent developmental tasks are at risk.

This article follows the twofold call by Walkley and Cox (2013) for school social workers to develop a heightened awareness of trauma exposure's impact on childhood development and to highlight trauma-informed practices in the school setting. In reference to the former, this article will not focus on the general impact of toxic stress, or chronic trauma, on early adolescents in the school setting, as this work has been widely documented. Rather, it begins with a synthesis of how exposure to trauma impairs early adolescent developmental tasks. As to the latter, we will outline and discuss the Animating Learning by Integrating and Validating Experience (ALIVE) program, a school-based, trauma-informed intervention that is grounded in a public health framework. The model uses psychoeducation, cognitive differentiation, and brief stress reduction sessions to promote socioemotional development and academic progress. We present two clinical cases as examples of trauma-informed, school-based practice, and then apply their experience working in an urban, public middle school to explicate intervention theory and practice for school social workers.

Impact of Trauma Exposure on Early Adolescent Developmental Tasks

Social development.

Impact of Trauma on Early Adolescent Development

Traumatic experiences may create difficulty with developing and differentiating another person's point of view (that is, mentalization) due to the formation of rigid cognitive schemas that dictate notions of self, others, and the external world ( Frydman & McLellan, 2014 ). For early adolescents, the ability to diversify a single perspective with complexity is central to modulating affective experience. Without the capacity to diversify one's perspective, there is often difficulty differentiating between a nonthreatening current situation that may harbor reminders of the traumatic experience and actual traumatic events. Incumbent on the school social worker is the need to help students understand how these conflicts may trigger a memory of harm, abandonment, or loss and how to differentiate these past memories from the present conflict. This is of particular concern when these reactions are conflated with more common middle school behaviors such as withdrawing, blaming, criticizing, and gossiping ( Card, Stucky, Sawalani, & Little, 2008 ).

Encouraging cognitive discrimination is particularly meaningful given that the second social developmental task for early adolescents is the re-orientation of their primary relationships with family toward peers ( Henderson & Thompson, 2010 ). This shift may become complicated for students facing traumatic stress, resulting in a stunted movement away from familiar connections or a displacement of dysfunctional family relationships onto peers. For example, in the former, a student who has witnessed and intervened to protect his mother from severe domestic violence might believe he needs to sacrifice himself and be available to his mother, forgoing typical peer interactions. In the latter, a student who was beaten when a loud, intoxicated family member came home might become enraged, anxious, or anticipate violence when other students raise their voices.

Cognitive Development and Emotional Regulation

During normative early adolescent development, the prefrontal cortex undergoes maturational shifts in cognitive and emotional functioning, including increased impulse control and affect regulation ( Wigfield, Lutz, & Wagner, 2005 ). However, these developmental tasks can be negatively affected by chronic exposure to traumatic events. Stressful situations often evoke a fear response, which inhibits executive functioning and commonly results in a fight-flight-freeze reaction. If a student does not possess strong anxiety management skills to cope with reminders of the trauma, the student is prone to further emotional dysregulation, lowered frustration tolerance, and increased behavioral problems and depressive symptoms ( Iachini et al., 2016 ; Saltzman, Steinberg, Layne, Aisenberg, & Pynoos, 2001 ).

Typical cognitive development in early adolescence is defined by the ambiguity of a transitional stage between childhood remedial capacity and adult refinement ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Casey and Caudle (2013) found that although adolescents performed equally as well as, if not better than, adults on a self-control task when no emotional information was present, the introduction of affectively laden social cues resulted in diminished performance. The developmental challenge for the early adolescent then is to facilitate the coordination of this ever-shifting dynamic between cognition and affect. Although early adolescents may display efficient and logically informed behaviors, they may struggle to sustain these behaviors, especially in the presence of emotional stimuli ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Because trauma often evokes an emotional response ( Johnson & Lubin, 2015 ), these findings insinuate that those early adolescents who are chronically exposed will have ongoing regulation difficulties. Further empirical findings considering the cognitive effects of trauma exposure on the adolescent brain have highlighted detriments in working memory, inhibition, memory, and planning ability ( Moradi, Neshat Doost, Taghavi, Yule, & Dalgleish, 1999 ).

Using a Public Health Framework for School-Based, Trauma-Informed Services

The need for a more informed and comprehensive approach to addressing trauma within the schools has been widely articulated ( Chafouleas et al., 2016 ; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011 ; Jaycox, Kataoka, Stein, Langley, & Wong, 2012 ; Overstreet & Chafouleas, 2016 ; Perry & Daniels, 2016 ). Overstreet and Matthews (2011) suggested that using a public health model to address trauma in schools will promote prevention, early identification, and data-driven investigation and yield broad-based intervention on a policy and communitywide level. A public health approach focuses on developing interventions that address the underlying causal processes that lead to social, emotional, and cognitive maladjustment. Opening the dialogue to the entire student body, as well as teachers and administrators, promotes inclusion and provides a comprehensive foundation for psychoeducation, assessment, and prevention.

ALIVE: A Comprehensive Public Health Intervention for Middle School Students

Note: ALIVE = Animating Learning by Integrating and Validating Experience.

Psychoeducation

The classroom is a place traditionally dedicated to academic pursuits; however, it also serves as an indicator of trauma's impact on cognitive functioning evidenced by poor grades, behavioral dysregulation, and social turbulence. ALIVE practitioners conduct weekly trauma-focused dialogues in the classroom to normalize conversations addressing trauma, to recruit and rehearse more adaptive cognitive skills, and to engage in an insight-oriented process ( Sajnani et al., 2014 ).

Using a parable as a projective tool for identification and connection, the model helps students tolerate direct discussions about adverse experiences. The ALIVE practitioner begins each academic year by telling the parable of a woman named Miss Kendra, who struggled to cope with the loss of her 10-year-old child. Miss Kendra is able to make meaning out of her loss by providing support for schoolchildren who have encountered adverse experiences, serving as a reminder of the strength it takes to press forward after a traumatic event. The intention of this parable is to establish a metaphor for survival and strength to fortify the coping skills already held by trauma-exposed middle school students. Furthermore, Miss Kendra offers early adolescents an opportunity to project their own needs onto the story, creating a personalized figure who embodies support for socioemotional growth.

Following this parable, the students’ attention is directed toward Miss Kendra's List, a poster that is permanently displayed in the classroom. The list includes a series of statements against adolescent maltreatment, comprehensively identifying various traumatic stressors such as witnessing domestic violence; being physically, verbally, or sexually abused; and losing a loved one to neighborhood violence. The second section of the list identifies what may happen to early adolescents when they experience trauma from emotional, social, and academic perspectives. The practitioner uses this list to provide information about the nature and impact of trauma, while modeling for students and staff the ability to discuss difficult experiences as a way of connecting with one another with a sense of hope and strength.

Furthermore, creating a dialogue about these issues with early adolescents facilitates a culture of acceptance, tolerance, and understanding, engendering empathy and identification among students. This fostering of interpersonal connection provides a reparative and differentiated experience to trauma ( Hartling & Sparks, 2008 ; Henderson & Thompson, 2010 ; Johnson & Lubin, 2015 ) and is particularly important given the peer-focused developmental tasks of early adolescence. The positive feelings evoked through classroom-based conversation are predicated on empathic identification among the students and an accompanying sense of relief in understanding the scope of trauma's impact. Furthermore, the consistent appearance of and engagement by the ALIVE practitioner, and the continual presence of Miss Kendra's list, effectively counters traumatically informed expectations of abandonment and loss while aligning with a public health model that attends to the impact of trauma on a regular, systemwide basis.

Participatory and Somatic Indicators for Informal Assessment during the Psychoeducation Component of the ALIVE Intervention

Notes: ALIVE = Animating Learning by Integrating and Validating Experience. Examples are derived from authors’ clinical experiences.

In addition to behavioral symptoms, the content of conversation is considered. All practitioners in the ALIVE program are mandated reporters, and any content presented that meets criteria for suspicion of child maltreatment is brought to the attention of the school leadership and ALIVE director. According to Johnson (2012) , reports of child maltreatment to the Connecticut Department of Child and Family Services have actually decreased in the schools where the program has been implemented “because [the ALIVE program is] catching problems well before they have risen to the severity that would require reporting” (p. 17).

Case Example 1

The following demonstrates a middle school classroom psychoeducation session and assessment facilitated by an ALIVE practitioner (the first author). All names and identifying characteristics have been changed to protect confidentiality.

Ms. Skylar's seventh grade class comprised many students living in low-income housing or in a neighborhood characterized by high poverty and frequent criminal activity. During the second week of school, I introduced myself as a practitioner who was here to speak directly about difficult experiences and how these instances might affect academic functioning and students’ thoughts about themselves, others, and their environment.

After sharing the Miss Kendra parable and list, I invited the students to share their thoughts about Miss Kendra and her journey. Tyreke began the conversation by wondering whether Miss Kendra lost her child to gun violence, exploring the connection between the list and the story and his own frequent exposure to neighborhood shootings. To transition a singular connection to a communal one, I asked the students if this was a shared experience. The majority of students nodded in agreement. I referred the students back to the list and asked them to identify how someone's school functioning or mood may be affected by ongoing neighborhood gun violence. While the students read the list, I actively monitored reactions and scanned for inattention and active avoidance. Performing both active facilitation of discussion and monitoring students’ reactions is critical in accomplishing the goals of providing quality psychoeducation and identifying at-risk students for intervention.

After inspection, Cleo remarked that, contrary to a listed outcome on Miss Kendra's list, neighborhood gun violence does not make him feel lonely; rather, he “doesn't care about it.” Slumped down in his chair, head resting on his crossed arms on the desk in front of him, Cleo's body language suggested a somatized disengagement. I invited other students to share their individual reactions. Tyreke agreed that loneliness is not the identified affective experience; rather, for him, it's feeling “mad or scared.” Immediately, Greg concurred, expressing that “it makes me more mad, and I think about my family.”

Encouraging a variety of viewpoints, I stated, “It sounds like it might make you mad, scared, and may even bring up thoughts about your family. I wonder why people have different reactions?” Doing so moved the conversation into a phase of deeper reflection, simultaneously honoring the students’ voiced experience while encouraging critical thinking. A number of students responded by offering connections to their lives, some indicating they had difficulty identifying feelings. I reflected back, “Sometimes people feel something, but can't really put their finger on it, and sometimes they know exactly how they feel or who it makes them think about.”

I followed with a question: “How do you think it affects your schoolwork or feelings when you're in school?” Greg and Natalia both offered that sometimes difficult or confusing thoughts can consume their whole day, even while in class. Sharon began to offer a related comment when Cleo interrupted by speaking at an elevated volume to his desk partner, Tyreke. The two began to snicker and pull focus. By the time they gained the class's full attention, Cleo was openly laughing and pushing his chair back, stating, “No way! She DID!? That's crazy”; he began to stand up, enlisting Tyreke in the process. While this disruption may be viewed as a challenge to the discussion, it is essential to understand all behavior in context of the session's trauma content. Therefore, Cleo's outburst was interpreted as a potential avenue for further exploration of the topic regarding gun violence and difficulties concentrating. In turn, I posed this question to the class: “Should we talk about this stuff? I wonder if sometimes people have a hard time tolerating it. Can anybody think of why it might be important? Sharon, I think you were saying something about this.” While Sharon continued to share, Cleo and Tyreke gradually shifted their attention back to the conversation. I noted the importance of an individual follow-up with Cleo.

Natalia jumped back in the conversation, stating, “I think we talk about stuff like this so we know about it and can help people with it.” I checked in with the rest of the class about this strategy for coping with the impact of trauma exposure on school functioning: “So it sounds like these thoughts have a pretty big impact on your day. If that's the case, how do you feel less worried or mad or scared?” Marta quickly responded, “You could talk to someone.” I responded, “Part of my job here is to be a person to talk to one-on-one about these things. Hopefully, it will help you feel better to get some of that stuff off your chest.” The students nodded, acknowledging that I would return to discuss other items on the list and that there would be opportunities to check in with me individually if needed.

On reflection, Cleo's disruption in the discussion may be attributed to his personal difficulty emotionally managing intrusive thoughts while in school. This clinical assumption was not explicitly named in the moment, but was noted as information for further individual follow-up. When I met individually with Cleo, Cleo reported that his cousin had been shot a month ago, causing him to feel confused and angry. I continued to work with him individually, which resulted in a reduction of behavioral disruptions in the classroom.

In the preceding case example, the practitioner performed a variety of public health tasks. Foremost was the introduction of how traumatic experience may affect individuals and their relationships with others and their role as a student. Second, the practitioner used Miss Kendra and her list as a foundational mechanism to ground the conversation and serve as a reference point for the students’ experience. Finally, the practitioner actively monitored individual responses to the material as a means of identifying students who may require more support. All three of these processes are supported within the public health framework as a means toward assessment and early intervention for early adolescents who may be exposed to trauma.

Individualized Stress Reduction Intervention

Students are seen for individualized support if they display significant externalizing or internalizing trauma-related behavior. Students are either self-referred; referred by a teacher, administrator, or staff member; or identified by an ALIVE practitioner. Following the principle of immediate engagement based on emergent traumatic material, individual sessions are brief, lasting only 15 to 20 minutes. Using trauma-centered psychotherapy ( Johnson & Lubin, 2015 ), a brief inquiry addressing the current problem is conducted to identify the trauma trigger connected to the original harm, fostering cognitive discrimination. Conversation about the adverse experience proceeds in a calm, direct way focusing on differentiating between intrusive memories and the current situation at school ( Sajnani et al., 2014 ). Once the student exhibits greater emotional regulation, the ALIVE practitioner returns the student to the classroom in a timely manner and may provide either brief follow-up sessions for preventive purposes or, when appropriate, refer the student to more regular, clinical support in or out of the school.

Case Example 2

The following case example is representative of the brief, immediate, and open engagement with traumatic material and encouragement of cognitive discrimination. This intervention was conducted with a sixth grade student, Jacob (name and identifying information changed to ensure confidentiality), by an ALIVE practitioner (the second author).

I found Jacob in the hallway violently shaking a trash can, kicking the classroom door, and slamming his hands into the wall and locker. His teacher was standing at the door, distressed, stating, “Jacob, you need to calm down and go to the office, or I'm calling home!” Jacob yelled, “It's not fair, it was him, not me! I'm gonna fight him!” As I approached, I asked what was making him so angry, but he said, “I don't want to talk about it.” Rather than asking him to calm down or stop slamming objects, I instead approached the potential memory agitating him, stating, “My guess is that you are angry for a very good reason.” Upon this simple connection, he sighed and stopped kicking the trash can and slamming the wall. Jacob continued to demonstrate physical and emotional activation, pacing the hallway and making a fist; however, he was able to recount putting trash in the trash can when a peer pushed him from behind, causing him to yell. Jacob explained that his teacher heard him yelling and scolded him, making him more mad. Jacob stated, “She didn't even know what happened and she blamed me. I was trying to help her by taking out all of our breakfast trash. It's not fair.”

The ALIVE practitioner listens to students’ complaints with two ears, one for the current complaint and one for affect-laden details that may be connected to the original trauma to inquire further into the source of the trigger. Affect-laden details in case example 2 include Jacob's anger about being blamed (rather than toward the student who pushed him), his original intention to help, and his repetition of the phrase “it's not fair.” Having met with Jacob previously, I was aware that his mother suffers from physical and mental health difficulties. When his mother is not doing well, he (as the parentified child) typically takes care of the household, performing tasks like cooking, cleaning, and helping with his two younger siblings and older autistic brother. In the past, Jacob has discussed both idealizing his mother and holding internalized anger that he rarely expresses at home because he worries his anger will “make her sick.”

I know sometimes when you are trying to help mom, there are times she gets upset with you for not doing it exactly right, or when your brothers start something, she will blame you. What just happened sounds familiar—you were trying to help your teacher by taking out the garbage when another student pushed you, and then you were the one who got in trouble.

Jacob nodded his head and explained that he was simply trying to help.

I moved into a more detailed inquiry, to see if there was a more recent stressor I was unaware of. When I asked how his mother was doing this week, Jacob revealed that his mother's health had deteriorated and his aunt had temporarily moved in. Jacob told me that he had been yelled at by both his mother and his aunt that morning, when his younger brother was not ready for school. I asked, “I wonder if when the student pushed you it reminded you of getting into trouble because of something your little brother did this morning?” Jacob nodded. The displacement was clear: He had been reminded of this incident at school and was reacting with anger based on his family dynamic, and worries connected to his mother.

My guess is that you were a mix of both worried and angry by the time you got to school, with what's happening at home. You were trying to help with the garbage like you try to help mom when she isn't doing well, so when you got pushed it was like your brother being late, and then when you got blamed by your teacher it was like your mom and aunt yelling, and it all came flooding back in. The problem is, you let out those feelings here. Even though there are some similar things, it's not totally the same, right? Can you tell me what is different?

Jacob nodded and was able to explain that the other student was probably just playing and did not mean to get him into trouble, and that his teacher did not usually yell at him or make him worried. Highlighting this important differentiation, I replied, “Right—and fighting the student or yelling at the teacher isn't going to solve this, but more importantly, it isn't going to make your mom better or have your family go any easier on you either.” Jacob stated that he knew this was true.

I reassured Jacob that I could help him let out those feelings of worry and anger connected to home so they did not explode out at school and planned to meet again. Jacob confirmed that he was willing to do that. He was able to return to the classroom without incident, with the entire intervention lasting less than 15 minutes.

In case example 2, the practitioner was available for an immediate engagement with disturbing behaviors as they were happening by listening for similarities between the current incident and traumatic stressors; asking for specific details to more effectively help Jacob understand how he was being triggered in school; providing psychoeducation about how these two events had become confused and aiding him in cognitively differentiating between the two; and, last, offering to provide further support to reduce future incidents.

Germane to the practice of school social work is the ability to work flexibly within a public health model to attend to trauma within the school setting. First, we suggest that a primary implication for school social workers is not to wait for explicit problems related to known traumatic experiences to emerge before addressing trauma in the school, but, rather, to follow a model of prevention-assessment-intervention. School social workers are in a unique position within the school system to disseminate trauma-informed material to both students and staff in a preventive capacity. Facilitating this implementation will help to establish a tone and sharpened focus within the school community, norming the process of articulating and engaging with traumatic material. In the aforementioned classroom case example, we have provided a sample of how school social workers might work with entire classrooms on a preventive basis regarding trauma, rather than waiting for individual referrals.

Second, in addition to functional behavior assessments and behavior intervention plans, school social workers maintain a keen eye for qualitative behavioral assessment ( National Association of Social Workers, 2012 ). Using this skill set within a trauma-informed model will help to identify those students in need who may be reluctant or resistant to explicitly ask for help. As called for by Walkley and Cox (2013) , we suggest that using the information presented in Table 1 will help school social workers understand, identify, and assess the impact of trauma on early adolescent developmental tasks. If school social workers engage on a classroom level in trauma psychoeducation and conversations, the information in Table 3 may assist with assessment of children and provide a basis for checking in individually with students as warranted.

Third, school social workers are well positioned to provide individual targeted, trauma-informed interventions based on previous knowledge of individual trauma and through widespread assessment ( Walkley & Cox, 2013 ). The individual case example provides one way of immediately engaging with students who are demonstrating trauma-based behaviors. In this model, school social workers engage in a brief inquiry addressing the current trauma to identify the trauma trigger, discuss the adverse experience in a calm but direct way, and help to differentiate between intrusive memories and the current situation at school. For this latter component, the focus is on cognitive discrimination and emotional regulation so that students can reengage in the classroom within a short time frame.

Fourth, given social work's roots in collaboration and community work, school social workers are encouraged to use a systems-based approach in partnering with allied practitioners and institutions ( D'Agostino, 2013 ), thus supporting the public health tenet of establishing and maintaining a link to the wider community. This may include referring students to regular clinical support in or out of the school. Although the implementation of a trauma-informed program will vary across schools, we suggest that school social workers have the capacity to use a public health school intervention model to ecologically address the psychosocial and behavioral issues stemming from trauma exposure.

As increasing attention is being given to adverse childhood experiences, a tiered approach that uses a public health framework in the schools is necessitated. Nevertheless, there are some limitations to this approach. First, although the interventions outlined here are rooted in prevention and early intervention, there are times when formal, intensive treatment outside of the school setting is warranted. Second, the ALIVE program has primarily been implemented by ALIVE practitioners; the results from piloting this public health framework in other school settings with existing school personnel, such as school social workers, will be necessary before widespread replication.

The public health framework of prevention-assessment-intervention promotes continual engagement with middle school students’ chronic exposure to traumatic stress. There is a need to provide both broad-based and individualized support that seeks to comprehensively ameliorate the social, emotional, and cognitive consequences on early adolescent developmental milestones associated with traumatic experiences. We contend that school social workers are well positioned to address this critical public health issue through proactive and widespread psychoeducation and assessment in the schools, and we have provided case examples to demonstrate one model of doing this work within the school day. We hope that this article inspires future writing about how school social workers individually and systemically address trauma in the school system. In alignment with Walkley and Cox (2013) , we encourage others to highlight their practice in incorporating trauma-informed, school-based programming in an effort to increase awareness of effective interventions.

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Case studies in child welfare

About this guide, child welfare case studies, real-life stories, and scenarios, social services and organizational case studies, other case studies, using case studies.

This guide is intended as a supplementary resource for staff at Children's Aid Societies and Indigenous Well-being Agencies. It is not intended as an authority on social work or legal practice, nor is it meant to be representative of all perspectives in child welfare. Staff are encouraged to think critically when reviewing publications and other materials, and to always confirm practice and policy at their agency.

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.

• Real cases project Three case studies, drawn from the New York City Administration for Children's Services. Website also includes teaching guides
• Protective factors in practice vignettes These vignettes illustrate how multiple protective factors support and strengthen families who are experiencing stress. From the National Child Abuse Prevention Month website
• Child welfare case studies and competencies Each of these cases was developed, in partnership, by a faculty representative from an Alabama college or university social work education program and a social worker, with child welfare experience, from the Alabama Department of Human Resources

• Immigration in the child welfare system: Case studies Case studies related to immigrant children and families in the U.S. from the American Bar Association
• White privilege and racism in child welfare scenarios From the Center for Advanced Studies in Child Welfare more... less... https://web.archive.org/web/20190131213630/https://cascw.umn.edu/wp-content/uploads/2013/12/WhitePrivilegeScenarios.pdf
• You decide: Would you remove these children from their families? Interactive piece from the Australian Broadcasting Corporation featuring cases based on real-life situations
• A case study involving complex trauma This case study complements a series of blog posts dedicated to the topic of complex trauma and how children learn to cope with complex trauma
• Fostering and adoption: Case studies Four case studies from Research in Practice (UK)
• Troubled families case studies This document describes how different families in the UK were helped through family intervention projects
• Parenting case studies From of the Pennsylvania Child Welfare Resource Center's training entitled "Understanding Reactive Attachment Disorder"
• Children’s Social Work Matters: Case studies Collections of narratives and case studies

• Race for Results case studies Series of case studies from the Annie E. Casey Foundation looking at ways of addressing racial inequities and supporting better outcomes for racialized children and communities
• Systems of care implementation case studies This report presents case studies that synthesize the findings, strategies, and approaches used by two grant communities to develop a principle-guided approach to child welfare service delivery for children and families more... less... https://web.archive.org/web/20190108153624/https://www.childwelfare.gov/pubPDFs/ImplementationCaseStudies.pdf
• Child Outcomes Research Consortium: Case studies Case studies from the Child Outcomes Research Consortium, a membership organization in the UK that collects and uses evidence to improve children and young people’s mental health and well-being
• Social work practice with carers: Case studies
• Social Care Institute for Excellence: Case studies
• Learning to address implicit bias towards LGBTQ patients: Case scenarios [2018] more... less... https://web.archive.org/web/20190212165359/https://www.lgbthealtheducation.org/wp-content/uploads/2018/10/Implicit-Bias-Guide-2018_Final.pdf
• Using case studies to teach
• Last Updated: Aug 12, 2022 11:21 AM
• URL: https://oacas.libguides.com/case-studies

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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 – 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

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 – 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 – 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 – 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 - 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 – 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 – 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 – 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 – 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 - 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 - 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 – 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 – 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 - 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 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 – 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 - 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 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 Darwen Blackpool 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 – 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 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 – 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 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 – 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 – 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 - 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 - 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 - 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 – 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 - 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 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 – 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 – 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 - 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 - 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 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 - 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 – 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 – 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 – 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 – 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 – 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 – 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

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 – 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

Serious physical harm and neglect of a 6-month-old baby by their parents in January 2017. JS was born prematurely to teenage parents supported through the Family Nurse Programme.  Learning for professionals includes: recognise when a multi-agency approach is needed and what support may be needed; consider whether their service is best placed to deal with the presenting issue; follow guidance, protocols and procedures; share information; be able to recognise a safeguarding concern and access supervision from safeguarding lead; challenge robustly when parents do not listen to advice and instructions or administer medication which is not approved for a child; consider whether all children who attend A&E with excessive drowsiness without an immediately identifiable cause should have their urines sent for toxicology. Recommendations include: ensure that pre-birth protocol is embedded and used in all appropriate cases; ensure that thresholds are properly understood; ensure that health partners have in place robust provisions for supervision and ‘did not attend’ (DNA) policies; roll out a neglect identification tool; launch a prevention campaign aimed at parents and carers about the safe handling and storage of drugs. Model: uses a systems review methodology. Keywords: child abuse identification, child neglect, information sharing, inter-agency cooperation, newborn babies, teenage parents > Read the overview report

2020 – Sandwell – Child NS

Death of a 2-month-old child due to asphyxiation. Mother found Child NS lifeless in the bed beside her after waking up following a night out. Learning includes: information about all members of the family should be sought from GPs during assessments and conferences; assessments of a child’s needs should consider any additional needs of siblings; and practitioners need to bear in mind that parents might not disclose key information. Recommendations include: improve the effectiveness of informing parents about the dangers of co-sleeping; consider how to promote the wellbeing of all immediate family members who have experienced a neonatal death; and consider how to ensure the needs of siblings are considered collectively as well as individually. Keywords: disguised compliance, infant deaths, pregnancy, professional curiosity, siblings, sleeping behaviour > Read the overview report

2020 – Sefton – Beatrice

Injuries to an 8-week-old girl in 2019. Beatrice was taken to a walk-in centre concerning a rash and was found to have unexplained bruising. An ambulance was called and Beatrice was taken to hospital where scans showed 13 fractures to ribs and legs of differing ages. Learning: local authorities should liaise around support to care leavers living across boundaries; where there is a history as a care leaver, background information should be sought from the responsible authority; police should take a more holistic view of a person's circumstances and consider information sharing to protect a child, even in cases where the child is not yet born. Recommendations: agencies working with care leavers must be aware of the right for care leavers for service provision up to the age of 25-years-old; request guidance on information sharing between local authorities where care leavers are not living in the area of the responsible authority; ensure information sharing policies are in place and include all cases, not just those managed under formal child protection procedures. Keywords: injuries, asperger’s syndrome, suicide, mental health, parenting capacity, professional curiosity > Read the overview report

2020 – Sheffield – Archie

Death of a 15-year-old boy in May 2018. Archie was fatally stabbed by another young person. Learning: embedded in the recommendations but also includes: impact of bereavement must not be underestimated. Recommendations: when a parent elects to home educate their child, the local authority should seek reassurances that the child is receiving a balanced education, including a home visit for an assessment by a trained professional; local authority must develop and communicate a clear escalation process for children not on school roll; ensure that structures are in place to assess, refer and intervene with vulnerable people who may be exploited by gangs and organised crime groups; implement child protection conferences that assess risk and develop plans in line with increased understanding of contextual safeguarding. Keywords: adolescent boys, child deaths, bereavement, child criminal exploitation, home education > Read the overview report

2020 – Solihull – SC17 Unborn Baby A

Death of an unborn baby due to suicide of the mother who was 37-week pregnant in April 2019. Learning: identifies strong practice, particularly in relation to prompt follow up when the mother did not attend or could not be contacted by the midwife, social worker and housing officer. Recommendations: substance misuse midwifery team should consider informing women on the substance misuse pathway that a positive toxicology result will lead to a referral to social care at the point of testing; conduct a review analysing current referral processes and pathways. Keywords: suicide, substance misuse, pregnancy, partner violence > Read the overview report

2020 – Southampton – Freddie

Sexual abuse of a boy under 8-years-old from January 2014 to October 2016. Learning: includes: importance of management support and supervision when working with intrafamilial child sexual abuse; the value of seeking additional input from specialised services in helping professionals remain objective and child focused; not letting biases of professionals towards parents hamper judgements and undermine decision making. Recommendations: ensure that the plans for children subject to child protection plans are fit for purpose and have pace; examine blocks and barriers to effective multi-agency work around the issue of child sexual abuse; and increase the knowledge and confidence of practitioners in assessing and working with cases involving child sexual abuse. Keywords: child sexual abuse, harmful sexual behaviour, child neglect, physical abuse, interagency collaboration > Read the overview report

2020 – South Gloucestershire – Toby

Death of a 5-week-old infant boy in January 2018. Cause of death was initially assumed to be sudden infant death syndrome (SIDS), but the post-mortem found numerous rib fractures and evidence of non-accidental head injury. Learning: lack of collaborative working between health professionals has an impact on information sharing and parents’ and children’s vulnerabilities not being properly understood or responded to; a lack of clarity within health agencies about why information is being shared, what to do with it and whether to follow it up results in ineffectual information sharing. Recommendations: develop systems and tools to enable midwives to facilitate the reporting of low-level concerns such as maternal presentation; observations about father’s presence, interaction with baby and professionals and their role in parenting should be routine; improve the capacity for midwives to work in a continuity of care model, especially where additional needs are known or suspected. Keywords: infant death, fractures, physical abuse, non-accidental head injuries, midwives. > Read the overview report

2020 – St Helens – Child B

Disclosure by a 14-year-old girl in January 2019 of four offences of rape by an adult male. Learning relates to: the multi-agency sexual exploitation process; child in need/child protection; the significance of neglect as a factor which underlies adolescent vulnerability; bullying; early intervention to prevent child sexual exploitation; information sharing; school nurse involvement; safeguarding roles and responsibilities; public awareness of child exploitation; the voice of the child. Recommendations: ensure that children and young people assessed as at high or medium risk of sexual exploitation are immediately flagged on the information systems of all agencies who are in contact with them; ensure that the support provided to children and young people at risk of sexual exploitation also considers the current and future needs of younger siblings living in the same household. Keywords: rape, disclosure, grooming, bullying, assessment of children, child sexual exploitation > Read the overview report

2020 – Staffordshire – Child D

Death of a 6-week-old infant in April 2014. Both parents received prison sentences for offences of child cruelty and causing or allowing the death of Child D in 2019. Learning: identifies no specific learning regarding predisposing factors, known needs or risk factors relating to the family that would have raised concerns to a level that would have led to different level of intervention being offered or undertaken.  Recommendations include: ensure that midwifery, health visiting and early help assessment records include a standard section that prompts practitioners to ask questions about whether either parent or carer has any other children and if so the level of contact held with their children. Keywords: sudden infant deaths, injuries, health visitors, contact > Read the overview report

2020 – Suffolk - Young Person Mary

Death of a 13-year-old girl in February 2018 following a severe asthma attack. Her brother had died seven years before, aged 9-years-old, also following an asthma attack. Learning includes: the way in which agencies and organisations recognise, respond to and manage long term life-threatening but common conditions such as asthma needs to be improved; highly articulate, plausible, and manipulative parents require confident and assertive practice, and a focus on the core issues; professionals need to act in the child's best interests and consider what their life (in all aspects) is like; professionals must challenge parental assertions, views, and behaviours from a child-centred viewpoint; parental views should not override evidence-based concerns; agencies need to coordinate or communicate sufficiently to fully understand what the issues are; failures by parents to comply with advice in relation to health care issues should be treated as a safeguarding matter, which triggers child protection processes, as necessary. Recommendations include: improve the way long term conditions are managed such as evidencing in health records that every missed appointment matters holistically; supervisors focus on and audit the degree of assertive practice evidenced by practitioners in a case, and ensure staff are trained and supported in terms of their practice with challenging or plausible parents and carers; introduce better approaches to utilise contextual and historical information in assessing cases when multiple agencies are involved; and that the focus on assessing the risk of harm is changed from an incident focussed approach to a context focussed one. Keywords: child deaths, children with a chronic illness, family conflict, home environment, medical care neglect > Read the overview report

2020 – Sunderland – Baby Kate

Death of a 10-month-old girl, Baby Kate, who died four days after admission to hospital with a serious head injury. Medical investigations also revealed a second injury. Learning includes: practitioners finding limitations in available pathways; systems and practices struggling to deal with the nature of domestic abuse and coercive control; the need to equip practitioners with training and tools to assist in dealing with disguised compliance; the need to consider risks to children as part of a wider picture recognising the full impact of abusive situations. Recommendations include: consider how domestic violence perpetrator work is incorporated as an action into child protection plans; ensure practitioners understand coercive control, and that tools and processes are in place that support in evidencing and acting upon concerns; regional medical practices consider how information on adult patients is shared within ongoing safeguarding children processes. Keywords: infants, non-accidental head injuries, disguised compliance, partner violence > Read the overview report

2020 – Surrey – Child A

Death of a 4-week-old infant in April 2017. Cause of death was identified as sudden unexpected death in infancy (SUDI) associated with co-sleeping. Learning includes: services thinking about children within the context of their family and being mindful of repeat patterns of behaviour within families; professionals recognising when parental deflection may create risk for a child; professionals being aware of indicators of abuse and understanding when to share information about these indicators. Recommendations include: ensure school staff have training on indicators of abuse and have the competencies to safeguard children; information sharing training should include the directive that when parents do not give permission to share information, staff should consider if a child is at risk of harm before a decision to not share information is made; when there is disparity between parent’s views and those of their children, professionals should maintain focus on the child. Keywords: infant deaths, sudden infant death, sleeping behaviour, siblings, single parent families > Read the overview report

2020 – Surrey – Child G

Review of the support received by Child G between 2014 and 2019, including in relation to allegations of sexual abuse by her special guardian in August 2018. Learning includes: communication challenges across partnerships working with a family with multi-faceted needs; the Special Guardianship Order report and recommendation was not subject to sufficient scrutiny; the need for professionals to be aware of the possibility of trauma and current abuse, in children presenting with distress and high levels of disturbance; delays to accessing therapeutic support. Recommendations include: ensure that family support is consistently applied and not stepped back due to resource pressures; ensure there are mechanisms to review caseload size and social work shortages; review of processes for undertaking Special Guardianship assessments; review training on trauma-informed practice and sexual abuse. Keywords: special guardianship orders, child sexual abuse, voice of the child, child neglect, sex offender, disclosure > Read the overview report

2020 – Surrey – Children HH, II and JJ

Sexual assault of a child and possession of indecent images in August 2015. Learning: the lack of certainty in the assessment of those who access indecent images of children; the danger of relying on earlier assessments without reviewing them with agencies involved; the importance of identifying what changes in an offender or their situation might lead to that offender being assessed as presenting a greater risk of carrying out harmful behaviour. Recommendations: work with other bodies to review the approach to families in which a member has committed offences in relation to online indecent images of children; ensure that professional staff have sufficient skills and knowledge to work with those who access indecent images of children online and their families. Keywords: abusive fathers, child abuse images, child sexual abuse, sexually abusive parents, risk assessment, internet > Read the overview report

2020 – Surrey – Baby KK

Death of a 9-month-old infant, from heart failure and chest infection in April 2016. Baby KK was born prematurely and experienced health problems including bronchiolitis, sepsis and injuries requiring nine hospital admissions during his life. Learning: need for understanding of roles in partnership working relationships so that opportunities for review and assessment of a child's needs are not missed; tendency for hospital professionals to focus on the presenting illness or injury and not to consider other explanations; limited involvement of hospital professionals in safeguarding work; reluctance of general practitioners to refer directly to children’s social care; and the fluctuating nature of neglect and the inconsistent ability of parents may undermine professionals’ ability to see and respond to neglectful parenting. Recommendations: makes no recommendations but poses several considerations for the safeguarding board and partner agencies for the eight findings identified. Model: uses the SCIE Learning Together model for case reviews, a systems approach which provides a theory and method for understanding why good and poor practice occur. Keywords: infant deaths, child neglect, information sharing, parenting capacity, family violence, professional curiosity > Read the overview report

2020 – Surrey – Baby LL

Death of a 4-month-old boy in May 2016. The post mortem identified the cause of death as acute pneumonia. Learning includes: issues of professional psychiatric opinion undermining social workers' views on the risks posed by parents; the need for consistent safeguarding practices in paediatric and accident and emergency teams, so that opportunities to identify hidden injuries are not missed; professionals sharing information on the presenting evidence, but not always clearly communicating underlying concerns and relevant historical information; GPs should have access to the records of family members to understand a family's history and be aware of risk factors and past child protection concerns; the importance of professionals understanding financial challenges faced by families, and identifying risks that financial pressures may pose to children. Recommendations: makes no recommendations. Model: uses SCIE Learning Together systems model. Keywords: infant deaths, siblings, child neglect, parental capacity, history > Read the overview report

2020 – Surrey – Family M

Serious harm and sexual abuse of children whilst living with a relative under a Special Guardianship Order. The review concerns six children, of whom four were removed from one situation where they were likely to suffer significant harm to another situation where they experienced severe abuse. Learning: the need to share information across the multi-agency network; practitioners need to be equipped to undertake assessments which include hearing the voice of the child, understanding the meaning of a child’s behaviour, and maintaining professional curiosity; friends and family assessments should always include consideration of the impact of placement on all children in the household. Recommendations: ensure that there is a focus on the voice and lived experience of children in assessments and interventions; consider the child’s history, the history of their care givers and the motivation underlying their application to look after the child; the Safeguarding Children Partnership should work with partner agencies to develop a strategy on recognising and working with child sexual abuse within the family; and agencies should evaluate their supervision systems and provide an opportunity for practitioners to analyse complex family situations. Keywords: special guardianship orders, kinship foster care, voice of the child, deception, professional curiosity, information sharing, child abuse > Read the overview report

2020 – Sutton – Child O

Serious harm suffered by a 11-week-old baby boy as a result of head injury indicative of abusive trauma in October 2016. Learning: focuses on the following themes: timely record keeping and information sharing, including relevant past histories; engagement with fathers, young people and hard to reach individuals, including at or below the child in need threshold; high quality, reflective, restorative supervision and management oversight; planning to achieve outcomes; professional scepticism/challenge; adherence to agency and multi-agency policy, procedures and good practice in a timely way, especially when dealing with new born babies; consider the impact of adverse childhood experiences; incorporate family culture and context into assessments; quality assurance of supervision for health providers. Recommendations include: ensure the needs and risks of new born babies are given sufficient attention in their own right; promote restorative practice; seek multi-agency involvement before closing a child in need case. Keywords: supervision, record keeping, parenting capacity, non-attendance, non-accidental head injury, newborn babies > Read the overview report

2020 – Sutton – Child T

Death of a 17-year-old boy by suicide in November 2019. Learning includes: there needs to be a personalised approach to identifying a child's needs, to ensure that children with autism spectrum disorders (ASD) and conduct disorders are effectively safeguarded within education settings; it is crucial for services to listen to the child and to question the child's field of perception. Recommendations include: promote a family-based practice model across the safeguarding partnership that is underpinned by trauma informed, contextual and restorative principles; ensure that the SEND partnership conducts a review to address the issues holistically before consideration of an exclusion; challenge agencies and partnerships in how they listen to young people for transition to adult services. Keywords: suicide, adolescent boys, autism, listening, transition to adulthood > Read the overview report

2020 – Swindon – Child G

Death of a 10-week-old baby boy in March 2017. Child G was a twin, born prematurely and spent the first six weeks of his life in hospital. When discharged the twins lived with their mother and father, and older half sibling (Child I) and Mr B, Child I’s father who pleaded guilty to the manslaughter of Child G. Learning includes: evidence that there was a potential systemic weakness in the way that information about unborn babies is sought and shared; professionals should always be alert to the possibility that family members may not always tell the truth. Recommendations include: ensuring that staff use the correct unambiguous terminology; professionals should consider consulting with the GP's of parents as this will avoid missing information on parental mental health and parenting capacity; professionals should document and share any history of risk/vulnerability when making referrals and providing or seeking information. Model: sets out findings using the Welsh Model methodology. Keywords: infant deaths, premature infants, professional curiosity, non-accidental head injuries, family violence, disguised compliance > Read the overview report

2020 – Tameside – Child V

Significant non-accidental head injuries to a 7-week-old infant in 2018, attributed to shaking. Learning: focuses on the following themes: preventing abusive head trauma; opportunities to consider safeguarding in health appointments pre- and post-birth; information sharing to enable wider safeguarding. Recommendations include: explore opportunities locally for professionals to be more aware of the significance of adverse childhood experiences and the importance of proactive professional enquiry regarding family histories. Model: uses the Welsh Child Practice Review model. Keywords: infants, shaking, physical abuse, adverse childhood experiences > Read the overview report

2020 – Thurrock – Frankie

Death of a 15-year-old boy in the summer of 2018. Frankie was fatally stabbed when attacked by a group of adolescent males in London. Learning and recommendations are integrated and include: ensure timely notifications to relevant persons when a child dies outside of the area in which they reside; improve notification processes for agencies when a child becomes the subject of a child in need plan; review permanent exclusion processes within schools to reduce the potential for safeguarding risks to children at risk of exclusion; understand how to incorporate the concept of contextual safeguarding in the assessment of risk to children in the future; evaluate how partner agencies support families affected by gang association; assess how partner agencies share intelligence related to gang affiliations; recommendation made to the National Child Safeguarding Practice Review Panel to consider a national thematic review because of the prevalence of similar incidents across the country. Keywords: murder, adolescent boys, social work, crime, exclusion from school, information sharing > Read the overview report

2020 – Thurrock – Sam and Kyle

Death of a 2-year-old boy in January 2018. Cause of death was unascertained. Sam’s older sibling Kyle was placed on a child protection plan after Sam’s death, and subsequently placed in foster care. Learning: there is an impression of agencies working in silos rather than developing a shared understanding of the case; professionals concentrated on their own engagement with parents and their compliance, rather than attempting to place the child at the centre. Recommendations: review procedure for the escalation of concerns and for resolving differences of view between professionals and agencies; explore better co-operation between agencies when handling complex or persistent cases; review inter-agency procedures for establishing agreement with families of written care plans. Keywords: child deaths, information sharing, teenage pregnancy, parenting capacity, neglect identification, voice of the child, siblings > Read the overview report

2020 – Walsall – Alex

Significant injuries to an 11-month-old boy. Alex was admitted to hospital with cardiac and respiratory failure from suspected non-accidental injuries. Learning: expediting social work assessment timescales may impact the quality of assessments; children who are looked after may be at risk of harm and being in foster or connected care does not automatically mean safety; professionals should recognise the difference between various fostering arrangements and prioritise visits and reviews accordingly. Recommendations: assessments for connected carers should include a thorough review of family dynamics and explore motivations to care for children; ensure that unannounced visits to connected carer placements are undertaken during the assessment phase and post placement; when children are placed in another local authority, social workers should seek support from where the child has been placed and reciprocate arrangements with other local authorities; that recommendations are raised with the Family Justice Board and the Department for Education. Keywords: infants, injuries, children in care, kinship foster care, assessment > Read the overview report

2020 – Waltham Forest – Child C

Death of a 14-year-old boy in January 2019. Child C was stabbed by four men, one of whom was sentenced to life imprisonment. Learning: time spent out of school constitutes a significant risk to children who are vulnerable, and the current arrangements governing home education contribute to this risk; failure to capitalise on a ‘reachable’ moment for a child who was being criminally exploited. Recommendations: government to review the guidance on home education; implementation of a national system for responding to exploitation of children by county lines gangs; and a review of arrangements for recovering children to ensure they are brought back by adults with skills relevant to working with children who are being criminally exploited. Keywords: child criminal exploitation, child deaths, adolescent boys, exclusion from school, home education, information sharing > Read the overview report

2020 – Waltham Forest – Child D

Unexplained death of a 4-month-old baby boy in November 2018. Learning includes: assessing the needs and risks of families experiencing domestic abuse is a complex task; some practitioners are still not confident about using escalation; practitioners don’t always record important information which results in significant information not being shared when required; there is a tendency for some practitioners to minimise the significance of parents using alcohol and being over optimistic about reports by parents of their alcohol consumption. Recommendations: makes no recommendations but raises questions to Newham Safeguarding Children Partnership and Waltham Forest Safeguarding Children Board. Keywords: infant deaths, partner violence, alcohol misuse, information sharing, optimistic behaviour > Read the overview report

2020 – Waltham Forest – Khalsa

Unexpected death from bronchial asthma of Khalsa, a 14-year-old boy, in October 2019. Learning: communication between multiple medical services and trusts did not allow practitioners to understand and contribute to the risk discussion; the need to create systems that enable young people to have a voice to participate in their health plans, specifically when this may be overridden by parental influence; the perception of asthma as not being potentially life threatening can impact on how some professionals engage in professional curiosity. Recommendations: ensure timely information sharing between multiple universal services and acute hospital trusts; and increase awareness of asthma and its management across agencies and communities. Keywords: child deaths, children at risk, children with a chronic illness, voice of the child, fathers, information sharing > Read the overview report

2020 – Wandsworth – Child A

Injury and acute illness of a 6-month-old boy, taken to hospital in March 2018. Hospital staff found that Child A had a fractured rib and was seriously underweight and malnourished with a throat abscess. Learning: professionals should be able to assess when to explore parental backgrounds, indicators of vulnerability, and adverse childhood experiences; training for practitioners in neurodiversity; how professionals should use feelings of unease or discomfort to inform assessment and decision making; the role of early help services in working with and supporting vulnerable families. Recommendations: strengthening professional training and screening on autistic spectrum disorder, ADHD and anxiety disorders, and what such difficulties mean for parents' understanding of information from health agencies; when children's services check if a child and their family are known to the service, the whole family and household should be included; reviewing the effectiveness of the mechanism for alerts to community health services of children attending accident and emergency and other urgent care NHS services. Keywords: infants, child neglect, adults with disabilities, adults with learning difficulties, malnutrition, fractures > Read the overview report

2020 – Wandsworth – Frankie

Death of a 3-year-old boy in July 2016. Frankie was a hospital inpatient for life threatening asthma leading up to his death, and died within 24 hours of discharge. Learning: medical neglect is less understood across all agencies and within the health system which is a weakness in the multi-agency children safeguarding system; consider the impact of parents' social class upon relationships with health professionals; parental challenge around medication is common but there is a lack of robust strategies to manage this in the hospital; absence of other categories of neglect appear to have reassured practitioners. Recommendations: hospitals to explore how clinical teams manage parental consent for emergency treatment; hospitals must review how they manage severe illness in children when a parent favours alternative therapy; GPs and health visitors must have an agreed plan when following up issues of concern with families; all services must be able to evidence how their workforce participates in reflective safeguarding supervision which supports their learning and development. Keywords: child death, medical care, child neglect, prescription drugs, parent-professional relationships > Read the overview report

2020 – Warwickshire – Alice and Beth

Death of two sisters aged 3- and 1-years-old in 2018. The mother was convicted of murder and imprisoned. Learning: where a family moves between areas, the new authority and relevant partners need to be informed; where possible more information should be achieved and explored when referrals come to the multi-agency safeguarding hub (MASH) to better understand the nuances of the referral; when concerns raised about parents can be easily refuted there is a danger that professionals can be prone to dismiss other information in the same vein. Recommendations: encourage professionals to adopt an investigative, questioning and professionally curious approach when considering the history of a case; ensure that professionals understand and adhere to the policy on 'Protecting children who move across local authority borders’; ensure that GPs are clear on the pathways and procedures for making timely referrals to children services. Keywords: abuse allegations, child deaths, filicide, professional curiosity, housing, referral procedures > Read the overview report

2020 – Warwickshire – Amy

Disclosure of sexual abuse by a 12-year-old girl, Amy, who was sexually abused by her mother's partner and gave birth as a result of rape. Learning: agencies not recognising and responding to issues of coercive and controlling behaviour; agencies not putting the child first; agencies not recognising anger in a child as an appropriate response to trauma; agencies failing to provide effective advocacy for the child. Recommendations: when a new adult joins a family, who are open to children's services and are deemed to be vulnerable, partner agencies should assess any risk of significant harm posed by this adult; children's services use information from all sources, and use 'healthy’ scepticism and cautious optimism, when making decisions concerning families; front facing staff in health and social care receive training to identify indicators of coercive and controlling behaviour; children brought to an antenatal clinic should be seen on their own at some point on first appointment. Keywords: child sexual abuse, sexually abused girls, pregnancy, voice of the child, abusive men > Read the overview report

2020 – Warwickshire – Child K

Injury of a 12-week-old girl, taken to hospital in January 2017 with a skull fracture. Parents stated that the mother dropped Child K during a domestic abuse incident. Learning includes: although guidance and procedures do not differentiate between day time and out of hours child protection situations, in practice out of hours services cannot fully replicate daytime services; inter-agency strategy discussions should be held whatever the circumstances for child protection enquiries; clarify in emergency situations if children are protected and accommodated under Section 20 or Section 46 of the Children Act 1989; written agreements, asking that one parent ensures there is no contact between another parent and their children, may not be realistic and may provide false assurance in cases of domestic abuse. Recommendations include: consider how effective current police structure is in ensuring that Warwickshire Police can fulfil their roles as stated in Working Together 2015; Warwickshire Police to consider whether officers involved in child protection investigations have sufficient participation in inter-agency safeguarding training. Keywords: infants, injuries, family violence, physical abuse, siblings, voice of the child.​ infants, injuries, family violence, physical abuse, siblings, voice of the child > Read the overview report

2020 – West Sussex – Baby T

Death of a 10-week old baby boy in 2017 as the result of non-accidental head injuries. Baby T’s father was convicted of manslaughter and grievous bodily arm and received a custodial sentence. Learning: preparation for parenthood needs to involve both parents learning practical and emotional aspects of caring for a new born baby, managing crying, and access to advice and support when needed; when a baby is taken to hospital with symptoms indicating potential harm, consider the possibility of non-accidental injury. Recommendations: Safeguarding Partnership should continue to use ICON: Babies Cry, You Can cope! and DadPad (prevention of abusive head trauma tools) and evaluate these programmes; medical professionals should provide documented analysis of any symptoms of non-accidental head injury. Keywords: infants, crying, physical abuse, shaking, fathers > Read the overview report

2020 – West Sussex – Child U

Death of a 3-month-old boy in 2017. Child U died after reportedly falling from his parent's bed onto the floor. Learning: the need for professionals to ask detailed questions about the use of prescribed or over the counter medication and consider the impact of any dependence on parenting, including the impact of withdrawal; the importance of information sharing about a parent's misuse of prescribed drugs; if there is a lack of certainty in a child protection case, considering a timely high-level meeting of professionals from the main agencies involved. Recommendations: that local substance misuse training covers risks from prescription and over the counter drugs and the need to share information; consider the government's review of prescription drugs to determine if findings can be used to strengthen local safeguarding practices. Model: Significant Incident Learning Process (SILP) methodology. Keywords: infant deaths, head injuries, drug misuse, prescription drugs > Read the overview report

2020 – West Sussex – Child V

Concerns that an infant was seriously harmed due to fabricated or induced illness (FII) in 2017. Learning: the potential for parents to act as conduits for information between professionals which may become a route for misinformation; where a child has been identified as a child in need, a child in need plan should be the overarching planning and review process; professionals should maintain focus on the needs of the child; the need for professional curiosity and scepticism with regard to possible neglect and abuse. Recommendations: the need to deal with fabricated or induced illness (FII) as robustly as other forms of abuse and neglect, following local and national guidance; early recognition and action in respect of perplexing presentations; practitioners have a basic understanding of the features of perplexing presentations and FII; when there are unexplained concerns about feeding and weight gain, the parent-child relationship should be considered as well as possible medical causes. Model: Significant Incident Learning Process (SILP) methodology.  Keywords: infants, fabricated or induced illness (FII), physical abuse, child neglect > Read the overview report​

2020 – West Sussex – Family W

Significant neglect of two siblings, including neglect of their physical, emotional, social developmental, health and medical needs. Learning: at times the focus was on the adults rather than the lived experiences of the children; over-optimism about the likelihood of the adult carers improving their care of the children; a lack of challenge to adult family members which led to gaps in information. Identifies good practice, including: direct work carried out by the school nurse, which allowed the child’s voice to be heard and shared; recognition by dentist that one of the children’s decayed teeth and bleeding gums were indicative of neglect. Recommendations:  highlights the improved outcomes that have been identified and should be addressed, including: multi-agency partners can evidence a shared responsibility for the safeguarding and protection of children; multi-agency assessments, risk assessments and effective safety plans are secured and monitored within the child protection conference process, to ensure the best outcomes for children; amend the pathway for capacity assessments of carers with learning difficulties so that they can be undertaken at an earlier stage. Keywords: child neglect, parenting capacity, adults with learning difficulties, optimistic behaviour > Read the executive summary

2020 – Wiltshire – Child L

Significant non-accidental injuries to a 3-year-6-month-old girl. Child L's father was convicted of grievous bodily harm and sentenced to 9 years in prison. Learning focuses on: issues around communication and information sharing between agencies; reluctance to initiate early help assessments; the need for curious and holistic practice and getting the whole picture by knowing the whole family; the need to engage with fathers and male carers, instead of the focus being primarily on the mother. Recommendations:  revise midwifery and health visitor pathways; revise multi-agency protocol on bruising and injuries in non-mobile babies and children, including guidance for parents; a thematic review into significant physical injuries to children under 1-year-old; a pilot project focused on engaging fathers and developing models of good practice. Keywords:  pre-school children, injuries, abusive fathers, communication, information sharing > Read the overview report

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• Diabetes Care for Children & Young People

Vol:05 | No:01

Children and young people’s diabetes care: Case study

• 12 Jul 2016

This case study demonstrates the physical and psychological difficulties faced by many young people with type 1 diabetes. Over the year following her diagnosis, Max had a deterioration in glycaemic control despite reporting that little had changed in her management. Detailed assessment revealed a number of psychosocial factors that were preventing her from achieving good control. However, working with her multidisciplinary team, she was able to address these issues and improve her blood glucose levels. This article outlines these issues and the action plan that Max and her diabetes team drew up to overcome them.

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This case study represents the challenges and issues, both physical and psychological, faced by a young person with type 1 diabetes and the support given by her diabetes multidisciplinary team (MDT). Implications for practice are addressed using current evidence-based research. The names of the child and family have been anonymised to protect their identity.

Case study Max (a pseudonym) is a 17-year-old girl who was diagnosed with type 1 diabetes 4 years ago at the age of 13 years. She and her mother were shocked and upset by the diagnosis, and both felt its management would be too great a task to take on by themselves.

Max is an only child and lives with her mother, a single parent. She attends the local state comprehensive school and is popular with her peer group. Her mother was very involved in her care and diabetes management from the onset. Despite this, her diabetes control deteriorated over time ( Table 1 ). In October 2012, her HbA 1c was 56 mmol/mol (7.3%); however, over the next year, this increased to 84 mmol/mol (9.8%) in July 2013. She found it difficult to count the carbohydrate portions in her food and her injections were hurting much more than when she was first diagnosed. She also expressed a fear of hypoglycaemia and of “looking stupid” in front of her friends.

Max and her MDT discussed treatment options to improve her glycaemic control. She refused insulin pump therapy but agreed to a blood glucose monitor and bolus advisor to assist with her regimen of multiple daily insulin injections (MDI). She is now using the bolus advisor confidently and has had regular one-to-one sessions with a psychologist. She is having fewer hypoglycaemic episodes and her HbA 1c has improved; in January 2016 it was 69 mmol/mol (8.5%) and in April 2016 it was 58 mmol/mol (7.5%).

Discussion Diagnosis Max and her mother were extremely shocked and upset by the diagnosis of type 1 diabetes and the potential severity of the condition and intense management required. Both felt it would be too great a task to take on by themselves.

Kübler-Ross and Kessler (2005) suggested that a diagnosis of diabetes is a life-changing event comparable to the experience of loss, and that children and families will often go through the five stages of grief defined by Kübler-Ross (1970) and outlined in Box 1 . They use this as a coping strategy to enable them to eventually acknowledge the condition. However, many families never reach the fifth stage of acceptance and many will fluctuate between the stages.

Although Max and her mum did accept the diagnosis eventually, at times both of them reverted to the earlier stages of grief. The diabetes MDT supported the family from diagnosis and will continue to support them throughout their time within the paediatric diabetes service, through the transition period with both paediatric and young people’s teams, until discharged to adult diabetes care.

The diabetes MDT was established after the Best Practice Tariff was introduced in 2012. It consists of doctors, nurses, dietitians, a psychologist and a personal assistant. It is well recognised that the MDT needs to work together in close cooperation to achieve good practice, and this can be strengthened by using written protocols, guidelines and targets (Brink, 2010). Logic would suggest that centres with MDTs and the same approaches and treatment regimens would have similar outcomes, yet the Hvidøre Childhood Diabetes Study Group has shown this is not the case (de Beaufort et al, 2013). In terms of glycaemic control, there were notable differences in patient outcomes across 21 diabetes clinics, all of which were committed to MDT-based practice. Although factors such as age, type of insulin regimen and socioeconomic status were shown to have some influence over specific outcomes, they did not explain the apparent differences between these clinics.

Family/social history Max is an only child and lives with her mother, a single parent. East et al (2006) suggested that rapid social change over the past 20 years has seen a marked increase in the number of mother-headed single-parent families. Max attends the local state comprehensive school, where she is generally doing well. She is popular with her peer group. La Greca et al (1995) suggested that peer relationships are important in diabetes management, as children and young people (CYP) may receive considerable emotional support from their friends. However, on occasions, Max’s peer relationships have had a counterproductive effect on her, and she feels she is different from her friends as the only one who has diabetes. This at times affects her self-esteem and impacts her diabetes control.

Max’s mother was very involved in her care and diabetes management from the onset. Anderson and Brackett (2005) suggested that parents typically take on most of the responsibility for management of diabetes when children are young or newly diagnosed.

Deterioration in diabetes control Max’s diabetes control had deteriorated since her diagnosis ( Table 1 ). In October 2012, her HbA 1c was 56 mmol/mol (7.3%), which indicated a good level of diabetes control and a reduced risk of diabetes complications, as suggested by the DCCT (Diabetes Control and Complications Trial; DCCT Research Group, 1994). At her subsequent diabetes clinic appointments up to July 2013, she reported that “nothing had really changed,” except she “didn’t have time to think about her diabetes,” although she felt guilty because she knew she could make herself ill and her mum would get upset. She stated that it was hard counting the carbohydrate portions in her food and her injections were hurting much more than when she was first diagnosed. Her height and weight remained static.

Diabetes care is greatly influenced by psychosocial factors when they obstruct people’s ability to manage their diabetes and achieve good metabolic control. A team-based approach to addressing an individual’s ability to cope is critical (Kent et al, 2010). It is important for healthcare professionals to be aware of how CYP think at the different stages of their development, as their understanding of illness and chronic health conditions is often greater than that of their peers. Jean Piaget (1896–1980) investigated cognitive processes in children, calling them “schemas”. By the time children reach around 12 years of age, they can describe illness in terms of non-functioning or malfunctioning of an internal organ or process. Later in development they can appreciate that a person’s thoughts or feelings can affect the way the body functions, which demonstrates an awareness of psychological factors (Taylor et al, 1999).

Spear (2013) proposed that we can begin to understand how young people with type 1 diabetes think, feel and behave if we consider the cognitive and biological changes that occur during adolescence. Glasper and Richardson (2005) suggested there is now a growing awareness that CYP are able to make their own decisions if given information in an age-appropriate manner. Gillick competence identifies children aged under 16 years as having the capacity to consent to their own treatment if they understand the consequences (NSPCC, 2016).

Butler et al (2007) suggest that adolescence is a time of upheaval when young people have to deal with the influence of peers, school life and developing their own identity, as well as all the physiological changes that occur. Young people with type 1 diabetes have the added responsibility of developing autonomy regarding the self-management of their condition. Hanas (2006) suggests that parents should continue to take part in their child’s diabetes care into adolescence and not hand the responsibility to the young person too early. Snoek and Skinner (2002) suggest that intensive self-management of diabetes is complex and time-consuming, and creates a significant psychosocial burden on children and their families.

There are significant challenges for CYP to engage in effective diabetes self-management. Several of these were identified with Max and her mother:

• Deterioration in diabetes control.
• Difficulty with carbohydrate counting.
• Insulin omission.
• Fear of hypoglycaemia.
• Painful injections.

Action plan An action plan was discussed between Max and the MDT. As she was on an MDI regimen (a long-acting insulin at bedtime and rapid-acting insulin with meals), a bolus advisor/blood glucose monitor was demonstrated and discussed with her and her mum. Max felt she would be able to use this to help eliminate the calculations which, although she was capable of doing them, she often lacked time to do so. With further discussion, Max said she was “scared of getting it wrong and having a hypo”. Insulin pump therapy was discussed but she did not want to “have a device attached to my body because it would remind me all the time that I have diabetes”. Insulin pump therapy is recommended as a treatment option for adults and children over 12 years of age with type 1 diabetes whose HbA 1c levels remain above 69 mmol/mol (8.5%) on MDI therapy despite a high level of care (NICE, 2015a).

The National Service Framework standard 3 (Department of Health, 2001) recommends empowering people with diabetes and encourages them and their carers to gain the knowledge and skills to be partners in decision-making, and giving them more personal control over the day-to-day management of their diabetes, ensuring the best possible quality of life. However, if a diabetes management plan is discussed in partnership with a (Gillick-competent) young person but they elect not to comply with the plan despite full awareness of the implications of their actions, then the diabetes team should support them whilst trying to encourage them to maintain the treatment plan. This can be very difficult and frustrating at times, as a healthcare professional is an advocate for the patient, and promotion of the best interests of the patient is paramount.

Psychology involvement Max was reviewed by the psychologist to assess her psychological health and wellbeing. The psychologist used the Wellbeing in Diabetes questionnaire (available from the Yorkshire and Humber Paediatric Diabetes Network) to assess her and identify an optimal plan of care.

The psychology sessions were focussed on her issues around the following:

• Worry about deterioration in control.
• The consequences of insulin omission.

Max had a series of one-to-one appointments and some joint sessions with the paediatric diabetes specialist nurse and/or dietitian, so this linked into other team members’ specialities.

Carbohydrate counting and use of a bolus advisor The dietitian assessed Max and her mother’s ability to carbohydrate count using a calculator, food diagrams and portion sizes, and both of them were able to demonstrate competency in this task. Garg et al (2008) have shown that the use of automated bolus advisors is safe and effective in reducing postprandial glucose excursions and improving overall glycaemic control. However, this can only be true if the bolus advisor is being used correctly and is confirmed as such by comparing blood glucose and HbA 1c results before and after initiation of the bolus advisor, and observing the patient using the device to ensure it is being used safely and correctly.

Barnard and Parkin (2012) propose that, as long as safety and lifestyle are taken into consideration, advanced technology will benefit CYP, as inaccurate bolus calculation can lead to persistent poor diabetes control. These tools can help with removing the burden of such complex maths and have the potential to significantly improve glycaemic control.

Insulin omission and fear of hypoglycaemia Max also expressed her fear of hypoglycaemia and of “looking stupid” in front of her friends. She admitted to missing some of her injections, especially at school. Wild et al (2007) suggest that a debilitating fear of hypoglycaemia can result in poor adherence to insulin regimens and subsequent poor metabolic control. Crow et al (1998) describe the deliberate omission or reduced administration of insulin, which results in hyperglycaemia and subsequent rapid reduction in body weight. Type 1 diabetes predisposes a person to a high BMI. Adolescent girls and adult women with type 1 diabetes generally have higher BMI values than their peers without the condition (Domargård et al, 1999). Affenito et al (1998) observed that insulin misuse was the most common method of weight control used by young women with type 1 diabetes. However, Max’s weight remained stable and there was no clinical indication that she was missing insulin to lose weight; rather, it was her fear of hypoglycaemia that drove her to omitting insulin at school. With the use of the bolus calculator, she was reassured about her calculations for insulin-to-carbohydrate ratios, but it was reinforced with her that the device would only work efficiently if she used it correctly with each meal.

Painful injections Max also highlighted that her injections were now more painful than when she was first diagnosed, and this was causing her distress each time she had to inject. Injection technique was discussed with her and demonstrated using an injection model, and her injection technique was observed and appeared satisfactory. She was using 5-mm insulin needles and so was switched to 4-mm needles, as recommended by Forum for Injection Technique (2015) guidelines.

Appropriate technique when giving injections is key to optimal blood glucose control; however, evidence suggests that injection technique is often imperfect. Studies by Strauss et al (2002) and Frid et al (2010) revealed disturbing practices in relation to injection technique, with little improvement over the years. Current diabetes guidelines do not include detailed advice on injection technique, and only the guidance on type 2 diabetes in adults (NICE, 2015b) makes any reference to providing education about injectable devices for people with diabetes. However, the older Quality Standard for diabetes in adults (NICE, 2011) recommends a structured programme of education, including injection site selection and care (Diggle, 2014).

Conclusion The issues and concerns this young girl had were identified and addressed by the diabetes MDT. She was assessed by several members of the team, and a credible, evidence-based action plan was put into place to assist her and her mother to manage her diabetes at this difficult time. Max is now using the bolus advisor confidently and having fewer hypoglycaemic episodes, and her HbA 1c has improved. She prefers using the 4-mm injection pen needles, although she remains hesitant when giving injections; she will still not consider insulin pump therapy. Her one-to-one sessions with the psychologist have now ceased, but she is aware she can access a psychologist at clinic on request, or if the MDT assesses that her psychological health has deteriorated.

When a child in a family develops a chronic condition such as type 1 diabetes, effective communication is vitally important to address issues with the family at the earliest stage so that problems can be discussed and, hopefully, resolved before they escalate out of control. Upon reflection, the team could have become more intensely involved at an earlier stage to prevent Max’s diabetes management issues and stop her HbA 1c from reaching such a high level. Furthermore, the new NICE (2015a) guideline has set the target HbA 1c at ≤48 mmol/mol (6.5%), so there is still some work to be done. However, the outcome of this case appears to be favourable at present.

Affenito SG, Rodriguez NR, Backstrand JR et al (1998) Insulin misuse by women with type 1 diabetes mellitus complicated by eating disorders does not favorably change body weight, body composition, or body fat distribution. J Am Diet Assoc 98 : 686–8 Anderson BJ, Brackett J (2005) Diabetes in children. In: Snoek FJ, Skinner TC (eds). Psychology in Diabetes Care (2nd edition). John Wiley & Sons, Chichester Barnard K, Parkin C (2012) Can automated bolus advisors help alleviate the burden of complex maths and lead to optimised diabetes health outcomes? Diabetes Care for Children & Young People 1 : 6–9 Brink SJ (2010) Pediatric and adolescent multidisciplinary diabetes team care. Pediatr Diabetes 11 : 289–91 Butler JM, Skinner M, Gelfand D et al (2007) Maternal parenting style and adjustment in adolescents with type I diabetes. J Pediatr Psychol 32 : 1227–37 Crow SJ, Keel PK, Kendall D (1998) Eating disorders and insulin-dependent diabetes mellitus. Psychosomatics 39 : 233–43 de Beaufort CE, Lange K, Swift PG et al (2013) Metabolic outcomes in young children with type 1 diabetes differ between treatment centers: the Hvidoere Study in Young Children 2009. Pediatr Diabetes 14 : 422–8 Department of Health (2001) National Service Framework: Diabetes . DH, London. Available at: http://bit.ly/18OpAzL (accessed 24.02.16) Diabetes Control and Complications Trial Research Group (1994) Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. J Pediatr 125 : 177–88 Diggle J (2014) Are you FIT for purpose? The importance of getting injection technique right . Journal of Diabetes Nursing 18 : 50–7 Domargård A, Särnblad S, Kroon M et al (1999) Increased prevalence of overweight in adolescent girls with type 1 diabetes mellitus. Acta Paediatr 88 : 1223–8 East L, Jackson D, O’Brien L (2006) Father absence and adolescent development: a review of the literature. J Child Health Care 10 : 283–95 Forum for Injection Technique (2015) The UK Injection Technique Recommendations (3rd edition). Available at: http://bit.ly/1QeZU2E (accessed 24.02.16) Frid A, Hirsch L, Gaspar R et al (2010) The Third Injection Technique Workshop in Athens (TITAN). Diabetes Metab 36 (Suppl 2): 19–29 Garg SK, Bookout TR, McFann KK et al (2008) Improved glycemic control in intensively treated adult subjects with type 1 diabetes using insulin guidance software. Diabetes Technol Ther 10 : 369–75 Glasper EA, Richardson J (2005) A Textbook of Children’s and Young People’s Nursing . Churchill Livingston, London Hanas R (2006) Type 1 Diabetes in Children, Adolescents and Young Adults (3rd edition). Class Publishing, London: 329, 349–50 Kent D, Haas L, Randal D et al (2010) Healthy coping: issues and implications in diabetes education and care. Popul Health Manag 13 : 227–33 Kübler-Ross E (1970) On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and Their Own Families . Tavistock Publications, London Kübler-Ross E, Kessler D (2005) On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss . Simon & Schuster UK, London La Greca AM, Auslander WF, Greco P et al (1995) I get by with a little help from my family and friends: adolescents’ support for diabetes care. J Pediatr Psychol 20 : 449–76 NICE (2011) Diabetes in adults (QS6). NICE, London. Available at: www.nice.org.uk/guidance/qs6 (accessed 24.02.16) NICE (2015a) Diabetes (type 1 and type 2) in children and young people: diagnosis and management (NG18). NICE, London. Available at: www.nice.org.uk/guidance/ng18 (accessed 24.02.16) NICE (2015b) Type 2 diabetes in adults: management (NG28). NICE, London. Available at: www.nice.org.uk/guidance/ng28 (accessed 24.02.16) NSPCC (2016) A Child’s Legal Rights: Gillick Competency and Fraser Guidelines . NSPCC, London. Available at: http://bit.ly/1Tj6DcF (accessed 24.02.16) Snoek FJ, Skinner TC (2002) Psychological counselling in problematic diabetes: does it help? Diabet Med 19 : 265–73 Spear LP (2013) Adolescent neurodevelopment. J Adolesc Health 52 (Suppl 2): 7–13 Strauss K, De Gols H, Hannat I et al (2002) A pan-European epidemiologic study of insulin injection technique in patients with diabetes. Practical Diabetes International 19 : 71–76 Taylor J, Müller D, Wattley L, Harris P (1999) The development of children’s understanding. In: Nursing Children: Psychology, Research and Practice . Stanley Thornes, Cheltenham Wild D, von Maltzahn R, Brohan E et al (2007) A critical review of the literature on fear of hypoglycemia in diabetes: implications for diabetes management and patient education. Patient Educ Couns 68 : 10–5

Do youth workers have a role in improving diabetes transition services?

Cgm for children and young people with type 1 diabetes: nice criteria and effects of decision fatigue and alarm fatigue  , improving paediatric diabetes in england: areas of focus, delays in accessing continuous glucose monitoring in people with type 1 diabetes, celebrating may ng: the woman behind the obe, fiona campbell awarded an obe for services to paediatric diabetes, diabetes transition: a time to act.

Can the involvement of youth workers improve diabetes care for young people transitioning to adult diabetes services?

The impact of decision fatigue and alarm fatigue in children and young people using continuous glucose monitoring

NHSEI National Clinical Lead for Diabetes in Children and Young People, Fulya Mehta, outlines the areas of focus for improving paediatric diabetes care.

16 Nov 2022

NICE guidance urges local trusts to improve processes and advocate for CGM use in children and young people.

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Bold Vision, Educator Power, and Focus on Compensation: Laying Groundwork for Transformation in New Mexico

Early educator compensation case study series.

By Annie Dade , Caitlin McLean , Silvia Muñoz and Raúl Chávez • April 8, 2024 • Part of Learning Community: Bold on Early Care and Education Compensation

New Mexico has accomplished bold reforms to their early childhood education and care system in the last four years, building on over a decade of advocacy and educator organizing. Learn how the fight for fair compensation for early educators was central to the effort – and the political and administrative challenges it continues to face.

Main Findings

Building on more than a decade of grassroots organizing and advocacy, New Mexico leaders have initiated several early care and education policy reforms dedicated to supporting early educator compensation since 2019. The state established a number of ongoing targeted wage supplement programs and used time-limited federal pandemic relief funds to provide a $3/hour raise for educators across the sector. New Mexico has also reformed its subsidy system by dramatically broadening eligibility for families and using a cost model accounting for increased compensation to establish higher reimbursement rates, the first state in the country to do so.  

Several elements were key to achieving these reforms and laying the groundwork for long-term change: 

• Leadership and a centralized state agency have maintained a bold vision for the systemic reforms and advancing workforce compensation. 
• Educator- and community-led organizing proved critical to winning necessary state funding to make good on New Mexico’s vision for compensation.

The state’s recent initiatives do not yet amount to sustained, transformative changes to compensation. However, by establishing key elements for progress and identifying challenges along the way, this case study highlights one state’s journey to advancing early educator compensation.

Suggested Citation

Dade, A., McLean, C., Muñoz, S., & Chávez, R. (2024). Bold Vision, Educator Power, and Focus on Compensation: Laying Groundwork for Transformation in New Mexico. Early Educator Compensation Case Study Series . Center for the Study of Child Care Employment, University of California, Berkeley. https://cscce.berkeley.edu/publications/case-study/new-mexico/

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The 3-Word Remedy for Anxiety

The liberating power of "so, what if": speculative thinking reduces anxiety..

Updated April 9, 2024 | Reviewed by Michelle Quirk

• What Is Anxiety?
• Find counselling to overcome anxiety
• Consistent with the cognitive behavioral therapy approach, speculative thinking challenges your anxiety.
• The phrase, "So what if?" is a great way to use speculative thinking to zap your worries.
• "So what if?" helps us find the freedom to explore alternatives to anxious thoughts and see a brighter future.

Anxiety often lurks in our minds, weaving its tendrils into our thoughts and emotions. It's a persistent companion, whispering doubts, fears, and uncertainties.

Yet, amidst this mental maze, lies a powerful tool—the simple question: "So, what if?" Further along in this post, I will share Sarah's story—a brief, inspiring case study of the power of "So, what if?"

This idea of challenging our irrational beliefs is soundly based on the tenets of cognitive behavioral therapy —the most widely researched set of clinical interventions used by mental health professionals. Similar to "So, what if?," the question, "What is the worst thing that can happen?" is another worry squashed. That's because most of the time, the worst thing does not happen—and even if it does, we usually find a way to deal with it when push comes to shove.

Yet, I still prefer the 1, 2, 3 punch of "So, what if?" This three-word question is more succinct, and it effectively calls on us to step up and directly call out and challenge that irrational self-talk that gets in our way.

This seemingly innocuous inquiry holds the key to unlocking a path toward liberation from anxiety's grip. By engaging in speculative thinking, we venture into the realm of possibility, where anxieties lose their potency, and we find the freedom to explore alternatives and envision brighter futures.

Understanding Anxiety

Anxiety, in its essence, is a response to uncertainty and perceived threats. It manifests as a relentless cycle of worry, ruminating on potential dangers and negative outcomes. Whether it's fretting about the future, dwelling on past mistakes, or feeling overwhelmed by current challenges, anxiety constrains our ability to think clearly and act decisively. It's a cognitive trap that ensnares us in a web of "what ifs" without offering resolution or relief.

The Power of Speculative Thinking: Enter "So, What If?"

A subtle yet transformative shift in perspective: Instead of succumbing to the paralyzing grip of anxious thoughts, we pivot toward curiosity and imagination . Speculative thinking invites us to entertain possibilities beyond the confines of our fears.

When I was researching my book The Anxiety, Depression , & Anger Toolbox for Teens , I learned how speculative thinking is a valuable tool to quell not just teen anxiety but also worries amongst people of all ages. Speculative thinking encourages us to explore alternative narratives, envision positive outcomes, and consider the potential for growth and resilience .

Lowering Anxiety Through Speculation

• Reframing perspectives: "So, what if?" prompts us to reframe our perspectives on uncertainty and adversity. Rather than viewing challenges as insurmountable obstacles, we see them as opportunities for learning and growth. By embracing uncertainty as a natural part of life's journey, we cultivate resilience and adaptability.
• Empowering choices: Speculative thinking empowers us to reclaim agency in the face of anxiety. Instead of feeling helpless and overwhelmed, we recognize that our choices shape the course of our lives. By exploring different scenarios and their potential outcomes, we gain clarity and confidence in our decision-making process.
• Cultivating creativity : Anxiety often stifles creativity, trapping us in rigid patterns of thinking. "So, what if?" unleashes the imagination, inviting us to explore uncharted territory and envision novel solutions. By embracing uncertainty as a catalyst for innovation, we tap into our creative potential and discover new possibilities.
• Building resilience: Speculative thinking fosters resilience by challenging us to confront our fears and uncertainties head-on. Rather than avoiding discomfort, we lean into it, recognizing that growth often emerges from adversity. By embracing the unknown with courage and curiosity, we develop the inner strength to navigate life's inevitable challenges.

Case Study: Sarah's Story

Sarah, a young professional commercial realtor, was plagued by anxiety about her career prospects. Faced with uncertainty in her industry's mounting pressure to succeed, she felt paralyzed by fear of failure.

However, through the practice of speculative thinking, Sarah began to explore alternative pathways and envision a future filled with possibilities. Instead of dwelling on worst-case scenarios, she asked herself, "So, what if I believe I can succeed? What if I give my best effort? So, what if this career does not work out—I will find something else that is a better fit for me. In the meantime, I'm giving this my best shot."

These questions liberated Sarah from the grip of anxiety, empowering her to take proactive steps toward her goals with newfound clarity and confidence. One of Sarah's colleagues who saw that she appeared more optimistic , empowered, and motivated invited her to assist with a large sale. Sarah leveraged this success to propel herself forward and became a rising star in her office.

"So, what if?"—a simple question with profound implications for our mental well-being. In a world fraught with uncertainty and anxiety, speculative thinking offers a beacon of hope and possibility. By embracing curiosity, creativity, and resilience, we can transcend the confines of anxious thoughts and chart a course toward a brighter, more fulfilling future. So, the next time anxiety threatens to overshadow your daily life and even your dreams , remember to ask yourself: "So, what if?"

Apolinário-Hagen, J., Drüge, M., Fritsche, L. (2020). Cognitive Behavioral Therapy, Mindfulness-Based Cognitive Therapy and Acceptance Commitment Therapy for Anxiety Disorders: Integrating Traditional with Digital Treatment Approaches. In: Kim, YK. (eds) Anxiety Disorders. Advances in Experimental Medicine and Biology, vol 1191. Springer, Singapore. https://doi.org/10.1007/978-981-32-9705-0_17

van Dis EAM, van Veen SC, Hagenaars MA, et al. Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2020;77(3):265–273. doi:10.1001/jamapsychiatry.2019.3986

Jeffrey Bernstein, Ph.D. , is a psychologist and the author of seven books, including 10 Days to a Less Defiant Child.

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Creating culturally-informed protocols for a stunting intervention using a situated values-based approach ( WeValue InSitu ): a double case study in Indonesia and Senegal

• Annabel J. Chapman 1 ,
• Chike C. Ebido 2 , 3 ,
• Rahel Neh Tening 2 ,
• Yanyan Huang 2 ,
• Ndèye Marème Sougou 4 ,
• Risatianti Kolopaking 5 , 6 ,
• Amadou H. Diallo 7 ,
• Rita Anggorowati 6 , 8 ,
• Fatou B. Dial 9 ,
• Jessica Massonnié 10 , 11 ,
• Mahsa Firoozmand 1 ,
• Cheikh El Hadji Abdoulaye Niang 9 &
• Marie K. Harder 1 , 2  

BMC Public Health volume  24 , Article number:  987 ( 2024 ) Cite this article

Metrics details

International development work involves external partners bringing expertise, resources, and management for local interventions in LMICs, but there is often a gap in understandings of relevant local shared values. There is a widespread need to better design interventions which accommodate relevant elements of local culture, as emphasised by recent discussions in global health research regarding neo-colonialism. One recent innovation is the concept of producing ‘cultural protocols’ to precede and guide community engagement or intervention design, but without suggestions for generating them. This study explores and demonstrates the potential of an approach taken from another field, named WeValue InSitu , to generate local culturally-informed protocols. WeValue InSitu engages stakeholder groups in meaning-making processes which ‘crystallize’ their envelope of local shared values, making them communicable to outsiders.

Our research context is understanding and reducing child stunting, including developing interventions, carried out at the Senegal and Indonesia sites of the UKRI GCRF Action Against Stunting Hub. Each national research team involves eight health disciplines from micro-nutrition to epigenetics, and extensive collection of samples and questionnaires. Local culturally-informed protocols would be generally valuable to pre-inform engagement and intervention designs. Here we explore generating them by immediately following the group WeValue InSitu crystallization process with specialised focus group discussions exploring: what local life practices potentially have significant influence on the environments affecting child stunting, and which cultural elements do they highlight as relevant. The discussions will be framed by the shared values, and reveal linkages to them. In this study, stakeholder groups like fathers, mothers, teachers, market traders, administrators, farmers and health workers were recruited, totalling 83 participants across 20 groups. Themes found relevant for a culturally-informed protocol for locally-acceptable food interventions included: specific gender roles; social hierarchies; health service access challenges; traditional beliefs around malnutrition; and attitudes to accepting outside help. The concept of a grounded culturally-informed protocol, and the use of WeValue InSitu to generate it, has thus been demonstrated here. Future work to scope out the advantages and limitations compared to deductive culture studies, and to using other formative research methods would now be useful.

Peer Review reports

Although progress has been made towards the SDG of ‘Zero Hunger by 2025’, the global rates of malnutrition and stunting are still high [ 1 ]. Over the past 20 years, researchers have implemented interventions to reduce undernutrition, specifically focussing on the first 1000 days of life, from conception to 24 months [ 2 ]. However, due to both differing determinants between countries [ 3 , 4 ] as well as varying contextual factors, it is clear that no single fixed approach or combination of approaches can be relied on when implementing stunting interventions [ 5 , 6 , 7 ]. Furthermore, when external researchers design interventions for local areas in Low- and Middle-Income Countries (LMICs) they can often overlook relevant local cultural factors that consequently act as barriers to intervention uptake and reduce their effectiveness, such as geographical factors and the levels of migration in certain populations [ 8 , 9 ], or social norms or perceptions relating to accepting outside help, and power dynamics related to gender [ 10 , 11 , 12 ]. The inclusion of cultural level factors in behaviour change interventions has been proposed as a requirement for effective interventions [ 13 ]. However, despite the breadth of literature highlighting the negative impacts from failing to do this, the lack of integration or even regard of local culture remains a persistent problem in Global Health Research [ 14 ], possibly hindering progress towards the SDGs. Thus, there is a need for approaches to integrate local cultural elements into intervention design.

This lack of understanding of relevant local culture, social norms and shared values also has ethical implications. The field of Global Health Ethics was predominantly developed in the Global North, in High Income Countries (HICs), embedding values common in those countries such as the prominence of individual autonomy [ 15 , 16 ]. Researchers from HICs carrying out research in LMICs may wrongly assume that values held in the Global North are universal [ 14 ] and disregard some local values, such as those related to family and collective decision making, which are core to many communities in LMICs. It is therefore important for outside researchers to have an understanding of relevant local values, culture and social norms before conducting research in LMICs so as not to impose values that do not align with local culture and inadvertently cause harm or offence [ 16 , 17 ]. The importance of this is compounded by the colonial history that is often present in relationships between research communities in HICs and LMICs, and the fact that the majority of the funding and leading institutions are still located in the Global North [ 18 , 19 ]. Thus, conscious steps must be taken to avoid neo-colonialism in Global Health Research [ 20 ]. From a health-equity perspective, it is essential to ensure that those in vulnerable communities are not hindered from involvement in interventions to improve nutrition. Encouraging uptake by such communities could be provided if salient local shared values, norms and culture were taken into account [ 21 ].

In a recent paper, Memon et al., (2021) highlight the usefulness of first creating a cultural protocol that can precede and guide subsequent stages of community engagement or intervention design to ensure that salient local values are known to external researchers coming into the community [ 16 ]. We adopt the use of the concept of a cultural protocol, referring to locally-generated guidance about key values, norms, behaviours and customs relevant to working with the local community. However, we prefer the term, ‘culturally-informed protocol’ since this relates to only cultural elements deemed salient by the researchers, and locally, rather than any comprehensive notion of culture, nor extending beyond the research context.

Memon et al. (2021), point out links between the creation of such a protocol and existing codes of practice that have already been created for some cultures such as the Te Ara Tika, a Guideline for Māori Research Ethics [ 22 ]. Currently, research and interventions in Global Health can be informed by a stage of formative research involving one-to-one interviews, focus groups or direct observations, which can sometimes be ethnographic in nature such as within Focussed Ethnographic Studies or Rapid Assessment Procedures [ 23 , 24 , 25 ]. Although these methods can be effective to inform intervention designs, they have disadvantages like: can take long periods to complete [ 26 ], can be resource intensive [ 26 ] and can lack cultural acceptability [ 27 ]. These limitations may account for the frequent neglect of their use generally, highlighted by Aubel and Chibanda (2022) [ 14 ]. Additionally, none of these methods work towards making explicit local values, or towards the creation of a culturally-informed protocol. In brief, the literature suggests a need to develop alternative methods of Formative Research for understanding locally relevant cultural elements, that are less time-consuming and can generate data that is more easily translatable to intervention design. In addition, these approaches must be applicable in different cultures. Additionally, the protocols produced must be actionable and practical not only for guiding interactions between research teams but also for guiding the initial stages of intervention design.

The work presented here aims to address several of these needs. It includes an exploration of the usefulness of the WeValue InSitu ( WVIS ) approach because that has previously been shown, in environmental management domains, to offer a way to gather in-depth values-based perspectives from a target population [ 28 , 29 ] It was first created through action research, and co-designed to enable civil society organisations to better understand and measure the values-based aspects of their work [ 30 ]. The core WeValue InSitu process (detailed in Table 1 ) involves the crystallization of shared values, with a facilitator guiding a group of participants with shared experiences, through cycles of tacit meaning-making (using a stage of photo-elicitation and triggering) [ 31 ], until they can articulate more explicitly their shared values, in concise and precise statements. These statements are then linked together in a framework by the participants. In an example case in Nigeria, the results of the WVIS approach hinted at the creation of a culturally-informed protocol through an analysis of the shared values frameworks to find cultural themes for the creation of an indicator tool that was used to evaluate several development scenarios based on their social acceptability [ 29 ].

Furthermore, it has been found that if a group of WVIS participants take part in a specialised focus group discussion (FGD), named Perspectives EXploration (PEX:FGD) immediately afterward the main workshop, then they easily and articulately express their perspectives on the topics raised for discussion - and with allusions to the shared values they had crystallised just prior. In an example from Shanghai, the PEX:FGDs focussed on eliciting perspectives on climate change, which were shown to be closely linked with the cultural themes existing within the shared values frameworks produced immediately prior [ 32 ]. In that case, the PEX:FGDs allowed the cultural themes generated during the main WVIS workshop to be linked more closely to the research question. Those results suggested that the WVIS plus PEX:FGD approach could be used to create a specialised culturally-informed protocol for improved intervention design.

In the study presented here, the WVIS approach was explored for the purpose of creating culturally-informed protocols to inform the planning of interventions within two localities of the UKRI GCRF Action Against Stunting Hub [ 33 ]. The work was carried out in two parts. Firstly, the WVIS main workshop was used to elicit cultural themes within the target communities, indicating key elements to consider to ensure ethical engagement. Secondly, the PEX focus group discussions focussed on life practices related to stunting which we explored for the purpose of tailoring the culturally-informed protocols to the specific purpose of improving the design of an example intervention. The Action Against Stunting Hub works across three sites where stunting is highly prevalent but via different determinants: East Lombok in Indonesia (estimated 36% of under-fives stunted), Kaffrine in Senegal (estimated 16% of under-fives stunted) and Hyderabad in India (estimated 48% of under-fives stunted) [ 34 ]. We propose that, the information about local shared values in a given site could be used to inform the design of several interventions, but for our specific exploration the focus here is a proposed ‘egg intervention’, in which pregnant women would be provided with an egg three times per week as supplement to their diet. This study proposes that identifying shared values within a community, alongside information about local life practices, provides critical cultural information on the potential acceptability and uptake of this intervention which can be used to generate culturally-informed protocols consisting of recommendations for improved intervention design.

In this paper we aim to explore the use of the WVIS approach to create culturally-informed protocols to guide engagement and inform the design of localised egg interventions to alleviate stunting in East Lombok, Indonesia and Kaffrine, Senegal. We do this by analysing data about local shared values that are crystallized using the WeValue InSitu ( WVIS ) process to provide clear articulation of local values, followed by an analysis of life practices discussed during PEX:FGD to tailor the culturally-informed protocols for the specific intervention design.

Study setting

This research was exploratory rather than explanatory in nature. The emphasis was on demonstrating the usefulness of the WeValue InSitu ( WVIS ) approach to develop culturally-informed protocols of practical use in intervention design, in different cultural sites. This study was set within a broader shared-values workstream within the UKRI GCRF Action Against Stunting Hub project [ 33 ]. The Hub project, which was co-designed and co-researched by researchers from UK, Indonesia, Senegal and India, involves cohorts of 500 women and their babies in each site through pregnancy to 24 months old, using cross-disciplinary studies across gut health, nutrition, food systems, micro-nutrition, home environment, WASH, epigenetics and child development to develop a typology of stunting. Alongside these health studies are studies of the shared values of the communities, obtained via the WVIS approach described here, to understand the cultural contexts of that diverse health data. In this study the data from East Lombok, Indonesia and Kaffrine, Senegal were used: India’s data were not yet ready, and these two countries were deemed sufficient for this exploratory investigation.

The WVIS approach

The WVIS approach is a grounded scaffolding process which facilitates groups of people to make explicit their shared values in their own vocabulary and within their own frames (details in Fig. 1 and activities in Table 1 ). The first stage of the WVIS is Contextualisation, whereby the group identifies themselves and set the context of their shared experiences, for example, as ‘mothers in East Lombok, Indonesia’. Subsequently, there is a stage of Photo Elicitation, in which the group are first asked to consider what is important, meaningful or worthwhile to them about their context (e.g., ‘being mothers in East Lombok, Indonesia’) and then asked to choose photos from a localised set that they can use as props to help describe their answer to the group [ 29 ]. After this, a localised Trigger List is used. This Trigger List consists of 109 values statements that act as prompts for the group. Examples of these values statements are included below but all the statements begin with “it is important to me/us that…”. The group are asked to choose which statements within the trigger list resonate with them, and those are taken forward for group intersubjective discussion. After a topic of their shared values has been explored, the group begin to articulate and write down their own unique statements of them. These also all begin with “It is important to me/us that…”. After discussing all pressing topics, the group links the written statements on the table into a unique Framework, and one member provides a narrative to communicate it to ‘outsiders’. The WVIS provides a lens of each group’s local shared values, and it is through this lens that they view the topics in the focus group discussions which immediately follow, termed Perspectives EXplorations (PEX:FGDs).

Schematic of the macro-level activities carried out during the WeValue InSitu ( WVIS ) main workshop session

This results in very grounded perspectives being offered, of a different nature to those obtained in questionnaires or using external frameworks [ 31 ]. The specific PEX:FGD topics are chosen as pertinent to stunting contextual issues, including eating habits, food systems and environments, early educational environments, and perceptions of stunting. The local researchers ensured that all topics were handled sensitively, with none that could cause distress to the participants. The data for this study were collected over 2 weeks within December 2019–January 2020 in workshops in East Lombok, Indonesia, and 2 weeks within December 2020 in Kaffrine, Senegal.

The PEX:FGDs were kept open-ended so that participants could dictate the direction of the discussion, which allowed for topics that may not have been pre-considered by the facilitators to arise. Sessions were facilitated by local indigenous researchers, guided in process by researchers more experienced in the approach, and were carried out in the local languages, Bahasa in East Lombok, Indonesia and French or Wolof in Kaffrine, Senegal.

Development of localised WVIS materials

Important to the WVIS approach is the development of localised materials (Table 1 ). The main trigger list has been found applicable in globalised places where English is the first language, but otherwise the trigger lists are locally generated in the local language, incorporating local vocabulary and ways of thinking. To generate these, 5–8 specific interviews are taken with local community members, by indigenous university researchers, eliciting local phrases and ways of thinking. This is a necessary step because shared tacit values cannot be easily accessed without using local language. Examples of localised Trigger Statements produced this way are given below: (they all start with: “It is important to me/us that…”):

…there is solidarity and mutual aid between the people

…I can still be in communication with my children, even if far away

…husbands are responsible for the care of their wives and family

…the town council fulfils its responsibility to meet our needs

…people are not afraid of hard, and even manual work

Study participants

The group participants targeted for recruitment, were selected by local country Hub co-researchers to meet two sets of requirements. For suitability for the WVIS approach they should be between 3 and 12 in number; belong to naturally existing groups that have some history of shared experiences; are over 18 years old; do not include members holding significantly more power than others; and speak the same native language. For suitability in the PEX:FGD to offer life practices with relevance to the research topic of stunting, the groups were chosen to represent stakeholders with connections to the food or learning environment of children (which the Action Against Stunting Hub refer to as the Whole Child approach) [ 33 ]. The university researchers specialising in shared values from the UK, and Senegal and Indonesia respectively, discussed together which stakeholder groups might be appropriate to recruit. The local researchers made the final decisions. Each group was taken through both a WVIS workshop and the immediately-subsequent PEX:FGD.

Data collection and analysis

Standard data output from the WeValue session includes i) the jointly-negotiated bespoke Statements of shared values, linked together in their unique Framework, and ii) an oral recording of a descriptive Narrative of it, given by the group. These were digitized to produce a single presentation for each group as in Fig. 2 . It represents the synthesised culmination of the crystallisation process: a portrait of what was ‘important’ to each stakeholder group. Separately, statements from the group about the authenticity/ownership of the statements are collected.

An illustrative example of one digitized Shared Values Framework and accompanying Narrative from a teacher’s group in East Lombok, Indonesia. The “…” refers to each statement being preceded by “It is important to us that…”

When these Frameworks of ‘Statements of Shared Values’ are viewed across all the groups from one locality (Locality Shared Values Statements), they provide portraits of ‘what is important’ to people living there, often in intimate detail and language. They can be used to communicate to ‘outsiders’ what the general cultural shared values are. In this work the researchers thematically coded them using Charmaz constructionist grounded theory coding [ 35 ] to find broad Major Cultural Themes within each separate locality.

The second area of data collection was in the post- WVIS event: the PEX:FGD for each group. A translator/interpreter provided a running commentary during these discussions, which was audio recorded and then transcribed. The specific topics raised for each group to discuss varied depending on their local expertise. This required completely separate workstreams of coding of the dataset with respect to each topic. This was carried out independently by two researchers: one from UK (using NVivo software (Release 1.3.1)) and one from the local country, who resolved any small differences. All the transcripts were then collated and inductively, interpretively analysed to draw out insights that should be relayed back to the Action Against Stunting Hub teams as contextual material.

The extracts of discussion which were identified as relevant within a particular Hub theme (e.g. hygiene) were then meta-ethnographically synthesised [ 36 ] into ‘Hub Theme Statements’ on each topic, which became the core data for later communication and interrogation by other researchers within the Action Against Stunting Hub. These statements are interpretations of participants’ intended meanings, and links from each of them to data quotes were maintained, enabling future interpretations to refer to them for consistency checks between received and intended meaning.

In this investigation, those Hub Theme Statements (derived from PEX:FGD transcripts) were then deductively coded with respect to any topics with potential implications of the egg intervention. Literature regarding barriers and facilitators to nutrition interventions indicated the following topics could be relevant: attitudes to accepting help; community interactions; cooking and eating habits; traditional beliefs about malnutrition; sharing; social hierarchies [ 12 , 37 , 38 ] to which we added anything related to pregnancy or eggs. This analysis produced our Egg Intervention Themes from the data.

The Major Cultural Themes and Egg Intervention Themes were then used to create a set of culture-based recommendations and intervention specific recommendations respectively for each locality. These recommendations were then combined to form specialized culturally-informed protocols for the egg intervention in each locality: East Lombok, Indonesia and Kaffrine, Senegal. The process is displayed schematically in Fig.  3 .

Schematic representation of the method of production of the culturally-informed protocol for each locality

The preparation of the localised WVIS materials at each site took 6 hours of interview field work, and 40 person hours for analysis. The 10 workshops and data summaries were concluded within 10 workdays by two people (80 person hours). The analysis of the PEX:FGD data took a further 80 person hours. Thus, the total research time was approximately 200 person hours.

The stakeholder group types are summarised in Table 2 . The data is presented in three parts. Firstly, the Major Cultural Themes found in East Lombok, Indonesia and in Kaffrine, Senegal are described – the ones most heavily emphasised by participants. Then, the Egg Intervention Themes and finally, the combined set of Recommendations to comprise a culturally-informed protocol for intervention design for each location. Quotations are labelled INDO or SEN for East Lombok, Indonesia and Kaffrine, Senegal, respectively.

Major cultural themes from frameworks and narratives

These were derived from the Locality Shared Values Statements produced in the WVIS .

East Lombok, Indonesia

Religious values.

Islamic values were crucially important for participants from East Lombok, Indonesia and to their way of life. Through living by the Quran, participating in Islamic community practices, and teaching Islamic values to their children, participants felt they develop their spirituality and guarantee a better afterlife for themselves and their children. Participants stated the Quran tells them to breastfeed their children for 2 years, so they do. Despite no explicit religious official curriculum in Kindergarten, the teachers stated that it was important to incorporate religious teaching.

“East Lombok people always uphold the religious values of all aspects of social life.”

“It is important for me to still teach religious values even though they are not clearly stated in the curriculum.” – Workshop 1 INDO (teachers).

“In Quran for instance, we are told to breastfeed our kids for 2 years. We can even learn about that ” – Workshop 3 INDO (mothers).

Related to this was the importance of teaching manners to children and preventing them from saying harsh words. Teachers stated that it was important to create a happy environment for the children and to ensure that they are polite and well-behaved. Similarly, mothers emphasised the need to teach their children good religious values to ensure they will be polite and helpful to their elders.

“Children don’t speak harsh words.”

“My children can help me like what I did to my parents”.

– Workshop 8 INDO (mothers).

Togetherness within families and the community

The Locality Shared Values Frameworks stressed the importance of togetherness, both within family and community. Comments mentioned it being important that people rely heavily on their family and come together in times of need to support each other and provide motivation. This was also important more broadly, in that people in society should support each other, and that children grow up to contribute to society. This was also reflected in comments around roles within the family. Despite women being primary care givers, and men working to finance the family, participants stated that they follow a process of consultation to make decisions, and when facing hardships.

“that we have the sense of kinship throughout our society”.

“We have togetherness as mothers”.

“For the family side, whatever happens we need to be able to be united as a whole family. We need to have the [sense of] forgiveness for the sake of the children” – Workshop 2 INDO (mothers).

Attitudes about extra-marital pregnancy

In East Lombok, Indonesia, it was essential to both mothers and fathers that pregnancy happened within a marriage, this was to ensure that the honour of the family was upheld and that the lineage of the child was clear. The potential danger to health that early pregnancies can cause was also acknowledged.

“If they don’t listen to parents’ advice, there will be the possibility of pre-marital pregnancy happening, which will affect the family [so much].

The affect is going to be ruining the good name, honour and family dignity. When the children [are] born outside [of] marriage, she or he will have many difficulties like getting a birth certificate [and] having a hard time when registering to school or family” - Workshop 4 INDO (mothers).

“ To make sure that our children avoid getting married at a very young age and moreover [avoid] having free sex so that they will not get pregnant before the marriage” - Workshop 9 INDO (fathers).

Kaffrine, Senegal

The Major Cultural Themes which emerged from the Kaffrine data are described below. As these are grounded themes, they are different than those seen in East Lombok, Indonesia.

Access to healthcare

A recurring theme amongst the groups in Kaffrine were aspirations of affordable and easy-to-access healthcare. Community health workers stated the importance of encouraging women to give birth in hospitals and spoke of the importance of preventing early pregnancy which result from early marriages. Giving birth in hospitals was also a concern for Public Office Administrators who highlighted that this leads to subsequent issues with registering children for school. Mothers and fathers stated the importance of being able to afford health insurance and access healthcare so that they could take care of themselves.

“That the women give birth in the hospital” – Workshop 11 SEN (CHWS).

“To have affordable health insurance ” – Workshop 10 SEN (mothers).

“To have access to health care ” – Workshop 3 SEN (fathers).

“It is important that women give birth in the hospital in order to be able to have a certificate that allows us to establish the civil status” – Workshop 9 SEN (administrators).

Additionally, Community health workers spoke of their aspiration to have enough supplements to provide to their community so as to avoid frustration at the lack of supply, and mothers spoke of their desire to be provided with supplements.

“To have dietary supplements in large quantities to give them to all those who need them, so as not to create frustration” – Workshop 11 SEN (CHWS).

Another aspect of access to healthcare, was mistrust between fathers and community health workers. Community health workers explained that sometimes men can blame them when things go wrong in a pregnancy or consider their ideas to be too progressive. Thus, to these community health workers the quality of endurance was very important.

“Endurance (Sometimes men can accuse us of influencing their wives when they have difficulties in conceiving)” – Workshop 5 SEN (CHWs).

Another recurring theme was the importance of having secure employment and a means to support themselves; that there were also jobs available for young people, and that women had opportunities to make money to help support the family. This included preventing early marriages so girls could stay in school. Having jobs was stated as essential for survival and important to enable being useful to the community and society.

“To have more means of survival (subsistence) to be able to feed our families”.

“To have a regular and permanent job”.

“We assure a good training and education for our children so that they will become useful to us and the community”.

“ Our women should have access to activities that will support us and lessen our burden” – Workshop 3 SEN (fathers).

It was considered very important to have a religious education and respect for religious elders. Moreover, living by, and teaching, religious values such as being hard working, humble and offering mutual aid to others, was significant for people in Kaffrine.

“Have an education in the Islamic Culture (Education that aligns with the culture of Islam)”.

“Respect toward religious leaders” – Workshop 3 SEN (fathers).

“ To organize religious discussions to develop our knowledge about Islam ” - Workshop 10 SEN (mothers).

“ Have belief and be prayerful and give good counselling to people ” - Workshop 4 SEN (grandmothers).

Egg intervention themes from each country from perspectives EXplorations focus group discussion data

Below are results of analyses of comments made during the PEX:FGDs in East Lombok, Indonesia and Kaffrine, Senegal. The following codes were used deductively: attitudes to accepting outside help, traditional gender roles, food sharing, traditional beliefs, social hierarchies and understanding of stunting and Other. These topics were spoken about during open discussion and were not the subject of direct questions. For example, topics relating to traditional gender roles came up in East Lombok, during conversations around the daily routine. Thus, in order to more accurately reflect the intended meaning of the participants, these were labelled food practices, under the “Other” theme. If any of the themes were not present in the discussion, they are not shown below.

Attitudes to accepting outside help

Few mentions were made that focussed on participants attitudes to accepting outside help, but participants were sure that they would not make changes to their menus based on the advice of outside experts. Additionally, teachers mentioned that they are used to accepting help from local organisations that could to help them to identify under-developed children.

“ We don’t believe that [the outsiders are] going to change our eating habits or our various menus ” – Workshop 3 INDO (Mothers).

Traditional gender roles

In East Lombok, mothers spoke about how their husbands go to work and then provide them with daily money to buy the food for the day. However, this was discussed in relation to why food is bought daily and is thus discussed below in the topics Other – Food practices.

Food sharing

In East Lombok, Indonesia, in times when they have extra food, they share it with neighbours, in the hope that when they face times of hardship, their neighbours will share with them. Within the household, they mentioned sharing food from their plate with infants and encouraging children to share. Some mothers mentioned the importance of weekly meetings with other mothers to share food and sharing food during celebrations.

“ Sometimes we share our food with our family. So, when we cook extra food, we will probably send over the food to our neighbour, to our families. So, sometimes, with the hope that when we don’t have anything to eat, our neighbour will pay for it and will [share with] us.” – Workshop 3 INDO (Mothers).

“Even they serve food for the kids who come along to the house. So, they teach the kids to share with their friends. They provide some food. So, whenever they play [at their] house, they will [eat] the same.” – Workshop 2 INDO (Mothers).

Understanding of stunting

The teachers in East Lombok were aware of child stunting through Children’s Development Cards provided by local healthcare organizations. They stated that they recognise children with nutrition problems as having no patience period, no expression, no energy for activities and less desire to socialise and play with other children. The teachers said that stunted children do not develop the same as other children and are not as independent as children who are the proper height and weight for their development. They also stated that they recognise stunted children by their posture, pale faces and bloated stomachs. They explained how they usually use the same teaching methods for stunting children, but will sometimes allow them to do some activities, like singing, later, once the other children are leaving.

“ They have no patience period, don’t have any energy to do any of the activities. No expression, only sitting down and not mingling around with the kids. They are different way to learn. They are much slower than the other kids .” – Workshop 1 INDO (teachers).

“ When they are passive in singing, they will do it later when everyone else is leaving, they just do it [by] themselves ” – Workshop 1 INDO (teachers).

Specific views on eggs

In East Lombok, Indonesia, there were no superstitions or traditional beliefs around the consumption of eggs. When asked specifically on their views of eggs, and if they would like to be provided with eggs, women in East Lombok said that they would be happy to accept eggs. They also mentioned that eggs were a food they commonly eat, feed to children and use for convenience. Eggs were considered healthy and were common in their house.

“ We choose eggs instead. If we don’t have time, we just probably do some omelettes or sunny side up. So, it happens, actually when we get up late, we don’t have much time to be able to escort our kids to the school, then we fry the eggs or cook the instant noodles. And it happens to all mothers. So, if my kids are being cranky, that’s what happens, I’m not going to cook proper meals so, probably just eggs and instant noodles.” – Workshop 3 INDO (Mothers).

Other important topics – food practices

Some detailed themes about food practices were heard in East Lombok, Indonesia. The women were responsible for buying and preparing the food, which they purchased daily mainly due to the cost (their husbands were paid daily and so provided them with a daily allowance) and lack of storage facilities. They also bought from mobile vendors who came to the street, because they could buy very small amounts and get occasional credit. The mother decided the menu for the family and cooked once per day in the morning: the family then took from this dish throughout the day. Mothers always washed their fruits and vegetables and tried to include protein in their meals when funds allowed: either meat, eggs, tofu or tempeh.

“ One meal a day. They [the mothers] cook one time and they [the children] can eat it all day long. Yes, they can take it all day long. They find that they like [to take the food], because they tend to feel hungry.” – Workshop 6 INDO (Mothers).

“ They shop every day because they don’t have any storage in their house and the other factor is because the husband has a daily wage. They don’t have monthly wage. In the morning, the husband gives the ladies the money and the ladies go to the shop for the food. ” – Workshop 4 INDO (Mothers).

In Kaffrine, the following themes emerged relating to an egg intervention: they were different in content and emphasis to Lombok and contained uniquely local cultural emphases.

Mothers were welcoming of eggs as a supplement to improve their health during pregnancy and acknowledged the importance of good nutrition during pregnancy. However, they also mentioned that their husbands can sometimes be resistant to accepting outside help and provided an example of a vaccination programme in which fathers were hesitant to participate. However, participants stated that the Government should be the source of assistance to them (but currently was not perceived to be so).

“But if these eggs are brought by external bodies, we will hesitate to take it. For example, concerning vaccination some fathers hesitate to vaccinate their children even if they are locals who are doing it. So, educating the fathers to accept this is really a challenge” – Workshop 11 SEN (CHWs).

Some traditional gender roles were found to be strong. The participants emphasised that men are considered the head of the household, as expected in Islam, with the mother as primary caregiver for children. This is reflected in the comments from participants regarding the importance of Islam and living their religious values. The men thus made the family decisions and would need to be informed and agree to any family participation in any intervention – regardless of the education level of the mother. The paternal grandmother also played a very important role in the family and may also make decisions for the family in the place of the father. Community Health Workers emphasised that educating paternal grandmothers was essential to improve access to healthcare for women.

“There are people who are not flexible with their wives and need to be informed. Sometimes the mother-in-law can decide the place of the husband. But still, the husband’s [permission] is still necessary.” – Workshop 1 SEN (CHWs).

“[We recommend] communication with mothers-in-law and the community. Raise awareness through information, emphasizing the well-being of women and children.” – Workshop 1 SEN (CHWs).

“The [grand]mothers take care of the children so that the daughters in-law will take care of them in return So it’s very bad for a daughter in law not to take care of her mother in-law. Society does not like people who distance themselves from children.” – Workshop 4 SEN (grandmothers).

Social hierarchies

In addition to hierarchies relating to gender/position in the family such as grandmothers have decision making power, there was some mention of social hierarchies in Kaffrine, Senegal. For example, during times of food stress it was said that political groups distribute food and elected officials who choose the neighbourhoods in which the food will be distributed. Neighbourhood leaders then decide to whom the food is distributed, meaning there is a feeling that some people are being left out.

“ It’s political groups that come to distribute food or for political purposes…organizations that often come to distribute food aid, but in general it is always subject to a selection on the part of elected officials, in particular the neighbourhood leaders, who select the people they like and who leave the others ” – Workshop 11 SEN (CHWs).

Participants explained that during mealtimes, the family will share food from one large plate from which the father will eat first as a sign of respect and courtesy. Sometimes, children would also eat in their neighbour’s house to encourage them to eat.

“ Yes, it happens that we use that strategy so that children can eat. Note that children like to imitate so that’s why we [send them to the neighbour’s house]” – Workshop 11 SEN (CHWs)”.

Traditional beliefs about malnutrition

In Kaffrine, Senegal, some participants spoke of traditional beliefs relating to malnutrition, which are believed by fewer people these days. For example, uncovered food might attract bad spirits, and any person who eats it will become ill. There were a number of food taboos spoken of which were thought to have negative consequences for the baby, for example watermelon and grilled meat which were though to lead to birth complications and bleeding. Furthermore, cold water was thought to negatively impact the baby. Groups spoke of a tradition known as “bathie” in which traditional healers wash stunted children with smoke.

“ There are traditional practices called (Bathie) which are practiced by traditional healers. Parents are flexible about the practice of Bathie ” – Workshop 1 SEN (CHWs).

Causes of malnutrition and stunting were thought to be a lack of a balanced diet, lack of vitamin A, disease, intestinal worms, poor hygiene, socio-cultural issues such as non-compliance with food taboos, non-compliance with exclusive breastfeeding and close pregnancies. Malnutrition was also thought by some to be hereditary. Numerous signs of malnutrition were well known amongst the groups in Kaffrine. For example, signs of malnutrition were thought to be a big bloated belly, diarrhoea, oedema of the feet, anaemia, small limbs and hair loss as well as other symptoms such as red hair and a pale complexion. Despite this, malnutrition was thought to be hard to identify in Kaffrine as not all children will visit health centres, but mothers do try to take their babies heights and weights monthly. The groups were aware of the effect of poverty on the likelihood of stunting as impoverished parents cannot afford food. Furthermore, the groups mentioned that there is some stigma towards stunted children, and they can face mockery from other children although most local people feel pity and compassion towards them. Malnourished children are referred to as Khiibon or Lonpogne in the local language of Wolof.

“ It is poverty that is at the root of malnutrition, because parents do not have enough money [and] will have difficulty feeding their families well, so it is the situation of poverty that is the first explanatory factor of malnutrition here in Kaffrine” – Workshop 9 SEN (administrators).

“It can happen that some children are the victim of jokes for example of mockery from children of their same age, but not from adults and older ” – Workshop 9 SEN (administrators).

Pregnancy beliefs

In Kaffrine, Senegal, there were concerns around close pregnancies, and pregnancies in women who were too young, and for home births. Within the communities there was a stigma around close pregnancies, which prevented them from attending antenatal appointments. Similarly, there were superstitions around revealing early pregnancies, which again delayed attendance at health centres.

Groups acknowledged the role of good nutrition, and mentioned some forbidden foods such as salty foods, watermelon and grilled meat (which sometimes related back to a traditional belief that negative impacts would be felt in the pregnancy such as birth complications and bleeding). Similarly, drinking cold water was thought to negatively affect the baby. Beneficial foods mentioned included vegetables and meat, during pregnancy.

“ Often when a woman has close pregnancies, she can be ashamed, and this particularly delays the time of consultation” – Workshop 5 SEN (CHWs).

“Yes, there are things that are prohibited for pregnant women like salty foods” – Workshop 11 SEN (CHWs).

In Kaffrine, Senegal, some participants spoke of a traditional belief that if a pregnant woman consumes eggs then her baby might be overweight, or have problems learning how to talk. Despite this, mothers in Kaffrine said that they would be happy to accept eggs as a supplement, although if supplements are provided that require preparation (such as powdered supplements), they would be less likely to accept them.

“These restrictions are traditional, and more women no longer believe that eggs will cause a problem to the child. But if these eggs are brought by external bodies, we will hesitate to take it.” – Workshop 11 SEN (CHWs).

“They don’t eat eggs before the child starts speaking (the child only eats eggs when he starts talking). This is because it’s very heavy and can cause bloating and may also lead to intestinal problems.” – Workshop 4 SEN (grandmothers).

Other important topics – access to health services

For the participants in Kaffrine, Senegal, accessing health services was problematic, particularly for pre- and post-natal appointments, which faced frequent delays. Some women had access due to poor roads and chose to give birth at home. Access issues were further compounded by poverty and social factors, as procedures in hospitals can be costly, and women with close pregnancies (soon after an earlier one) can feel shame from society and hide their pregnancy.

“Women really have problems of lack of finances. There are social services in the hospital; but those services rarely attend to women without finances. Even when a child dies at birth they will require money to do the necessary procedure ” – Workshop 11 SEN (CHWs).

Creation of the culturally-informed protocols

Recommendations that comprise a culturally-informed protocol for intervention design in each locality are given in Table 3 .

The Major Cultural Themes, and specific Egg Intervention Themes drawn out from only 9–11 carefully planned group sessions in each country provided a rich set of recommendations towards a culturally-informed protocol for the localised design of a proposed Egg Intervention for both East Lombok, Indonesia and Kaffrine, Senegal. A culturally-informed protocol designed in this way comprises cultural insights which are worthy of consideration in local intervention design and should guide future stages of engagement and provide a platform from which good rapport and trust can be built between researchers and the community [ 16 ]. For example, in Kaffrine, Senegal, the early involvement of husbands and grandmothers is crucial, which reflects values around shared decision making within families that are noted to be more prevalent in LMICs, in contrast to individualistic values in HICs [ 16 , 39 ]. Similarly, due to strong religious values in both East Lombok, Indonesia and Kaffrine, Senegal, partnerships with Islamic leaders is likely to improve engagement. Past studies show the crucial role that religious leaders can play in determining social acceptability of interventions, particularly around taboo topics such as birth spacing [ 40 ].

The WVIS plus PEX:FGD method demonstrated here produced both broad cultural themes from shared values, which were in a concise and easy-to-understand format which could be readily communicated with the wider Action Against Stunting Hub, as well as life practices relevant to stunting in Kaffrine, Senegal and in East Lombok, Indonesia. Discussions of shared values during the WVIS main workshop provided useful cultural background within each community. PEX:FGD discussion uncovered numerous cultural factors within local life practices that could influence on the Egg Intervention engagement and acceptability. Combining themes from the WVIS workshop and PEX:FGDs allowed for specific recommendations to be made towards a culturally-informed protocol for the design of an Egg Intervention that included both broad cultural themes and specific Intervention insights (Table 3 ). For example, in Kaffrine, Senegal, to know that the husband’s authoritative family decision-making for health care (specific) is rooted in Islamic foundations (wider cultural) points to an Intervention Recommendation within the protocol, involving consultations with Islamic Leaders to lead community awareness targeting fathers. Similarly, in East Lombok, Indonesia the (specific) behaviour of breastfeeding for 2 years was underpinned by (wider cultural) shared values of living in Islam. This understanding of local values could prevent the imposition of culturally misaligned values, which Bernal and Adames (2017) caution against [ 17 ].

There are a number of interesting overlaps between values seen in the WVIS Frameworks and Narratives and the categories of Schwartz (1992) and The World Values Survey (2023) [ 41 , 42 ]. For example, in both Kaffrine, Senegal and East Lombok, Indonesia, strong religious values were found, and the groups spoke of the importance of practicing their religion with daily habits. This would align with traditional and conservation values [ 41 , 43 ]. Furthermore, in Kaffrine, Senegal participants often mentioned the importance of mutual aid within the community, and similar values of togetherness and respect in the community were found in East Lombok, Indonesia. These would seem to align with traditional, survival and conservation values [ 41 , 43 ]. However, the values mentioned by the groups in the WVIS workshops are far more specific, and it is possible that through asking what is most worthwhile, valuable and meaningful about their context, the participants are able to prioritise which aspects of their values are most salient to their daily lives. Grounded shared values such as these are generally neglected in Global Health Research, and values predominant in the Global North are often assumed to be universal [ 14 ]. Thus, by excluding the use of a predefined external framework, we minimized the risk of imposing our own ideas of values in the community, and increased the relevance, significance and local validity of the elicited information [ 28 ].

Participatory methods of engagement are an essential step in conducting Global Health Research but there is currently a paucity of specific guidance for implementing participatory methods in vulnerable communities [ 16 , 44 ]. In addition, there is acknowledgement in the literature that it is necessary to come into communities in LMICs without assumptions about their held values, and to use bottom-up participatory approaches to better understand local values [ 14 , 16 ]. The WVIS plus PEX:FGD methodology highlighted here exemplifies a method that is replicable in multiple country contexts [ 28 , 32 ] and can be used to crystallize local In Situ Shared Values which can be easily communicated to external researchers. Coupled with the specialised FGD (PEX:FGD), values-based perceptions of specific topics (in this case stunting) can be elicited leading to the creation of specific Culture-based recommendations. This therefore takes steps to answer the call by Memon and colleagues (2021) for the creation of cultural protocols ahead of conducting research in order to foster ethical research relationships [ 16 ]. We believe that the potential usefulness of the WVIS approach to guide engagement and inform intervention design is effectively demonstrated in this study and WVIS offers a method of making explicit local values in a novel and valuable way.

However, we acknowledge that our approach has several limitations. It has relied heavily on the local university researchers to debate and decide which participant stakeholder groups should be chosen, and although they did this in the context of the Whole Child approach, it would have been advantageous to have involved cultural researchers with a deeper understanding of cultural structures, to ensure sufficient opportunities for key cultural elements to emerge. This would have in particular strengthened the intervention design derived from the PEX:FGD data. For example, we retrospectively realised that our study could have been improved if grandmothers had been engaged in East Lombok. Understanding this limitation leads to suggestion for further work: to specifically investigate the overlap of this approach with disciplinary studies of culture, where social interactions and structures are taken into account via formal frameworks.

There are more minor limitations to note. For example, the WVIS approach can only be led by a trained and experienced facilitator: not all researchers can do this. A training programme is currently under development that could be made more widely available through online videos and a Handbook. Secondly, although the groups recruited do not need to be representative of the local population, the number recruited should be increased until theoretical saturation is achieved of the themes which emerge, which was not carried out in this study as we focussed on demonstrating the feasibility of the tool. Thirdly, there is a limit to the number of topics that can be explored in the PEX:FGDs within the timeframe of one focus group (depending on the stamina of the participants), and so if a wider range of topics need formative research, then more workshops are needed. Lastly, this work took place in a large, highly collaborative project involving expert researchers from local countries as well as international experts in WVIS : other teams may not have these resources. However, local researchers who train in WVIS could lead on their own (and in this Hub project such training was available).

The need for better understanding, acknowledgement and integration of local culture and shared values is increasing as the field of Global Health Research develops. This study demonstrates that the WVIS plus PEX:FGD shared values approach provides an efficient approach to contextualise and localise interventions, through eliciting and making communicable shared values and local life practices which can be used towards the formation of a culturally-informed protocols. Were this method to be used for intervention design in future, it is possible that more focus should be given to existing social structures and support systems and a greater variety of stakeholders should be engaged. This study thus contributes to the literature on methods to culturally adapt interventions. This could have significant implications for improving the uptake of nutrition interventions to reduce malnutrition through improved social acceptability, which could help progression towards the goal of Zero Hunger set within the SDGs. The transferability and generalisability of the WVIS plus PEX:FGD approach should now be investigated further in more diverse cultures and for providing formative research information for a wider range of research themes. Future studies could also focus on establishing its scaling and pragmatic usefulness as a route to conceptualising mechanisms of social acceptability, for example a mechanism may be that in communities with strong traditional religious values, social hierarchies involving religious leaders and fathers exist and their buy-in to the intervention is crucial to its social acceptability. Studies could also focus on the comparison or combination of WVIS plus PEX:FGD with other qualitative methods used for intervention design and implementation.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request [email protected], Orcid number 0000–0002–1811-4597. These include deidentified Frameworks of Shared Values and Accompanying Narrative from each Group; deidentified Hub Insight Statements of relevant themes.

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Acknowledgements

We thank the Hub PI, Claire Heffernan, for feedback on a late draft of the manuscript.

The Action Against Stunting Hub is funded by the Medical Research Council through the UK Research and Innovation (UKRI) Global Challenges Research Fund (GCRF), Grant No.: MR/S01313X/1.

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Annabel J. Chapman, Mahsa Firoozmand & Marie K. Harder

Department of Environmental Science and Engineering, Fudan University, Shanghai, People’s Republic of China

Chike C. Ebido, Rahel Neh Tening, Yanyan Huang & Marie K. Harder

Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Nigeria

Chike C. Ebido

Preventive Medicine and Public Health, Université Cheikh Anta Diop (UCAD), Dakar, Senegal

Ndèye Marème Sougou

Faculty of Psychology, Universitas Islam Negeri Syarif Hidayatullah, Jakarta, Indonesia

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Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON) Universitas Indonesia, Jakarta, Indonesia

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Contributions

MKH formulated the initial research question and study design. AJC developed the specific research question. Data collection in Senegal involved CCE, NMS, AHD, FBD, RNT, CEHAN and JM. Data collection in Indonesia involved RA, RK, YH and MKH. Cultural interpretation in Senegal Involved AHD, FBD, NMS, RNT and JM. Analysis involved AJC and MF. AJC and MKH wrote the paper.

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Correspondence to Marie K. Harder .

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The research was conducted in accordance with the Declaration of Helsinki and has been approved by the Ethics Review Board of the University of Brighton, and national ethics committees for research in Indonesia and Senegal. Informed consent was obtained in the local vernacular language, Bahasa, French or Wolof. Participants retained a copy of the informed consent document for reference.

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Chapman, A.J., Ebido, C.C., Tening, R.N. et al. Creating culturally-informed protocols for a stunting intervention using a situated values-based approach ( WeValue InSitu ): a double case study in Indonesia and Senegal. BMC Public Health 24 , 987 (2024). https://doi.org/10.1186/s12889-024-18485-y

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Received : 27 September 2023

Accepted : 29 March 2024

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DOI : https://doi.org/10.1186/s12889-024-18485-y

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