Lessons learned from national and local experience.

1. Central Bedfordshire Local Safeguarding Children Board Lessons learned from national and local experience. For all practitioners and managers working with children and the adults who care for them.

2. Purpose of discussion To consider the lessons learned from local case audits and from serious case reviews carried out by other LSCB’s. To discuss the issues raised To consider current practice and improvements needed Central Bedfordshire Local Safeguarding Children Board

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

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

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

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

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

8. Lessons learned: False and non-compliance • Are interventions taking place? • Are they making a difference? • Measure interventions in terms of outcomes • What improvements do you expect to see in the child?

9. Lessons learned: Thresholds

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

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

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

13. Thank you! • Any feedback for the LSCB? • What can we do to support multi-agency safeguarding work and practice? • Please contact the team on 0300 300 6455 or e-mail the LSCB team at LSCB@centralbedfordshire.gov.uk