Serious Case Reviews

1. Serious Case Reviews Local Lessons & Actions www.hertsdirect.org/safeguardingchildren

2. Why do we undertake SCRs? Regulation 5 of the LSCB Regulations 2006 states: “(1)The functions of a LSCB in relation to its objective ....are as follows- (e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.”

3. When do we undertake SCRs? When a child dies andabuse or neglect is known or suspected to be a factor in the death, the LSCB should alwaysconduct a SCR into the involvement of the organisations and professionals in the lives of the child and family. (Working Together, 2010)

4. When do we consider undertaking SCRs? • When a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse; or • A child has been seriously harmed as a result of being subjected to sexual abuse; or • A parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004; or • A child has been seriously harmed following a violent assault perpetrated by another child or an adult; AND The case gives rise to concerns about the way local professionals and services worked together to safeguard the children.

5. What is the purpose of a SCR? • To establish what lessons there are about the way professionals and organisations worked individually and together. • To identify how theses lessons will be acted on; in what timescale; and what is expected to change • To improve intra- and inter-agency working & therefore better safeguard children.

6. Alternative methods of Learning • Partnership Case Reviews – a systemic model that is new to Hertfordshire building on the experience of the police. • Individual agency reviews – where one agency/organisation would review its work or involvement with a family. • Working groups to address specific case issues.

7. SCR in Hertfordshire 5 SCR completed in past year 3 deaths and 2 serious injuries 3 under 5 years old 1 teenager Parental mental health problem 3 cases Domestic Violence 4 cases Parent with learning disability 1 case Substance misuse 1 case Neglect 5 cases www.hertsdirect.org/safeguardingchildren

8. What were the lessons in Hertfordshire • Keeping a focus on the child • Can/are the parents meeting the child’s needs • Working across adult and children's services • Making best use of expertise • Accessing and taking account of past history • Start again syndrome & the rule of optimism www.hertsdirect.org/safeguardingchildren

9. What were the lessons in Hertfordshire • Assessing the impact of cumulative risk factors on parenting ability • Working with complexity • All significant adults should be included in assessments • The absence of fathers, male partners, relatives • Critical and authoritative child protection practice • Family & professional accountability

10. Implementing the Learning • SCR Panel has monitoring role • Evidence of progress against the Multi-agency and IMR plans • HSCB Sub- groups cross reference actions to ensure all actions taken forward • Actions cross referenced business plan

11. Evidence of Learning • 5 cases of Neglect – Pilot graded care profile • Multi- agency conference November • Updated Child Protection Procedures June 2010- Practice guidance • Audit quality of assessments in cases of neglect

12. Evidence of Learning • Assessments/Domestic violence- keeping the focus on the child • Developing multi-agency assessment tool • Reshaping front end of the service improve quality of assessments – Targeted Advice Service • Adult Safeguarding Board

13. Evidence of Learning • HSCB – Learning the Lessons programme • Partnership News • Social Care – Learning the lessons workshops and monthly bulletins • Evidence of good practice