Masterclass ACWA 2010 Learning from studies of child death and serious harm

1. Masterclass ACWA 2010Learning from studies of child death and serious harm Dr Marian Brandon (m.brandon@uea.ac.uk)

2. ACWA Masterclass4th August 2010 • Using inquiries for research • Understanding patterns - the child, the family, the practice in SCRs • Lessons for policy and practice improvement • Embedding findings into practice • Tools for practice

3. What is a serious case review?Working Together : A guide to interagency working to safeguard and promote the welfare of children 2010 • Carried out when: Abuse and neglect are known or suspected and a child has: i) died or ii) been seriously harmed and there is cause for concern as to the way in which (agencies) have worked together to safeguard the child • “The prime purpose of a SCR is for agencies and individuals to learn lessons (asap) to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children”

4. How is a serious case review compiled? • Individual Management Reviews (IMRs) of involvement with child and family from each service/agency involved • An Integrated Chronology of involvement with the child/family • Overview Report – bringing together and analysing information from all IMRs and recomendations for future action • Executive Summary – to be made public (eg published on Local Safeguarding Children Board website)

5. The Serious Case Review Studies England 2003-2009 Wales 1999-2009

6. Biennial Analyses – England (600+cases) • Building on the Learning from Serious Case Reviews: a two year analysis of child protection database notifications 2007-2009 (DfE ?2010) Sue Bailey, Pippa Belderson, Marian Brandon. • Understanding Serious Case Reviews and their Impact: A biennial analysis of serious case reviews 2005-07 (DCSF 2009) Marian Brandon, Sue Bailey, Pippa Belderson, Ruth Gardner, Peter Sidebotham, Jane Dodsworth, Catherine Warren and Jane Black. • Analysing Child Deaths and Serious Injury through Abuse and Neglect: What can we Learn? A Biennial Analysis of Serious Case Reviews 2003-2005 (DCSF 2008) Marian Brandon, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth, Jane Black.

7. Biennial Analyses – Wales (38 cases) • Still Learning How to Make Children Safer : An Analysis for the Welsh Assembly Government of Serious Case Reviews in Wales –18 cases Marian Brandon, Julie Young, Ruth Gardner, Jane Black (UEA/WAG 2010) • Learning How to Make Children Safer Part 2: An Analysis for the Welsh Assembly Government of Serious Child Abuse in Wales 10 cases-Marian Brandon, David Howe, Jane Black, Jane Dodsworth (UEA/WAG 2002) • Learning How to Make Children Safer: An Analysis for the Welsh Office of Serious Child Abuse in Wales 10 cases - Marian Brandon, Mark Owers, Jane Black (UEA/Welsh Office 1999)

8. Research questions (Derived from guidance in Working Together 2006 etc) • What are the themes and trends across reviews reports? • What can we learn about inter-acting risk factors? • What are the lessons for policy and practice? • (And for 2005-7 study) What can we learn about the process of SCRs to inform new guidance NB not preventability (overtly)

9. Methodology - England Layer 1- Mostly Quantitative Basic information from ‘notification’ database 2003-5 -161 cases. 2005-7 - 189 cases 2007-09 – 268 cases Layer 2 – Mostly Qualitative 2003-5 sub-sample of 47 cases, 2005-7 sample of 40 cases (information from Overviews reports)

10. Theory to understand: Ecological transactional analysis/ developmental theory Carer’s own relationship and history Carer’s state of mind, level of reflective function Social stress, relationships, environmental stressors Caregiving environment generated by carer Child’s behaviour, adaptive strategies, and developmental state.

11. A typical serious case review(death or serious injury of a child where abuse or neglect is a factor) “ [mother] had a series of violent partners…, suffered with mental health problems, anxiety and depression and was misusing alcohol. The family changed address frequently….all three children witnessed serious domestic abuse… [mother] failed to attend a number of medical appointments with the children.” • How different from any case on a social worker’s or health visitor’s case load where children don’t die??

12. The problem with learning from reviews of worst cases • Correlation not the same as causation (eg high level of co-existing domestic violence, mental ill health, substance misuse does not predict child death/serious injury) • The need for ‘scientific rigour not tragic anecdote.’ • Reviews are selective – they don’t represent all homicides or all serious injuries. • LSCBs have small numbers of SCRs (but growing) – how typical are these cases of child protection & safeguarding work?

13. Patterns in Serious Case Reviews • Are SCRs unique or part of a pattern? (Both). 350 SCRs between 2003-2007 studied – some patterns evident (and new 2007-09 study of 268 cases confirms patterns) • Known to Social Services?: Just under half of children NOT known to SS at time of incident (BUT ¾ known to SS in past) • CP Plan? (confirmed CP): Less than 1:5 children with a current CP plan (BUT in 1:3 cases, child or sib had plan in the past) • Physical injury the major cause of death. Neglect an underlying theme in many cases but rarely the principal cause of death. More neglect and sexual abuse as prime concern in serious harm cases.

14. Age of child at time of incident 2003-2005 2005-2007 2003-2005

15. Extension of Sidebotham’s classification of SUDI (2007) • A Infanticide and “covert” homicide • B Severe physical assaults • C Extreme neglect / deprivational abuse • D Deliberate / overt homicides • E/F Deaths related to but not directly caused by maltreatment, including suicides and deliberate self harm NB: Classifications differ in relation to the characteristics of the victims and perpetrators, the mode of death and the intentions behind the death.

16. Age profile of maltreatment related deaths (2005-07 n= 123)

17. Interacting factors

18. Categorisation of the 47 cases – 2003-05 • 1:3 = Neglect (known to many agencies, long term cases ‘start again syndrome’) • 1:3 = Physical assault, (known to few agencies, most shaken baby cases, context of known volatility and family violence in 87%) • 1:3 = Agency neglect (Older children over 13 years, long agency history, self neglect including suicide, assault of others, hard to help, agencies have given up).

19. Chaotic families: Professional responses & behaviour Overwhelmed chaotic families, negative family support, drugs, violence, mental ill health, criminality Invisible children Too much to achieve, low expectations, ‘success’ is getting through the door, muddle about confidentiality Efforts not to be judgemental, whole picture missed, silo practice.

20. Positive Practice Cycle Good, reflective, challenging supervision Clear communication with other agencies. Child seen. kept in mind, understood Good working relationships with children and their families

21. The struggle not to be overwhelmed (practitioners and reviewers) • ‘Do the simple things well’ (Laming 2003) - but acknowledge that child protection is NOT simple. • The capacity to understand the ways in which children are at risk of harm requires clear thinking. • Application of theory helps practitioners to hold steady in the midst of chaos • Practitioners who are overwhelmed, not just with the volume of work but by the nature of the work, may not be able to do even the simple things well. • “..ultimately the safety of a child depends on staff having the time, knowledge and skill to understand the child or young person and their family circumstances.” (Lord Laming 2009:10)

22. Tools for Practice and the review context

23. A typical serious case review(death or serious injury of a child where abuse or neglect is a factor) “[mother] had a series of violent partners…, suffered with mental health problems, anxiety and depression and was misusing alcohol. The family changed address frequently….all three children witnessed serious domestic abuse… [mother] failed to attend a number of medical appointments with the children.” • Biennial Analyses of Serious Case Reviews 2003-5 (161 cases) and 2005- 2007 (189 cases)

24. Understanding inter-acting risk factors and their impact on the child Ecological transactional perspective :better understanding of parental history/capacity and assessment of risk

25. Interacting risk factors: an ecological-transactional perspective • Importance of understanding parental psychology • Importance of historical context and a dynamic, analytical assessment (not incident driven) • Interaction between child and caregivers • Consider dynamics of engagement with professionals • Incorporate this way of thinking into multi-agency practice and SCR work.

26. Interacting risk factors: an ecological-transactional perspective • Importance of understanding parental psychology • Importance of historical context and a dynamic, analytical assessment (not incident driven) • Interaction between child and caregivers • Consider dynamics of engagement with professionals • Incorporate this way of thinking into multi-agency practice and SCR work.

27. Ecological transactional analysis(Brandon et al 2002) Carer’s own relationship and history Carer’s state of mind, level of reflective function Social stress, relationships, environmental stressors Caregiving environment generated by carer Child’s behaviour, adaptive strategies, and developmental state.

28. Case Study 1: baby K • Borderline child protection threshold, • poor cooperation, • parental mental health, • neglect, • large family size, • ‘start again’ syndrome

29. Baby K died age 8 weeks. 6th child of family • Differing professional views about the acceptability of poor, unhygienic conditions at home and other concerns. • Differing views about baby’s possible failure to thrive. Serious concerns from school about older siblings. • History of neglect, violence (between parents and towards children and from children) maternal depression, parental drug misuse. Father had conviction for violence with weapons. Sibling in residential care.

30. Professional Learning • Dangers of professionals ‘starting again’ with a new baby. • Increased family stresses missed (not coping with large family, worsening conditions at home, increased parental substance misuse). • Professional fear leaves children unprotected. • Lack of sustained professional challenge. Preoccupation with threshold rather than shared responsibilities.

31. Case Study 2: Ellie (age 3) • Neglect • Poverty and social isolation • Not meeting the threshold for intervention from children’s social care • Parental alcohol misuse and maternal depression

32. Background • Ellie, aged 3, youngest of 4 children, seriously burned in accident at home. Number of previous reports to CSC of all the children being seen with bruises, being left at home unsupervised and found wandering in the street. Pattern of the family being visited by CSC, an initial assessment being carried out, advice given and the case being closed. Concerns about the parents’ abilities to meet the children’s needs. Judged not to meet the threshold for safeguarding intervention.

33. Child, parent, environmental characteristics child’s needs/characteristics/behaviour • Ellie’s nursery, and her siblings’ schools, had concerns about the children’s appearance, often unkempt, wearing inadequate or dirty clothing. • Attendance records poor for all children. mother’s history/profile/parenting capacity • Several years in care as a child - concerns about her own mother’s caregiving. Returned home but a difficult relationship with mother. Known to CAMHS as a teenager - behavioural problems at home. • Relationship with Ellie’s father began at age 16 - father of all four children.

34. Child, parent, environmental characteristics Mother contd • Depression and panic attacks. • Her parenting just about ‘good enough’ although there were persistent concerns about adequate supervision. father’s history/profile/parenting capacity • Evidence of some domestic violence (police called to 1 incident). Problems with alcohol misuse. Little recorded information about him or his past. family environment • Overcrowding and unhygienic conditions. Little support from wider family, socially isolated. Neither parent in work, family had financial difficulties.

35. Analysis of Interacting Risk Factors • ‘depressed neglect’ “the run down feeling that pervades passively neglectful families can affect the spirits of those who work with them” (Howe 2005 p135). • Missing medical appointments, poor school attendance and resigned compliance with CSC assessments - pervasive apathy common in families where there is this type of neglect.

36. Analysis of inter-acting risks contd • Mother’s history and her current depression will mean that it’s difficult for her to keep her children ‘in mind’. • Need to know more about Ellie’s father - extent of domestic violence unclear, alcohol misuse may be a trigger. Other meanings of alcohol misuse?– does his behaviour contribute to the helplessness and listlessness in family? OR Does he provoke fear in the children and his partner? • Either way, in the presence of a drunk parent the child is likely to feel emotionally abandoned and frightened (Howe 2005 p184). • What is it like to be Ellie?

37. Hard to help adolescents- suicide • Death at (institution). previously accommodated, hard to help. On occasions mum had refused to have her home because she felt that she was being disruptive and she was unable to manage her behaviour. X was placed in a variety of foster placements and children’s homes. Following her last discharge from accommodation, she went to a hostel and B&B with intermittent periods of return home (suicide 16). • X was a carer for his disabled brother at home, and struggled both at school and in his home community where he was bullied (suicide age 14). • No one professional seems to have known them (x and her sister) or been able to gain access to them for any substantial length of time…Even the schools did not get to know them well enough to identify other problems (other than non school attendance). (suicide age 16) • Need for services to address trauma, rejection and long term abuse • Need for accessible CAMHS and outreach services for children at lower levels of intervention.

38. Template for a Chronology Summary (Brandon et al 2008:138) • Brief summary of family history: • Child’s history, profile, characteristics and behaviour: • Mother’s (or carer’s) history, profile, parenting capacity: • Father’s (or carer’s) history, profile, parenting capacity: • Family environment: • Characteristics of professional involvement: • Analysis of interacting risk factors: • Lessons learnt:

40. The serious case review/inquiry process Lessons learnt

41. Negative SCR cycle Positive SCR cycle

42. Level of intervention and degree of cooperation with agencies at time of incident n=47 Levels 3 and 4 Child protection/ regulatory/ restoratory services Levels 1 and 2 (Universal services and early needs) Lack of cooperation Co-operation

43. Level of services (Levels 1-4) and Degree of parental/child cooperation →