Child B SCR Learning Briefing - Final Version

Child B SCR Learning Briefing - Final Version

LEARNING FROM SERIOUS CASE REVIEWS- CHILD B

Amessage from Child B’s sibling to all professionals:

“You should’ve been on our side, not my mum’s. You should’ve listened to us but you didn’t, you picked her instead”.

CHILD B- Published3rd January 2017

Staffordshire LSCB commissioned a Serious Case Review (SCR) into the death of Child B in2014. The serious case review focusses specifically on services that were provided to Child B and her family from December 2012 until July 2014and explored how agencies worked together and individually prior to her death.

Working Together 2013 states that LSCB’s may use any learning model which is consistent with the principles in the guidance. It was agreed that this review would be conducted using the Social Care Institute for Excellence (SCIE) Learning Together systems methodology.

CHILD B'S STORY

Child B was a female child who mainly lived with her mother Adult S and her two older half-siblings. In July 2014 Child B died aged 14 months old. At the time of her death she was the subject of a child protection plan under the category of neglect; this was mainly attributable to concerns about her mother’s alcohol misuse. Following her death, Child B was the subject of a post-mortem examination. Whilst the cause of death was unascertained and concluded that Child B had died from natural causes, there were concerns that Child B had died while co-sleeping with her mother and maternal grandmother; both of whom were believed to have been under the influence of alcohol.

WHAT DID THE REVIEW TELL US?

We need to get better at recognising risk:

Despite repeated concerns about the likelihood of significant harm no child protection enquiries were ever conducted in relation to Child B or her siblings. There was sufficient evidence to indicate the children were at risk of significant harm and to justify child protection enquiries; instead the case was allocated for a child in need child social work assessment. It was not until a later period that a decision was made to initiate a child protection conference.

In total there were five critical incidents related to the children’s mother’s alcohol misuse,which represented missed opportunities to take protective safeguarding action on behalf of Child B and her siblings.

We need to keep a clear focus on the child:

All of thepractitioners who had direct contact with Child B’s mother liked her and she was described as being pleasant, intelligent and articulate. Professionals thought Child B’s mother had insight into her difficulties; she appeared to be seeking help and keen to overcome the problems she associated with the complex relationships she had with two of her children’s birth fathers. She was involved with a number of agencies, each of which believed she was actively engaged with their service with the intention of improving her own circumstances and as a consequence, improving her children’s circumstances.

In reality Child B’s mother did not engage with any agency in any meaningful way throughout the period of the review. As a consequence she never changed and her children’s circumstances never changed.

Despite this there is no evidence to indicate that Child B’s mother was ever challenged or confronted about the impact of her behaviour on her children.

We have to get better at talking to each other:

Following a referral to CSC in February 2014 there was no evidence that any multi-agency (lateral) information checks were undertaken prior to the start of the child in need (CIN) child social work assessment. Despite Child B’s mother’s involvement with a number of agencies and the fact that all three children were the subjects of CIN plans, there is virtually no record of any inter-agency communication prior to the initial child protection conference.

The agencies that were involved with Adult S all had information that was relevant to the safeguarding of Child B and her siblings.

We have to hear and listen to the child’s voice:

Child B’s older siblings were spoken to by police officers and Children’s Social Care (CSC) practitioners on a number of occasions. On each occasion that they were spoken to they repeated the same two things:

Their mother drank all of the time and they were frequently left to care for Child B; andThey no longer wished to live with their mother and wanted to stay with one of their birth fathers.

Practitionersdid not take what the children were saying about the extent of Adult S’s problematic drinking seriously and take action to move them to a safe place to secure their safety. It was believed by professionals that their mother’s excessive drinking was the exception rather than the rule, because this is what she was telling them.

If written agreements don’t work we need to take action:

A number of written agreementshad been put into place by CSC with Child B’s mother and extended family members. The written agreements were put in place in order to provide CSC with assurances that Child B’s mother and her extended family understood the concerns about the children and were prepared to act to secure their safety and welfare. The written agreementsmade it clear to all parties about where the children should live and placed a requirement on their mother that she would not drink whilst she had the care of the children. These were signed by all parties.

In reality the agreements were breached almost immediately by Adult S and her family. No action was taken with the family in response to these breaches and further written agreements were put into place.

We need to actively involve any men:

The birth fathers of Child B and one of her siblings were key figures in the way the concerns about the three children were managed. One of them was important because he regularly reported concerns about Child B’s mother’s drinking habits and he looked after the older siblings in times of crisis. The birth father of Child B was important because he was an alleged source of distress to Child B’s mother and a reported trigger for her drinking. He was also seen as a protective factor for Child B during one incident.

Both men attended the child protection meetings but they were not involved in the child social work assessment or spoken to alone by any practitioners about the nature and extent of Adult S’s use of alcohol, or the nature of their relationships with any of the children.

The failure to engage fully with the birth fathers both in the assessment and in the longer term planning for the children was a missed opportunity.

We all need to recognise neglect and the effect on children:

In the records of the interventions from all agencies prior to the child protection conference there is no mention of neglect or the impact of the children’s mother’s alcohol misuse on her children. Instead the focus was on the mother and providing her with the support she said she needed to address her personal difficulties. Even when the children became the subjects of child protection plans on the grounds of neglect, there was no acknowledgement of the impact of the neglect that the children had experienced.

It is likely that all of the children had experienced the consequences of their mother’s problematic drinking behaviour throughout their entire childhoods.

KEY MESSAGES FOR PRACTITIONERS:

SEE, LISTEN TO AND HEAR CHILDREN. What are they telling you and how does this confirm or change your views as a practitioner about their welfare and safety? Put yourself in their position and think - what is it like to live in this child’s shoes?

Understand risk factors and challenge the decision making of CSC or other partnerswhen you don’t think this is right. Use the SSCB Multi-agency Escalation Procedure on the SSCB website to help you to do this.

Child neglect is a complex issue and it’s easy for practitioners to lose focus of the child. Every time you see a child and when you leave them think about where your focus is - don’t be blindsided by the parent or carer’s behaviour or needs.

Children living with long term parental alcohol misuse can experience neglect through both physical and emotional harm–Ask about the parent / carer’s level and frequency of substance use – think - what impact does this have on their ability to provide safe, consistent care for their child/ren?

If you have any historical or current information about the welfare and potential safety of a child SHARE ITwith any other professionals involved in working with the child or adults. RECORD IT. You may hold a missing piece of a wider picture that helps to make sense of what it’s like to live in this child’s shoes. Without this our child protection system is unsafe.

The final responsibility for safeguarding children does not rest with Children’s Social Care- WE ALL OWN IT AND NEED TO SHARE IT if children are to be truly protected from harm. So DON’T ASSUMEthat protective action has been taken by another practitioner – CHECK IT HAS HAPPENED.

THINK- WHO ARE THE MEN IN THE CHILD’S LIFE?By engaging them we understand more about the nature of their relationship with the child/ren, other adults in the child’s life and whether they are a source of safety or danger.DON’T MAKE ASSUMPTIONS ABOUT THE ROLE THEY PLAY in the lives of their children or else you’re in danger of making false assumptions about their ability or otherwise to keep them safe.

Some adults will lie so you don’t know the full extent of the issues and their behaviours. Some adults will deny, minimise or distort the extent of their risky behaviour so you think they are good parents. THINK- how do you know parents or carers are telling you the truth (such as about their level of frequency of any substance use)?BE PROFESSIONALLY NOSEY AND DON’T TAKE INFORMATION AT FACE VALUE;check out what is being said with others to try and confirmit.

You should challenge parents/carersover any denials, minimisations or inconsistencies between what they are saying and any other known information.If you’re not feeling confident enough to make the challenge, go and get some support from your colleagues and managers to help you to do it.

We can all have a view about a family or situation and not change this even when we receive information that tells them that this view needs to change. Self-reflection, reflective supervisionand multi-agency meetings offer opportunities to challenge ourselves and others on any formed judgements and fixed views. This is critical to having safer local safeguarding arrangements.

A child protection conference is the arena for risk management. It has two key tasks to perform. 1. To understand, analyse and make explicit the risks that are present; and 2. To develop risk management plans that clearly identify the sources of likely harm; and what needs to happen to reduce the identified risk.At the conclusion of any conference all professionals and parents/carers alike should be in no doubt about what are the causes for concern, how serious these are, what needs to be done to reduce risk and needs, by whom and within what timescale. All actions should be reviewed every time there is a core group or conference. Think - What changes have been made to make this child’s life safer?

DISSEMINATION OF LEARNING

Sharing learning from serious case reviews and local learning reviews is vital if we are to work together to help strengthen our local safeguarding children arrangements and help to keep children and young people in Staffordshire safer.

This briefing has been produced as a publically facing document and should be used by all SSCB partner agencies as a key learning document within their own workforce to help raise the knowledge and skills of frontline practitioners working with children and their families. This briefing should be used to drive local improvements within multi-agency and single agency workforce, development and training arrangements.

The SSCB continues tocoordinate multi-agencyLessons from Serious Case Reviews Training events which are available for all practitioners to attend. To access SSCB Lessons from Serious Case Reviews please visit the SSCB website at:

If you would like to discuss this serious case reviewbriefing or any of its contents then please speak to your line manager, your representative on the SSCB or contact the SSCB Office at

THINK CHILD- SEE, LISTEN AND HEAR CHILDREN