April2014
Safeguarding Matters
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This special briefing for Children’s Social Care staff has been produced to share the important messages from National Serious Case Reviews.
These cases involve the death or serious injury of a child. In each case gaps in the practice of individual practitioners and multi-agency working have been identified. The details of the cases are upsetting but it is important we understand the context so we can continue to learn and develop confidence in best practice to promote and protect those who are vulnerable.
Use this special staff briefing in supervision, team meetings or learning events to prompt discussion and develop practice.
Dot Evans
Head of Service (Safeguarding)
Children’s Specialist Services
Ask yourself the following questions:
Recognition – Do you know what abuse lookslike?Whatarethethresholdsfor concern?
Report–Doyouknowwhotosharethis informationwith?Doyoufeelconfident totalktothatperson?Whatwillyoudo ifyouarenotlistenedto?Doyouknow howtoescalateconcern?Doyouknow howtowhistleblow?
Risk–Doyouknowwhatmakessome situationsmorerisky? Ifnot,doyoufeelconfidenttoask?Doyouknow what‘safe’lookslike?Acknowledgethe resilientfactors.
Relevance–Doyouunderstand the relevanceoftheinformationyouhave? Doesitmatterifyoudon’t?Itmaybe relevanttothebiggerpictureandanother agencymaythinkitiscriticallyrelevant.
Resistance–Doyoufeelconfidentto challengefamilies or colleagues?Can you recognisewhenpeoplearebeing evasive?
Relationships - Are you clear about the boundaries of your relationship with children, adults, families and carers? How do you avoid collusion? Are you clear what your role is?
Recording–Isyourrecordingclear, evidencedbased, withagreedactions andtimescales?Canyoustate‘inmy professionaljudgement’withconfidence?
Representing–Isthevoiceofthechild or adultheard?Howdoyouensurethey haveeveryopportunitytobepartofthe process?Canyou‘walkintheirshoes’?
Review–Whatareyourcontingency plans?Howdoyoucopewithchange?
Responsive-Howdoyoumanage optimismandpessimismascompletely naturalhumanresponses tocomplex situations?
Reflection-Doyouhavespace personallyandprofessionallytolearn? Howdoyouchallengeyourown judgements?
The Underwear Rule – NSPCC Campaign – Launch 13 January 2014
LastyeartheNSPCCranacampaigntoencourage parentsandcarersof5-11yearoldstotalktotheir childrenaboutkeepingsafefromsexualabuseandtobuildtheirconfidencebyencouragingthemtouse theUnderwearRule.Thisputsacrossthemessage thattheareascoveredbyyour underwearareyours andprivatetoyou.Ifanyonetouchesthoseareasyou shouldtellaparentorsomeoneyoutrust.Wewish to maintain and improve levels of awareness of the importance of talking to children.
The NSPCC have developed materials and a booklet for parents to support the campaign and you can view these on the NSPCC website:
rule_wda97129.html
BarrierstoRecognising,RespondingandReportingOrganisationalResponsibilities
Notes
1. / Providing safeguarding training opportunities.
2. / All staff and managers understanding their responsibility to undertake supervision as outlined in a Supervision Policy.
3. / Developing a culture where fellow professionals offer supervision.
4. / Changing the way organisations manage frontline staff will have an impact on how they interact with children and families. There is evidence that workers tend to treat the service user in the same way as they themselves are treated by their managers.
PractitionerResponsibilitiesandSelfAssessmentQuestions
(not an exhaustive list)
(notanexhaustivelist)
1. / How do I get through the front door and create a relationship where the family/parent is willing to tell me about the child and family?
2. / How do I ask challenging questions about very sensitive matters?
3. / How do I develop the expertise to sense that the child or parent or adult is being evasive? Do you reflect on the times when they have been evasive?
4. / How do I work directly with children and young people, vulnerable adults and their families to understand their experiences, worries, hopes and dreams, and to help them change?
5. / Do I recognise my intuitive skills (essentially derived from experience)? ‘Gut feelings are neither stupid nor perfect? They take advantage of the evolved capacities of the brain and are based on rules of thumb that enable us to act fast’. Gut instinct or feelings are part of your tool kit.
6. / Have I had time to reflect, to mull over the experience and learning from it, in supervision, for example, or in discussions with colleagues?
7. / Do I have the necessary skills to communicate with children and vulnerable adults with communication difficulties?
8. / Do I have knowledge of the development of children aged 0 -18 years?
9. / How do I assess the level of communication and engagement with the men in the family?
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(not an exhaustive list)
(notanexhaustivelist) / Notes
10. / Arethemenassociatedwiththefamily‘visible’?Istheirimpactbeing assessed? Lookforsignsof‘hidden’partners,big shoes,coatsetc. Askthechildren!Talktoneighbours.
11. / Whatislifereallylikeforthechildrenorvulnerableadultinthis family?
12. / AmIputtingtheneeds, viewsandwishesofthevulnerableadultorchildrenattheforefrontofinteractionandenquiry,oristheadult agendadominating?
13. / AmIrecognisingbarriersthatinhibitengagement andimplicationsfor practice?
14. / Hasmycaseloadrepeatedlyexposedmetointractableandlongterm problemscontributingtoanormalisationinmyresponse?Isthisa barriertomerecognising/understandingthesignificanceofdeviantor riskybehaviour?
15. / Hasmycaseloadnotexposedmetointractableandlongterm problemscontributingtoapossiblelackofrecognitioninmy response?Isthisabarriertomerecognising andunderstanding the significanceofdeviantorriskybehaviour?
16. / DoIhavetheknowledgeandskillstorecognisebruisingthatmaybe indicativeofanon-accidental injury?
17. / DoIunderstand myroleandresponsibilitieswithinthechild/adult improvementprotectionplan?
18. / DoIunderstand theresponsibilitiesofothermembersofthecore/
multi-agencygroup?
19. / HaveIcommunicated withallotheragenciesinvolvedindelivering theplan?
20. / AmIfeelingconfidentandcomfortableworkingwiththisfamily?If notwhynot?Isthisgutinstincttellingyousomething?
BasedonthelearningandrecommendationsfromSeriousCaseReviews2010-2013
Substance Misuse and Mental Health
December2013-Derbyshire-BDS12
Deathofa2-year-oldboyinMarch2013from
cardiacarrest.BDSswallowedhismother’smethadone, whichwasinachild’sbeaker.Mother
andfatherwere convictedofmanslaughter andreceivedcustodial sentences.Issuesidentified
include:overreliancebyuniversalhealthservicesonspecialisthealth professionalstoinformthemofchildprotectionconcerns; andlackofrecognitionofthresholdsforreferralto children’sservices.
Formoreinformationsee Derbyshire–SCRBDS12
December2013–Wolverhampton–DanielJones
Deathofa23-month-old boyinMay
2012,asaresultofingestingheroin. Fatherwasconvictedofmanslaughter andmotherwasconvictedofcausing orallowingthedeathofachild. Maternalhistoryofdrugandalcohol
misuseandoffending;shehadoneolderchildwho didnotlivewiththefamily.Paternalhistoryofprolific offendinganddrugmisuse.Familywaswellknownto children’sservices.Issuesidentified include:lackof focusonthechild;professionaloptimism;insufficient managementandsupervision;insufficientinformation sharing;andworkingwithresistanceandavoidance.
Formoreinformationsee: Wolverhampton–DanielJones
July 2013 – Lancashire – Baby E
Deathofa4-month-oldbabyboyfromaserioushead injuryinDecember2011.Bothparentshadbeen lookedafterchildren,hadexperiencedchildhoodabuse andwerechronicsubstance users.Identifies themesfor learningincluding:establishingaprofessionalleadin multi-agencyprocesses;acquiringcomprehensivesocial historiesfromparents;recognisingunemployment and povertyasriskfactors;recognisingdisguisedcompliance andmaintainingasufficientlevelofprofessional scepticism;impactofcoerciverelationshipson vulnerablewomen;andengagingwithmenand fathers.Setsoutkey findingsusingsystemsbased typologydevelopedbySCIE.
Formoreinformationsee Lancashire-BabyE
February2013–Manchester–ChildU
Deathofa4yearold girlinSeptember2011who
wassubjecttoachildprotectionplan.Motherpleaded guiltytomanslaughter onthegroundsofdiminished responsibilityandwasdetainedinasecuremental healthfacility.Historyofinappropriatesexualbehaviour bymothertowardsherdaughterandparentalmental healthissues.Identifies themesincludingmentallyillparents,substance misuse,childsexualabuseand hostilebehaviour.
Formoreinformationsee: Manchester–ChildU
Child Sexual Exploitation
December2013-EastSussex-ChildG
Abductionofa15-year-old girlin2012,byherteacher, MrK.ChildGwasinvolved inasexual relationshipwith MrK, whichbeganaround
her15th birthday.MrKwas foundguiltyofabductionandadmittedanumberofchargesofsexualactivity withachildunder16years;hereceivedacustodial sentence of5years.
Identifies seriousconcernsrelatingtoschool’sactions,including:failuretoidentifytheabuse andexploitationofChildG;fixedthinking;failuretohear concernsraisedbystudents; failuretoinvolveChildG’s mother;concernsaboutLADOresponse; insufficient recognitionofMrK’sinappropriateuseofTwitterto communicatewithChildG;andseriousconcernswiththewaysinwhichinformationwasrecorded,stored, retrievedandprovidedforthereview.
Formoreinformationsee: EastSussex-ChildG
December2013-RochdaleYoungPeople1,2,3,
4,5and6
Seriousandprolongedsexualexploitationof6adolescent girlsatthehandsofanumberofmen,whosubsequently receivedcriminalconvictions.Issuesidentifiedinclude: frequentincidencesofyoungpeoplemissingfrom home;recurrentattendancesatA&E;optimisticthinking; unqualifiedstaff;andinadequate supervision.Contains multi-agencyandsingleagencyrecommendations covering: placingyoungpeopleatriskofsexual exploitationwithspecialistfostercarersratherthansemi-independent livingaccommodation; andhavingatwin safeguardingfocuswhenworkingwithteenageparents andtheirchildren.
Formoreinformationsee: Rochdale-YoungPeople1,2,3,4,5and6
Neglect
November2013-Bradford-HamzahKhan
Deathofa4-year-oldboyinDecember2009,asaresultofchronicneglect;Hamzah’sbody wasdiscoveredbypoliceduringasearchofthefamilyhomeinSeptember2011.Mother wasconvictedofmanslaughter andchildcruelty inOctober2013.Maternalhistoryof: chronicalcoholdependency; depression;socialisolation;domesticabuse;andreluctanceto engagewithservices,includingregisteringchildrenforhealthandeducationservices.
Issues identified include:invisibilityofchildrentoeducationandhealthservices;failuretotakeintoaccounttheimpact onchildrenoflivingwithdomesticabuse;absence ofenquiryintothecultural andreligiouscomplexityofthe family;insufficientsignificancegiventodisclosurebyadolescents; lackofprofessionalcuriosity.
Formoreinformationsee Bradford-HamzahKhan
PhysicalandEmotionalAbuse
September2013-Coventry- DanielPelka
Thedeathof4yearDanielon3March2012,astheresultofanacutesubdural haematoma.Daniel’smotherandstepfatherwereconvictedofmurder inAugust 2013andsentenced to30 years’imprisonment. Foraperiodof
atleastsixmonthspriortohisdeath,Danielhadbeen starved,assaulted, neglectedandabused. Historyof incidentsofseriousdomesticabuseandviolence,chaotic lifestylewithmultiplehousemovesandalcoholmisusebymotherandvariouspartners.Issuesidentifiedinclude: deceptionofagenciesandservicesbymother;impactof witnessingviolenceonchildren;impactofculture,race andlanguage;andDaniel’sisolationand‘invisibility’.
Formoreinformationsee: Coventry-DanielPelka
October2013-Birmingham- KeanuWilliams
Deathofa2-year-oldboyinJanuary2011frommultipleinjuries.The motherwasconvictedofKeanu’s murderandof‘crueltytoachild’ inrespectofoneofhisolderhalf siblings;
shewassentenced to18 years
imprisonment. Motherspentperiodsoftimein fostercaresubjecttocareordersthroughoutherown childhood.Historyof:frequenthousemovesandperiods ofhomelessnessandfrequentchangesinmaternal relationships.Issuesidentified include:focusonthe child;professionalcuriosityinrelationtoinjuries. Recommendationsinclude:multi-agencyauditstotrackrecordsacrossagencies;criticalreviewoftheinteragency protocolforchildprotectionmedicalassessments.
Formoreinformationsee: Birmingham-KeanuWilliams
SexualAbuse
August2013-Birmingham-CaseNo.2010-11/3
Serious sexual assault of a toddler by an early years student and staff member at a nursery in
Birminghamin 2010. Knowledge of the incident came to light following an accusation by a
13-year-old girl of online grooming in January 2011.
Issues identified include: recruitment and screening procedures; management and team culture; inspection and complaints procedures; andearlyidentificationofonlinesexoffendersbypolice.
Recommendationsinclude:effectiverecruitment processes;balancingphysicalenvironmentsinnurserysettingsbetweenarespectforprivacyandreducingopportunitiestoabuse;rigorousinspectionsofearlyyearssettingsthatexaminethe implementationofsafeguardingpoliciesandprocedures.
Formoreinformationsee Birmingham-CaseNo.2010-11/3
DomesticHomicidesandChildDeaths
May2013-Surrey-ChildrenUandV
Deathofa7-year-oldboy(ChildU)andhis6-year-old sister(ChildV)on30September2012.Childrenwere foundonabridlewaywiththeirfatherwhowasalso deceased.Policeevidencelaterrevealedthatfather stabbedbothchildrenbeforetakinghisownlife.Mother haddiscloseddomesticabuse(verbal/emotional)toGPin October2011.
Lessonslearnedinclude:domesticabuse isachildprotectionissue;childrenshouldbeactively spokento,engagedwithandobservedbyprofessionals; andviolentactsthatleadtothedeathofchildrencan occurwithoutanypriorindication.
Formoreinformationsee Surrey-Children UandV
February2013 - Stoke-on-Trent- Case - No.SOT12(1)
Deathofapre-schoolagedchildinJanuary2012. Mother’spartnerwaschargedwithmurderandreceived alifesentence. Childlivedwithmother,fatherand threeelderhalfsiblings.Fatherwasphysicallyabusive andcontrollingtowardsmother,misusedalcoholand wasverballyabusivetowardoneofthesubjectchild’s siblings.Children witnessedsignificantdomesticviolence andexperiencedmultiplemovesbeforefatherwas convictedofassaultagainstmother.Issuesidentified include:lackofprofessionalcuriosity;lackoffocuson thechildrenduringdomesticabuseriskassessments;lackofassessmentofmother’sabilitytoprotectandcare forherchildren.
Formoreinformationsee Stoke-on-Trent-Case
No.SOT12(1)
Below is a summary of lessons learnt in York.
January2013–Wirral–ChildG
Deathofa17-year-oldgirlinMay2012,by strangulation.Herboyfriendatthetimeofherdeath waschargedwithhermurder.ChildGhadlearning difficulties,ADHDandbehaviouralproblemsandhad beenthesubjectofachildprotectionplanforneglectwhenshewasyounger.Shewaslivingindependentlyin specialistaccommodation atthetimeofherdeath.
Makesrecommendations fordevelopingprofessional understanding oftheeffects onchilddevelopmentand socialpresentationofmoderatelearningdifficulties; workingwithyoungpeoplewhoaresexuallyactivefrom ayoungage;andsafeguardingyoungpeoplewhoare16and17yearsold.
Formoreinformationsee:Wirral–ChildG