By Lorna Ponambalum, Safeguarding Consultant
Child
Safeguarding Practice Reviews (SPRs) formerly called Serious Case Reviews (SCRs)
We are
all responsible for Safeguarding! – The sad case of Victoria Climbie
Many of you will have heard of the shocking case of
Victoria Climbie. Victoria’s life was
short and tragic. She was abused and murdered by her great-aunt and her
great-aunt's boyfriend.
Her death prompted a public inquiry and the largest review
of child protection arrangements in the United Kingdom.
Victoria was born in the Ivory Coast. At the age of 7 she
arrived in Paris to live with her great-aunt Marie-Thérèse Kouao. The pair
travelled to England in April 1999 where they met Carl Manning who became Marie-Thérèse
Kouao’s boyfriend. It is not exactly known when the abuse started but it is
widely thought that it worsened when Victoria and her great aunt went to live
in the boyfriend’s flat in Haringey, North London.
Throughout the abuse, Victoria was burnt with cigarettes,
tied up for periods of longer than 24 hours, and hit with bike chains, hammers,
and wires. A number of agencies including the Police, Social Care from four
local authorities, members of a local church community and even the National
Society for the Prevention of Cruelty to Children (NSPCC) had contact with her
and noted the signs of abuse. However, neither of them decided to further
investigate or take any action.
After months of torture, Victoria died of hypothermia at
her aunt's flat. She had 128 injuries all over her body. She was just 8 years
old. The Home Office pathologist who later examined her corpse described the
case as "the worst case of child abuse" he had ever seen.
The
Laming Report – Lessons that needed to be learnt by all Professionals
Following Victoria’s death, a public inquiry, headed by
Lord Laming, was ordered. During the inquiry it was discovered that there were several
opportunities where Victoria could have been saved and where organisations
failed their duty of care. Lord Laming made 108 recommendations relating to
child protection in England, of which he says 46 should be implemented within
three months, 38 within six months and the rest within two years.
The
key recommendations are:
·
The creation of a ministerial Children and
Families Board, to be chaired by a Cabinet minister.
·
A new National Agency for Children and
Families, rather than a Child Protection Agency, that would report to the
ministerial board about all aspects of child welfare.
·
A Children's Commissioner for England, who
would run the Agency.
·
The creation of a national database on children
under 16, recording all those who come into contact with child protection
services.
·
A Government review of the law regarding the
registration of private foster carers.
·
Each local authority must establish a Committee
for Children and Families with members from the police authority, council, and
health service trusts.
·
New social work degrees.
·
Better sharing of information by agencies which
can currently be hindered by the Data Protection Act and Human Rights Act.
·
Shorter clearer guidance to one million
professional staff dealing with protecting children.
·
Random inspections by senior managers of case
files; social workers must check information from all child protection agencies
before doing home visits.
·
Local authorities must make child protection
available 24 hours a day and advertise a 24-hour free telephone referral number
by members of the public.
·
Hospital chiefs must ensure no child suspected
of having been abused is discharged without a plan for their future care.
·
Child protection must be included in the list
of ministerial priorities for the police.
Changes
to Legislations
Furthermore, Victoria’s death also prompted the
introduction of the Every Child Matters initiative and the amendment of the
Children Act 1999 which subsequently became the Children Act 2004. What also
was established under the Children Act 2004 were Serious Case Reviews (SCRs). Since 2018 the structure of these
reviews has changed because of amendments made to the Working Together to Safeguard Children
(Department for Education, 2018) guidance. Now they are referred to as Child Safeguarding Practice Reviews (SPRs).
Responsibility for learning lessons lies with a new
national panel – the Child Safeguarding
Practice Review Panel (the Panel), which was also set up by the Department
of Education in 2018. This is an independent panel which can commission reviews
of serious child safeguarding cases where they are complex and /or in the
national interest.
The aim of Child Safeguarding Practice Reviews (SPRs)
are to learn lessons to help prevent future similar
incidents as well as help professionals within organisations improve the way
they work together to safeguard children.
In addition to the Child Safeguarding Practice Review Panel
(known as the Panel) who is responsible
for these reviews at national level, there are local safeguarding partners who
are ultimately responsible at a local level.
A
Child Safeguarding Practice Reviews (SPRs) previously known as Serious Case
Reviews
A Child Safeguarding
Practice Reviews (SPRs) should take place if abuse or neglect is known, or
suspected, to have been involved and the following has happened:
·
A child has died.
·
A child has been seriously harmed and there is
cause for concern about how organisations or professionals work together to
safeguard the child.
·
The child dies in custody.
·
A child has died by suspected suicide.
If any of the above criteria has been met, then the local authority
should report the incident to Ofsted and the relevant Safeguarding Partnership
or Partnerships within five working days of becoming aware that the incident
has occurred.
At a local level, the safeguarding partners are expected
·
to identify and think about serious child
safeguarding cases whose specific issues impact on the local area.
·
commission and oversee child safeguarding
practice reviews of those cases, where they consider it to be appropriate.
The safeguarding partners then begin a rapid review
of the case to identify any necessary action required to ensure a child's
safety and consider what potential lessons could be learnt from carrying out a Child
Safeguarding Practice Review. Gathering this information will enable a decision
to be made about whether it is necessary to carry out a Child Safeguarding Practice
Review.
The local safeguarding partners will also liaise with the National
Child Safeguarding Practice Review Panel(the Panel) to discuss and agree
whether a case may raise issues which are complex or of national importance
such that a national review may be appropriate
A local Child
Safeguarding Practice Review are not automatically carried out despite
meeting the criteria. Consideration in deciding whether or not the incident is
serious is decided using the definition set out in Working Together to
Safeguard Children (Department for Education, 2018 document. Decisions on
whether to commence a review should be made transparently and with a view that
all parties involved including families are clearly informed of the rationale
behind it.
Once it is confirmed that a Child Safeguarding Practice
Review will be conducted, the local safeguarding partners will agree on the
methodology to be used and must ensure that practitioners, families, and
surviving children are fully involved. Participants in reviews should be
invited to contribute their perspectives without fear of being blamed for
actions they took in good faith.
The final report from a Child Safeguarding Practice Review is expected to be completed and
published within 12 months.
The report will include
·
a summary of any recommended improvements to be
made by persons in the area to safeguard and promote the welfare of children
·
a detailed analysis of why actions were taken
or not in response to the information gathered throughout the process
The recommendations made will be ultimately focus on
improving outcomes for children.
Furthermore, local safeguarding partners can also carry out
Multi-Agency Case Reviews or Partnership Reviews which do not meet the criteria
for a Child Safeguarding Practice Review, but are considered to offer
good opportunities to identify lessons for learning and ways in which
multi-agency practice to safeguard children and young people can be improved
locally.
The Child
Safeguarding Practice Review Panel (The Panel) which operate at a
national level is responsible for:
·
identifying serious child safeguarding cases
which raise issues that are complex or of national importance
·
overseeing the review of these cases
·
setting up a group of potential reviewers who
can undertake national reviews, a list of whom must be publicly available
·
agreeing the potential scope and methodology of
the review with the local safeguarding partners and engaging with them and
others involved in the case.
The Child Safeguarding
Practice Review Panel are also responsible for providing guidance on how to
conduct a local child safeguarding practice reviews and serious case reviews.
The guidance was published in April 2019 and is titled “Child Safeguarding
Practice Review Panel: Practice Guidance”
The Child
Safeguarding Practice Review Panel regards a ‘good’ review report as one
that includes:
·
a brief overview of the key circumstances, background,
and context of the case
·
a summary of why relevant decisions by
professionals were taken
·
a critique of how agencies worked together and
any shortcomings that were identified
·
consideration of whether any shortcomings are
features of practice in general
·
consideration of what would need to be done
differently to prevent harm occurring to a child in similar circumstances
·
recommendations for what needs to happen to
ensure that agencies learn from this case (Child Safeguarding Practice Review
Panel Guidance, 2019)
The
role of all agencies in relations to the Child Safeguarding Practice Review
Local safeguarding partners
should highlight findings from reviews with relevant agencies including the
Police, Housing, the Church, Health, Social Care and Education, Youth Offending
to name but a few. The outcomes and any actions for improvements should be disseminated
across all agencies through training or briefing events. There should also be a
regularly audit progress on the implementation of recommended improvements. The
improvement should be sustained through regular monitoring and follow up of
actions so that the findings from these reviews make a real impact on improving
outcomes for children and young people.
However, research and outcomes of
SCRs and SPRs have repeatedly shown the dangers of agencies failing to take
effective action:
These include:
·
failing to re-assess
concerns when situations do not improve
·
Failing to listen to
the views of the young person
·
Lack of challenge to
those who appear not to be taking action
·
Poor record keeping
·
Sharing information
across agencies too slowly or not at all
·
Failing to act on and
refer when there are early signs of abuse and neglect
Case
Study – Serious Case Review ‘EML’ 26.11.19
A recent example of, as it was
called then, a Serious Case Review took place in a London Borough where a 17.5-year-old
white female (known as EML in the review) with an “extensive history of
sometimes life-threatening self-harm was hit by a train and killed in April
2018. EML had been a patient at specialist mental health unit(Tier 4 Unit)
where she had been compulsory detained under S.3 (Treatment) of the Mental
Health Act 1983. On the day of her death, EML had been given S17 ‘leave of
absence’ from the unit and was accompanied home by a friend. Following an
inquest into her death in September 2018, the Coroner’s conclusion was that EML
had died by suicide.
Throughout her short life EML
self -harmed on 48 occasions, the first one was when EML was 14 years old and
there were 4 episodes which were described as life threatening.
EML had been affected by three
significant events in her life. In 2003 her paternal aunt had died by suicide
and her maternal grandfather had passed away of natural causes in 2013. In 2013
her maternal grandmother came to live with the family as she had been diagnosed
with dementia.
EML was in March 2016 detained
under S2 of the Mental Health Act which was then converted to S3(Treatment) in
April 2016.
EML was admitted to two Tier 4
Units. One was located 60 miles from EML’s home, the other in North London.
A number of agencies were
involved in her care
·
EML’s local authority
Children Social Care
·
CAMHS (Child and
Adolescent Mental Health) from three local authorities
·
Highfield Centre,
Oxford (A Tier 4 Unit)
·
Beacon Centre, North
London (A Tier 4 Unit)
·
Education – School
·
LA Pupil Services
·
NHS England
·
LA Safeguarding
Children Board (LSCB)
·
LA Clinical
Commissioning Group (CCG)
·
Barts Health NHS
Trust
·
Whittington Health
Trust
·
Oxford Health NHS
Foundation Trust
·
The Police
Issues raised in the review cited
·
At times poor coordination of care and support
·
Some involvement of LA Social Care was
appropriate although there was a thought that given the number of agencies involved,
Social Care could have fulfilled the role of a coordinator/facilitator
·
The extent of Community CAMHS involvement with
the case
·
Perceived poor communication and a failure to
share information between certain services such as between the Beacon and the
secondary school
·
Issues about clarity of roles such as the
Community CAMHS
·
Scope for more informed appreciation of the experiences,
wishes and feeling of EML in planning especially about her transition to Adult
Services
·
LCSB to alert agencies to training so that the
complexities of the Children Act 1989, Mental Health Act 2003 and the Mental
Capacity Act 2005 along with the Liberty Protection Safeguarding (LPS) are
better understood by professionals
·
LSCB should alert NHS England about the
negative consequences of unavailable local Tier 4 provision
·
Concerns about insufficient documentation of
communication between services
·
Concerns about record keeping of significant
events and communication between agencies
·
Concerns about information sharing and
effective multi agency work
·
Critical failure to ensure an effective
multi-agency partnership in EML’s planned return to school in late 2016 / early
2017.
·
Concern raised by EML’s parents that her eating
disorders was understated in the review and the early use of services to
address this were not utilised early enough.
·
Some disagreement between professionals over
the Autistic Spectrum Disorder (ASD) diagnosis.
The reviewer concluded the following:
“In summary EML’s premature and tragic death by suicide
was predictable, but occurred in spite of enormous effort expended by dozens of
skilled and conscientious professionals working predominantly through not
entirely, effective partnership, with a loving and committed family”
The role of Education in relations the Child
Safeguarding Practice Review
It is important for Designated Safeguarding Leads and other
colleagues with responsibility for safeguarding in schools familiarise
themselves with learning from Child Safeguarding Practice Review (SPRs)as
it is important to improve the ability to promote the welfare of children and
young people.
Under Working Together to Safeguard Children’s new
arrangements, the education sector is viewed as a ‘relevant agency’ but not a
statutory partner. However, we know that schools are constantly reviewing
policy and practice of safeguarding. Using the outcomes of the Child
Safeguarding Practice Review will help inform the process of learning and
thinking strategically about promoting the welfare and well-being of children
and young people in their care.
Learning from the Analysis of Serious Case
Reviews
The Social Care Institute for Excellence has recently
published a new resource for schools. The document is a summary of the
government's 3-year analysis of Serious Case Reviews (SCR) (2020), specifically
drawing out the important learning for schools, school leaders and DSLs.
This analysis draws together key trends and emerging themes
that have arising from reviews that were conducted following the death of a
child, or instance of a child coming to serious harm, because of abuse or
neglect. 368 Serious Case Reviews, involving a total of 404 children, were
reviewed by government research between April 2014 and March 2017. The report
was published in March 2020.
The report aimed to:
• recognise common themes and trends
across all Serious Case Review reports.
• sample reviews to better understand
systemic strengths and vulnerabilities of practice.
• examine the impact of policy changes
and initiatives; and
• Evaluate the degree to which recommendations
from reviews have been implemented and any impact on practice of these changes.
The Serious Case Review analysis for the education sector
can be found here:
The NSPCC also have a plethora of thematic briefings which
highlight learnings from case reviews that have been carried out when a child
dies or is seriously injured and abuse or neglect are suspected.
The briefings are a series of pertinent safeguarding topic
with each briefing drawing together key risk factors and practice
recommendations to help practitioners develop their understanding and respond
to the learning from case reviews.
The NSPCC briefings can be found here:
Bibliography
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