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Serious Case Reviews

Professionals and organisations protecting children need to reflect on the quality of their services. When things go wrong there needs to be a thorough analysis of what happened and why.

It’s important that lessons can be learnt and services improved to reduce the risk of future harm to children. When a child has been seriously harmed or died, and abuse or neglect is suspected or known to have happened, and there are concerns about the way agencies worked together, then the Wirral Safeguarding Children Board (WSCB) will undertake a Serious Case Review (as defined in Working Together to Safeguard Children 2015).

Findings and recommendations from Serious Case Reviews (SCR’s) will usually be published in full in a report, which will be publicly available on this website. The purpose of SCRs is to learn from what happened in individual cases so that future tragedies can be prevented.

Further information about how the WSCB undertakes Serious Case and other reviews can be found here: https://www.wirralsafeguarding.co.uk/professionals/learning-and-improvement/

 

Wirral Serious Case Reviews

Children I and J SCR The full report of the Children I and J Serious Case Review was published on the 18th May 2018. The report can be found below:

Wirral SCR Child I and Child J

a

Child H SCR – The WSCB is not publishing the full SCR report but has published the recommendations in the document below. The document will be regularly updated with progress. The WSCB expects all the recommendations to be addressed within 12 months (by November 2018).

The updated (March 2018) action plan is available below. The action plan is reviewed monthly by the WSCB’s Serious Case Review committee. The plan includes progress against each of the recommendations – there will be a number of actions behind each recommendation and the % progress is shown once actions are completed. Some actions will be completed quite quickly but others will take longer.

The next update will be provided by the WSCB in July 2018.

Child H Serious Case Review – Recommendations, Outcomes and Learningv7 May 18

 

Child G SCR – Full SCR Report:

Serious case review Report – Child G

Learning from Serious Case Reviews

Learning from both national and local SCR’s is embedded in the WSCB’s multi-agency training courses. The training programme includes a 90 minute learning from SCR’s briefing delivered by the WSCB. A copy of the presentation is here: Case Reviews – Oct 16

The WSCB also publishes a series of summary learning from SCR’s briefings which is updated quarterly and disseminated to professionals. The latest briefing document (June 2018) can be downloaded here:

 

Child Sexual Exploitation Learning from national Serious Case Reviews:

WSCB National Learning from SCR’s – CSE

 

Local Learning from Serious Case Reviews

Child Sexual Expolitation Learning from local reviews:

WSCB Local Learning from SCR’s – CSE

Child G – Case Study

Below is a Case Study drawn from the Child G Serious Case Review. The Case Study highlights significant features of the case and the learning for professionals and partner agencies.

WSCB Case Study Child G

Child G – Who’s Looking Out for the Teenagers? – A One day Conference for Professionals

A Wirral Serious Case Review highlighted the need for practitioners to have a greater understanding of the risks faced by older teenagers.  A number of concerns were raised and it was felt that the WSCB should embark on a large scale workshop to highlight the main issues raised in the review. In response to this the WSCB held a development day.

The day involved more than 150 multi-agency practitioners moving from table to table at half hour intervals to experience eleven different presentations, sessions and discussions with each table hosted by specialist colleagues from Health, Youth Service, Children’s Services, the Response Service, Adolescent Crisis Team, Youth Offending Service, Health Services, Wirral Metropolitan College, Transitions Team, Catch-22 and the Voluntary, Community and Faith Sector.

These were the topics for the day:

  • Child Sexual Exploitation and Runaways
  • Housing and Homelessness
  • Substance Misuse
  • Mental Health
  • Learning Difficulties and Autism
  • Neglect
  • Relationships and Domestic Abuse
  • Offending Behaviour
  • Leaving Care and Transition
  • Diversionary Activities

The workshops were vibrant and very well received. Teen Wirral were represented and one of the staff sat in on many sessions. The Wirral Youth Theatre gave a powerful performance to highlight issues of domestic abuse in teenage relationships.

 

Learning from the Conference

The learning has been incorporated into the multi-agency training from the WSCB and was widely shared with partners.

A summary of the day is available here:

WSCB Learning from Serious Case Reviews – Teenagers Conference Summary

Key Learning Messages:

  • Teenagers can be just as vulnerable and in need of our help as younger children
  • Be aware of the needs of vulnerable teenagers especially the corrosive impact of long term neglect
  • Maintain healthy scepticism and respectful uncertainty
  • Share information across agencies to ensure services are targeted and co-ordinated
  • Have a clear understanding of the thresholds of need
  • Make sure all professionals know how to access procedures and advice
  • Escalate concerns if you feel a child remains at risk
  • Take responsibility for professionals excellence and access training
  • Have access to reflective supervision

The learning was summarised into three awareness raising posters with key messages for professionals:

SCR Learning Poster Wirral

Mini SCR Wirral

SCR Learning Poster Teen Awareness female

Mini Teen awareness f

SCR Learning Poster Teen Awareness male

Mini Teen awarness m

Child F – Case Study

A second Case Study is included for the Child F Serious Case Review. This case was undertaken in 2009 following the drowning of a young girl by a family member.

WSCB Case Study Child F

A recommendation from this case was for the WSCB to ensure professionals have access to multi-agency training about Parental Mental Health. This course now runs regularly and details are on the training page: https://www.wirralsafeguarding.co.uk/courses/

 

Learning from Local Reviews

The WSCB also undertakes reviews of cases which do not reach the threshold for a SCR but are reviewed because the case is likely to provide useful multi-agency learning or the circumstances of the case were unusual. The reviews of these cases are not published but the learning is shared with the partnership and included in WSCB training.

The posters below capture the learning from recent cases reviewed by the WSCB:

  1. Child 2 – The case reviewed a young person who was the perpetrator of a serious crime. The young person had been looked after in a kinship carer arrangement and had been known to services for an extended period of time.

Child 2 Learning

2. Child 3 – This case was reviewed because it was suspected that a young person may have been being coerced into a forced marriage.

Case Review Learning Child 3

3. Child 4 –  is a baby who drowned, but survived with permanent injuries, having been left unsupervised in a baby bath seat.

The learning from the case included professionals, especially midwives and health visitors reinforcing the safe use of bath seats and bath safety advice. Wirral Community NHS Foundation Trust produced a Bath Safety Advice Leaflet which is routinely given out to families.

4. Child 5 – was an ex child looked after who was the victim of a physical assault. The case highlighted the need for care leavers to be supported if they feel isolated and for accommodation to be provided as close to family as possible when requested.

5. Child 6 – was a young girl who tragically died after accidentally setting fire to her clothes after playing with a lighter she found at home.

The review led to the Child Death Overview Panel (CDOP) and Merseyside Fire and Rescue Service highlighting the dangers of lighters and matches and issuing advice. This was also highlighted in the CDOP newsletter in summer 2017. The newsletter can be accessed below:

6. Child 7 – was an older teenager who became involved in anti-social and criminal behaviour with tragic consequences.

7. Child 8 – was a 2 year old child living in a home with parental substance misuse. Child 8 was harmed when he accidentally ingested methadone at home.

Learning from Reviews – Key Messages

The WSCB also periodically distils lessons from Serious Case Reviews into posters for professionals. These can be downloaded here. There is space on the posters for you to add the contact details of your safeguarding lead:

SCR Learning Poster Young Children

Mini Young Children and Babies
SCR Learning Poster Unborn Awareness

Mini Unborn Awareness

SCR Learning Poster Questionning Poster

Mini Questionning
SCR Learning Poster Online Abuse

Mini Online Abuse
SCR Learning Poster Neglect Vulnerable Children

Mini Neglect
SCR Learning Poster Neglect Risk Factors

Neglect Risk Factors
SCR Learning Poster Information Sharing

Mini Info Sharing
SCR Learning Poster Education

Mini Education
SCR Learning Poster CSE

Mini CSE
SCR Learning Poster Daniel Pelka

Mini Pelka

Referring Cases to the Wirral Safeguarding Children Board

All agencies and professionals in the WSCB partnership can refer cases to be considered for Serious Case Review or for multi-agency review below the SCR threshold. Before a referral is made the professional should discuss the case with their safeguarding lead. Professionals can also consult about potential referrals with the WSCB Business Manager ([email protected]).

Referrals are made using the Case Referral Form (available below). Forms should be securely emailed to:

[email protected]

scr-case-referral-form-2

All referrals for potential Serious Case Reviews are considered by the safeguarding board’s case review committee as per its statutory responsibility against the criteria for a serious case review published in Working Together (2015)

 

Safeguarding Practice Review Panel

On the 29th June 2018 the National Panel for Serious Case Reviews was replaced by the new National Child Safeguarding Review Panel.

The Child Safeguarding Practice Review Panel is responsible for commissioning and supervising reviewers for national child safeguarding practice reviews – these will replace Serious Case Reviews as new safeguarding arrangements take effect.

The purpose of a national child safeguarding practice review is to identify any improvements that should be made by safeguarding partners or others to safeguard and promote the welfare of children.

Duty on Local Authorities

From the 29th June 2018 local authorities will be required, under a new statutory duty, to notify the Panel of incidents where they know or suspect that a child has been abused or neglected and:

  1. the child dies or is seriously harmed in the local authority’s area; or
  2. while normally resident in the local authority’s area, the child dies or is seriously harmed outside England.

These notifications should be made within five working days of the local authority becoming aware of the incident.

Local authorities should continue to use Ofsted’s current online notification system to notify the Panel until a new system for the Panel goes live later in the year. Notifications made through this route will go to the Panel, Ofsted and the DfE.

The local authority should also report the incident, within the same five working days, to the relevant LSCB, or to the new local safeguarding partners when they become established.

 

Notifiable Incidents

For guidance about how to inform the WSCB of a notifiable incident involving a child please follow the link:

www.wirralsafeguarding.co.uk/notifiable-incidents-involving-children