Agenda item

Report of the Local Safeguarding Children’s Board

The Scrutiny Board considered a briefing note of the Business Manager for Adult and Children Safeguarding Boards, which detailed the outcome of the serious case review (SCR) relating to Child S.

Following the death of Child S in 2013, the Independent Chair of Coventry Local Safeguarding Children Board (LSCB) at that time agreed that this case should be the subject of a serious case review.  The SCR Report, including recommendations, and the resulting action plan were appended to the briefing note submitted.  Councillor M Mutton, Chair of the Scrutiny Board, reminded members that their role was not to hear the review, but to scrutinise the recommendation and review them.

Janet Mokades, current Independent Chair of the LSCB, attended the meeting and presented the recommendations and action plan that resulted from the SCR.  The Scrutiny Board noted the background to the case which, in summary, was that during the autumn of 2013 Mother S had called an ambulance to her home and Child S was found to be suffering from a serious head injury.  Child S was taken by ambulance to the University Hospital Coventry and Warwickshire (UHCW) accompanied by his mother, who stated that he had fallen down stairs at home.  Mother S’s partner, Male B, remained at home and did not attend the hospital. 

It had been clear when Child S’s arrived at UHCW that he was gravely unwell and later that day was transferred to Birmingham Children’s Hospital (BCH) due to the nature and seriousness of his injuries.  Upon arrival, he was taken straight to the operating theatre for emergency surgery.  Staff at both UHCW and BCH became concerned that, upon examination of scan results, the injury was not consistent with the explanation provided and the Coventry Emergency Social Care Duty Team were contacted along with West Midlands Police.  Following the surgery, Child S was taken to the paediatric intensive care unit and, despite the efforts of medical staff, he died the following day as a result of the injuries he had sustained.  Later the same day both Male B and Mother S were arrested on suspicion of murder.  In Autumn 2014, following a Police investigation, Male B was charged with murder and Mother S with neglect and allowing Child S’s death.

The purpose of the SCR was to establish the role of services and their effectiveness in the care of Child S, whether information was fully shared by the professionals involved, and whether procedures were appropriately followed.  This process would ensure that any deficiencies in services could be identified, and lessons learned to minimise the risk for another child.  This should also reassure the public and prevent the need or demand for further external inquiries.  In addition to an independent chair and a lead reviewer, the SCR panel included senior managers from each of the following key agencies:-

·  Coventry Social Care

·  West Midlands Police

·  West Midlands Fire Service

·  Coventry and Rugby Clinical Commissioning Group

·  Coventry and Warwickshire Partnership NHS Trust

·  University Hospitals Coventry and Warwickshire NHS Trust

·  Coventry Head of Safeguarding

·  Staffordshire West Midlands Probation Trust

The Scrutiny Board noted that the review covered, in detail, the period from early summer 2010 to the end of 2013, which included the period that Mother S was pregnant with Child S, through the child’s entire life, to the post mortem stage of early evidence gathering.  The report included details of Mother S’s early years, the story of Mother S and Child S, the relationship between Child S and his mother, what Child S was like, the relationship between Mother S and Male B, and significant events in the life of Child S. 

The SCR identified that all of the agencies involved had a picture of Child s and it was not one that raised concern.  There was evidence that he was seen, checked and spoken to and at no point did any professional raise any concerns about his health and wellbeing.  The review found no evidence that any signs of distress were missed or ignored by professionals.  The report identified a number of good examples where individuals and agencies were particularly adept at considering the voice of Child S.  However, it was found that there were some occasions where insufficient weight was applied to the voice of Child S and these were also highlighted in the report submitted.

The SCR had found no evidence that any agency or professional in Coventry could have prevented the death of Child S.  The review did highlight a number of areas where agencies in Coventry could improve their systems and work more effectively together, but it was felt that these improvements would not have affected the final, tragic outcome.  Whilst there were missed opportunities by agencies to intervene and place support around Child S and his mother, those interventions would not have prevented Mother S resuming her relationship with Male B, or prevented him from being in the house, alone, with Child S.  There was nothing anyone, except Mother S, could have done to prevent him being there.  None of the authorities or organisations that had involvement in Child S’s life could have foreseen the events that occurred; they could not have prevented his death.

The SCR made three recommendations to further improve safeguarding in Coventry.  These recommendations were those that required a multi-agency response.  The Scrutiny Board noted that the review had also identified a number of areas that individual agencies needed to consider and take action against and, in those cases where issues have been identified for a single agency, that agency should produce action plans that should be monitored through the LSCB performance framework.  They should continue to be subject to regular scrutiny by the Board until completion.

The recommendations that required a multi-agency response were:-

1.  The Coventry LSCB should monitor the plans for changes in structure, policy and service provision by agencies to assess how they will dovetail; ensuring that levels of child safeguarding are maintained.

2.  The Coventry LSCB should progress its priority relating to domestic violence and abuse by:

·  Forging stronger links with the Police and Crime Board;

·  Refining and consolidating the post Daniel Pelka joint screening process; and

·  Championing the work being done in Coventry to counter domestic violence and abuse.

3.  Coventry LSCB should ensure that all agencies:

·  Have policies and procedures in place for identifying those families that are proving hard to engage;

·  Scrutinise and, where necessary, tighten their procedures for working with families who are hard to engage;

·  Have protocols in place to share information between agencies about families that are hard to engage; and

·  Monitor staff compliance with the agreed procedures.

The multi-agency action plan appended to the report identified the actions required by each of the recommendations, which agencies were responsible for particular actions along with the expected outcomes and the current position.

Having considered the background to the SCR, the review findings and the recommendations, the Scrutiny Board expressed some concerns, in particular:-

a.  The domestic violence screening process and how agencies work collaboratively, particularly where they were aware of perpetrators who could potentially cause risk to children.  Members requested additional information from the Police and Crime Board on this issue and the numbers of perpetrators being monitored.

b.  How stronger links can be built between various agencies, such as the NSPCC and Barnardos, ensuring that each organisation understands what the others do and how the Council may assist with this.

c.  Understanding how the implementation of recommendations from all SCR’s is monitored and assurance received that they have improved outcomes for children.  Members requested that a progress report be submitted in 6 months time, to include the outcomes of implementation.

RESOLVED that the Education and Children’s Services Scrutiny Board (2):

1.  Note the recommendations in the report and the associated action plan and updates.

2.  Request that information be submitted to the Board about the Domestic Violence screening process, including information from the Police and Crime Board in respect of the number of perpetrators being monitored.

3.  Request that information be provided to the Board on how stronger links can be built between various agencies, such as the NSPCC and Barnardos,  and how the Council may assist with this.

4.  Request a progress report in 6 months on the implementation of recommendations from all Serious Case Reviews, including the outcome of the implementation.