Agenda item

Report of the Local Safeguarding Children’s Board

The Scrutiny Board considered a briefing note of the Serious Case Review Co-ordinator for Adult and Children Safeguarding Boards, which detailed the outcome of the Serious Case Review (SCR) relating to Child C, which was appended to the briefing note.  A SCR was undertaken where the abuse or neglect of a child was known or suspected and the child had died.  The briefing note highlighted that the primary aim of a SCR was to help agencies learn lessons from these events, and to use this experience to improve practice.

Each agency may make recommendations to support improvements in practice within their organisation. The on-going implementation and monitoring of these actions was the responsibility of the individual agency. Evidence of progress was regularly provided for the LCSB. This process enabled the LSCB to fulfil its responsibility for monitoring progress, and to be assured that the recommendations had been delivered in practice.  Recommendations that were multi-agency were the responsibility of the LSCB, and an action plan to address these recommendations was currently being progressed.

Following the death of Child C in April 2014, the Independent Chair of Coventry Local Safeguarding Children Board (LSCB) at that time, agreed this case should be the subject of a Serious Case Review.  Child C died at the age of 11 months after being left unsupervised in the bath with Sibling 1, aged two years.  The review was not able to establish the reason for the circumstances that led to the death of Child C and concluded that the sad death could not have been predicted or prevented by the professionals involved.

Janet Mokades, current Independent Chair of the LSCB attended the meeting and presented the recommendations and discussed the action plan.

The Scrutiny Board noted the background to the case which, in summary, was that when professionals visited the family home they observed a mother and, at times, a father who provided appropriate care and attention for their children, despite significant difficulties and disadvantages.  The review was unable to establish the reason for the circumstances that led to the death of Child C.  What had emerged was a concerning but familiar picture of the early stages of poor parental mental health, issues of domestic abuse and cannabis misuse.  The report noted that this had been recognised as a common theme in reviews locally and nationally.  There was evidence that the right referrals were being made and by the right people but the information was sometimes lost, incomplete or not acted upon.  The failure to explore maternal wellbeing meant the impact on the family and relationships was not well understood.  This, together with a lack of assessment of the couple’s cannabis use and limited reporting of the domestic abuse, meant that the level of risk was not recognised.  A poor referral and assessment process hindered the identification of the potential risks and needs of both the children and adults.

The report included details of methodology, process, chronology of the professional involvement with the family, referral and assessment, early help, children’s experiences, domestic violence and abuse, and parental emotional wellbeing.

The recommendations were:

1) Social Care

When a social care decision was made for a case to be transferred to a higher or lower level of priority, the decision and rationale for this must be clearly communicated across all partner agencies involved with the family.

2) a) Social Care

All professional referrals made in response to a child’s disclosure must result in the assessing social worker contacting the individual young people who had raised the allegation. Where there were known barriers to communication, the professionals involved should seek alternative methods of intervention to support the communication process which may also include advocacy support.

b) All agencies

When a young person was sharing a safeguarding concern with professionals about themselves or another young person, all necessary support should be given to allow that disclosure to be made including advocacy support.

3) NHS England (as commissioners of primary care), Public Health (as commissioners of the health visiting service) and the Clinical Commissioning Group (as commissioners of maternity services) all GP Providers, Coventry and Rugby GP alliance, Coventry and Warwickshire Partnership Trust (CWPT)  and University Hospitals Coventry and Warwickshire NHS Trust (UHCW). 

It was recommended that general practice managers with the primary care team facilitate regular meetings between all health professionals involved in the delivery of care for the 0-5 age group. This would provide a more structured opportunity for regular and ongoing discussion about vulnerable families and would enable a coordinated approach to the provision of health care and support, including signposting and referral, where appropriate.

4) LSCB

The LSCB should continue to monitor individual agency progress on responses to domestic violence.

Councillor M Mutton, Chair of the Scrutiny Board reminded Members that their role was not to re-hear the review, but to scrutinise the recommendations and review them, bearing in mind that policies had moved on since April, 2014.

The Scrutiny Board discussed the following concerns with the Chair of the LSCB:

·  Common Assessment Framework (CAF) threshold levels

·  Working with partners

·  Monitoring of SCR Recommendations

·  Use of language/terminology/ meanings by different agencies

·  Universal ‘triggers’ that indicate concern

·  Multi-layered impact of factors

·  Procedures and quality assurance audit

·  Working with families that had not met thresholds where engaging would be compulsory

Janet was thankful for the support of the Scrutiny Board.

RESOLVED that

1)  the recommendation action plan information discussed at the meeting be circulated to Members of Scrutiny Board from the LSCB

2)  the Scrutiny Board be updated on the new processes for ‘stepping up’ and ‘stepping down’ of cases

3)  the Scrutiny Board receive a report back on the Quality Assurance work regarding auditing procedures of front line cases