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 E, which was appended to the briefing note.  A SCR was undertaken when 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 organization.  The on-going implementation and monitoring of these actions was the responsibility of the individual agency.  Evidence of progress was regularly provided for the Local Safeguarding Children’s Board (LSCB).  This process enabled the LSCB to fulfill 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 E in May, 2014 the Independent Chair of LSCB at that time agreed this case should be the subject of a Serious Case Review in July, 2014.  Child E was a five-month old baby who died after he was found unconscious in a bed co-sleeping with adults following a party at his family home.  At the time of his death there were indications of drug use, cannabis cultivation in the property, poor home conditions, possible neglect and domestic violence in connection with the family.  The family were not open to specialist services at the time of Child E’s death and there had not been significant concerns identified prior to his death.  There was therefore concern as to whether previous contacts had correctly identified, assessed and acted on any risks, or offered support to the family, to mitigate the issues that became apparent at death.

The SCR report detailed the independence of the review, the family, circumstances surrounding the death and issues for consideration which included:

·  The context for family support and child care in the wider family circle – How were the children supervised and their safety ensured?

·  Home conditions in which the children were living – did these raise concerns for their welfare and safety?

·  Opportunities to observe and assess the levels of care and support and possible risks of neglect, through contact with the family and particularly home visits

·  Why the family did not access greater early help and support from children’s centres and pre-school settings?

·  What was known about any episodes of domestic violence, substance misuse or criminal activity that might have indicated safeguarding risks for the children?

·  Were there aspects of the medical and home care required by Child E’s sister for her health condition that may have affected the care provided to other children?

·  What aspects of previous contact with members of this family might have indicated any needs for the children?

·  Were there opportunities for the concerns that have led to the subsequent creation of child protection plans to be identified or shared between agencies at an earlier stage?

The recommendations were that the Coventry LSCB should:

1.  Seek assurance that the arrangements for each GP practice to have a named health visitor for regular and consistent contact, provides for the accurate and timely sharing of information about families in need.

2.  Request the Birmingham Children’s Hospital Foundation Trust to review the work of the Family Support Workers to ensure that they proactively engage with families attending for ongoing medical treatment, and record clearly what offers of support have been made and explored.

3.  Promote multiagency training on the combination of early risk factors that can arise for families and how these can be better recognised and assessed and incorporate the learning from this case in developing better awareness of early risk factors, neglect and accessing early help.

4.  Review the evidence of awareness by parents of the risks of co-sleeping, and where there are seen to be gaps, develop effective communication strategies about the risks and dangers, addressing both professional audiences and parents/families.

5.   Ensure that school attendance policies and guidance for all schools promote a more rigorous questioning of the reasons for absence, and that where medical reasons are provided these are explored to ensure that the family is receiving the best possible support to encourage attendance.

Janet Mokades, current Independent Chair of the LSCB attended the meeting and presented the recommendations and discussed the action plan and was supported by Hardeep Walker, the Serious Case Review Co-ordinator for Adult and Children Safeguarding Boards.  They discussed work with GP’s, multiagency training, co-sleeping and school attendance.

Councillor M Mutton, Chair of the Scrutiny Board reminded Members that their role was not to re-hear the review, but to scrutinize 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:

·  Press coverage of the case and the role of the Police and the Crown Prosecution Service

·  School attendance procedure’s

·  Similar recommendations identified in different SCR’s and how recommendations are monitored

·  Communication of co-sleeping information to parents

·  Partner’s different policies, communication and priorities

·  Professional curiosity, judgment, subjectivity and tolerance levels

Councillor M Mutton noted that quality of practice was on the Scrutiny Board work programme for next municipal year and the recommendations from the Serious Case Reviews considered this year would also be reviewed. 

RESOLVED that :

1)  The Scrutiny Board recommend that the Cabinet Member for Education audit attendance policies and procedures in schools and how absences are followed up

2)  A letter be written to West Midlands Police to provide reassurance that measures are in place to address the technical errors reported

3)  Sleep safe application launch information be shared with Members of the Scrutiny Board