Messages from Serious Case Reviews

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Messages from Serious Case Reviews

• Patrick Ayre
• Department of Applied Social Studies
• University of Bedfordshire
• Park Square, Luton
• email pga_at_patrickayre.co.uk
• web http//patrickayre.co.uk

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Learning from enquiries

• Those who cannot learn from history are doomed to
  repeat it
• (George Santayana)

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Plus ça change

• Every child matters Keeping children safe
• Jasmine Beckford, Kimberley Carlile, Tyra Henry
  Victoria Climbié, Lauren Wright and Ainlee
  Walker,
• Doing the simple things well

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Serious Case Reviews

• Held when a child has died or suffered serious
  harm and abuse or neglect suspected
• Aim to identify lessons to be learned
• Action plan drawn up

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Serious Case Reviews

• A panel of senior managers drawn from key local
  agencies
• Final report normally written by an experienced
  external consultant
• Examine management reviews prepared by each
  agency

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Serious Case Reviews

• Produce overview report and action plan
• Executive summary of report becomes a public
  document

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Learning from Past Experience Major themes from
SCR reviews of the 90s

• Inter-agency working
• Limited inter-agency co-operation and service
  integration, especially child and adult services
• Poor communication both between agencies and
  within agencies
• Health services and child protection variable
  levels of knowledge, especially among GPs and
  those in adult mental health service

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Learning from Past Experience

• Collecting and interpreting information
• Importance of comprehensive family assessments,
  especially male figures
• Need for medical evidence to be considered within
  the overall context
• Receiving, interpreting and dealing with
  referrals
• Understanding thresholds, especially the
  importance of neglect and emotional deprivation
  and the need to accumulate evidence

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Capturing chronic abuse

• Judging the impact of long-term abuse is an
  essential component of any assessment but how
  well do we do it?
• Judgements subjective and prone to bias
• Intangible Difficult to capture and compare
• High threshold for recognition
• Neglect is a pattern not an event

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Capturing chronic abuse

• Judging the quality of care is an essential
  component of any assessment but how well do we do
  it?
• Judgements subjective and prone to bias
• Intangible Difficult to capture and compare
• High threshold for recognition
• Neglect is a pattern not an event

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Our image of assessment
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The reality of assessment?
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Capturing chronic abuse

• Judging the quality of care is an essential
  component of any assessment but how well do we do
  it?
• Judgements subjective and prone to bias
• Intangible Difficult to capture and compare
• High threshold for recognition
• Neglect is a pattern not an event

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The pattern of neglect atypical
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The pattern of neglect typical
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The pattern of neglect
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The pattern of neglect
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The pattern of neglect
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What we would hope to find
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What we found
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What we found

• Chronic abuse and the principle of cumulativeness
• Incidents scattered through files
• The problem of proportionality
• Acclimatisation

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Pitfalls and How to Avoid Them

• Professionals think that when they have explained
  something as clearly as they can, the other
  person will have understood
• Parents behaviour, whether co-operative or
  uncooperative, is often misinterpreted
• Not enough weight to information from family
  friends and neighbours
• Not enough attention is paid to what children
  say, how they look and how they behave
• Attention is focused on the most visible or
  pressing problems and other warning signs are not
  appreciated
• When faced with an aggressive or frightening
  family, professionals are reluctant to discuss
  fears for their own safety and ask for help
• Information taken at the first enquiry is not
  adequately recorded, facts are not checked and
  reasons for decisions are not noted.
• In Cleaver, H, Wattam, C and Cawson, P Assessing
  Risk in Child Protection, NSPCC, 1998

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Information handling

• Picking out the important from a mass of data
• Interpretation
• Distinguishing fact/opinion too
  trusting/insufficiently critical
• Mistrusted source
• Decoyed by another problem
• False certainty undue faith in a known fact
• Discarding information which does not fit
• First impressions/assumptions
• Department of Health (1991) Child abuse A study
  of inquiry reports, 1980-1989, HMSO,

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Learning from Past Experience

• Decision-making
• Need for shared decision-making, especially in
  respect of not taking action or case closure
• Moving from data collection and sharing to
  strategic discussions and clear plans
• Planning a co-ordinated response across
  professionals and agencies

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Learning from Past Experience

• Relations with families
• Dealing with hostile families or those who
  withdraw
• Lack of awareness of the impact of domestic
  violence on children and their safety.
• Seeing the child as the client, focusing on his
  or her protection and not being distracted by
  other problems or by adult or sibling concerns

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A child centred approach

• The purpose of assessment is to understand what
  it is like to be that child (and what it will be
  like in the future if nothing changes)

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Learning from Past Experience (2002)

• Geographical mobility breaking contact
• Common understanding of what triggers an
  assessment of need or risk of significant harm?
• Information sharing and confidentiality
• Better identification of children vulnerable to
  abuse
• Understanding the process of change in public
  services

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ANALYSING CHILD DEATHS AND SERIOUS INJURY THROUGH
ABUSE AND NEGLECT (2003-5)

• Hard to help young people
• Hesitancy in challenging
• Hostile and difficult to engage families
• Start again syndrome.
• Very young children physically assaulted known to
  universal services or adult services rather than
  childrens social care
• Well over half domestic violence, or mental ill
  health, or parental substance misuse

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Hard to Help The complexity of the challenge

• Young people may be
• Victims,
• Perpetrators
• Parents
• Any combination of the above
• but have the same right to be safeguarded as any
  other child.

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The background

• The reviews showed that state care did not
  always support these young people fully and that
  they experienced agency neglect Brandon and
  others (2008).

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The young people

• Adolescence marks start of serious problems for
  many children
• Onset of mental health issues
• Family conflict
• Drug use, offending
• Sexual activity
• Running away

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The young people (Brandon and others)

• History of rejection, loss and, usually, severe
  maltreatment
• Long term intensive involvement from multiple
  agencies
• Parents history of abuse and current mental
  health and substance issues
• Difficult to contain in school
• Typically self-harming and misusing substances,
  often self-neglect

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The young people (Brandon and others)

• Numerous placement breakdowns
• Running away, going missing
• Risk of dangerous sexual activity including
  exploitation
• Sometimes placed in specialist settings, only to
  be withdrawn because of running away

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The young people (My experience)

• Long involvement, but not always intense
• Sometimes few placements, but all wrecked by the
  young person
• Common factor that local services just did not
  know what to do with them.
• By the time of the incident, for many of the
  young people, little or help was being offered
  because agencies appeared to have run out of
  helping strategies (Brandon and others, 2008).

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The response

• Reluctance to identify mental illness and
  suicidal intent (CAMHS)
• Failure to respond in a sustained way to extreme
  distress manifested in risky behaviour (sex,
  drugs, suicide attempts)
• Arguing between agencies about responsibility and
  thresholds
• Reasons for running not addressed adequately

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The response

• Running away leads to discharge
• More generally, does rejection of services lead
  to total abandonment?
• Age used as a reason for not imposing services
• No proper assessment of competence
  allowed/forced to choose
• Dealing with incidents but failing to recognise
  patterns

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The obstacles

• Hard to get a purchase on the system
• Wrong children, wrong adults (Ayre, 2000)
• Lack of off-the-shelf resources
• The limited resources are poorly coordinated and
  integrated
• Government targets not child centred or child
  driven
• Different agency agendas and mutual
  misunderstanding falling down the gap

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The solutions?

• Biehal (2005) recommends adolescent support teams
  in the community but is that enough?
• The complexity of the challenge requires flexible
  collaborative, individualised responses built
  around the young person

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Learning from recent SCRs

• Information drawn from
• About 30 Serious Case Reviews and expert witness
  reports undertaken in local authorities around
  England since 2003
• A review of reviews undertaken for one
  authority

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Learning from recent SCRs

• Key areas of concern
• Assessment practice
• Response to overload
• Communication and collaboration
• Child protection meetings and conferences
• Case management

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Assessment Practice

• Great disquiet over assessment practice
• Failure to give sufficient weight to relevant
  case history
• Facts recorded faithfully but not always
  critically appraised
• Guidance and thresholds

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Assessment Practice

• Use of trained staff
• Assessment of male carers
• Maintenance of a wholly child-centred approach
• Formal assessment of risk (How do you do a risk
  assessment?)

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Risk assessment

• The dangers involved (that is the feared
  outcomes)
• The hazards and strengths of the situation (that
  is the factors making it more or less likely that
  the dangers will realised)
• The probability of a dangerous outcome in this
  case (bearing in mind the strengths and hazards)
  
• The further information required to enable this
  to be judged accurately and
• The methods by which the likelihood of the feared
  outcomes could be diminished or removed.

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Response to overload

• Acclimatisation at individual and agency levels
• Lack of a strategic multi-agency response

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The Child Safeguarding System (nominal)
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The Child Safeguarding System (actual?)
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Collaboration and communication

• Communication generally found to be good but
• Communication with hospitals
• Referrals
• Medical reports
• Mental health or drugs issues

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Mental health or drugs issues

• Working on the same case but not working jointly
• Mutual incomprehension and misunderstanding
• False expectations and assumptions
• Abdicating responsibility
• Need for interpreters

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Child protection meetings

• Attendance at conferences
• Protection plans omit objectives and outcomes
• Removal from the register
• Use of strategy meetings
• Proliferation of meeting types

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Case management

• File management reading, recording decisions,
  auditing
• Case closure
• Chronologies
• CP and teenagers
• Effectiveness of Emergency Duty Teams

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Training

• General disquiet over the level of training in
  child protection
• Specific training for children's services and
  mental health workers
• Enhanced training for conference chairs and or
  independent professionals
• Interagency training to cover the roles and
  priorities of the key agencies

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References

• Brandon M. et al (2008) Analysing child deaths
  and serious injury through abuse and neglect
  What can we learn? London, Department for
  Children. Schools and Families
• Falkov, A. (1996) A Study of Working Together
  Part 8 Reports Fatal Child Abuse and Parental
  Psychiatric Disorder, London Department of
  Health
• James, G. (1994) Study of Working Together Part 8
  Reports, London Department of Health
• Owers, M., Brandon, M. and Black, J. (1999)
  Learning How to Make Children Safer An Analysis
  for the Welsh Office of Serious Child Abuse Cases
  in Wales, University of East Anglia/Welsh Office
• Sinclair, R and Bullock, R (2002) Learning from
  Past Experience A Review of Serious Case
  Reviews, London Department of Health

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Learning from Public Enquiries

• The unholy trinity following cp tragedies
• aggressive public pillorying of agencies
• ever more detailed recommendations resulting from
  public enquiries
• increasingly intricately wrought practice
  guidance from central government

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CLIMATIC CONDITIONS

• Climate of fear
• Climate of mistrust
• Climate of blame

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HOW DID WE GET TO WHERE WE ARE NOW?

• This history may create a system
• excessively concerned with identifying and
  eliminating danger rather than promoting
  well-being and undertaking treatment or therapy.
• excessively concerned with procedures and process
  rather than with objectives and outcomes.
• defensive, reactive and concerned with the
  collection of evidence at the expense of the
  assessment of need and proactive, co-operative,
  preventive provision.

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Trusting procedures

• Procedural proliferation
• Blaming and training
• The myth of predictability

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Procedures as a net to catch problems
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Procedures as a net to catch problems
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Procedures as a net to catch problems
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Procedures as a net to catch problems
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