- Child Safeguarding Practice Review Panel:
- National Learning from Serious Case Reviews
- Serious Case Reviews and Thematic Reviews published by Croydon Safeguarding Children Partnership
- Chid Y SCR
- Child Q SCR: “Where were you when I was six?”
- Vulnerable Adolescents Thematic Review 2019
- Child A & Baby N – published 22nd February 2019
- Child ‘L’ – SCR published 22nd August 2018
- Child “Joe” – SCR Published 26th February 2018
- Child J and Child K – SCR Published 15th February 2018
Serious Case Reviews (SCRs) Learning Reviews and Child Safeguarding Practice Reviews occur when:
- abuse or neglect of a child is known or suspected and
- the child has died or been seriously harmed.
Any partner agency may refer a case to the CSCP if they consider the criteria is met for a SCR. The Independent Chair makes the decision of whether to instigate a SCR following discussion with the sub-group representatives.
The prime purpose of a SCR is for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children. After the completion of each review the CSCP will publish an anonymised Final Report.
Child Safeguarding Practice Review Panel:
Please see Working Together 2018 for information about the introduction and functions of the new Child Safeguarding Practice Review Panel.
National Learning from Serious Case Reviews
www.seriouscasereviews.rip.org.uk is a site dedicated to providing materials to support learning in practice for LSCBs, social work and early help, police and criminal justice, health and education practitioners.
Pathways to harm, pathways to protection (July 2016) analyses 293 Serious Case Reviews (SCRs) relating to incidents which occurred between 1 April 2011-31 March 2014. This is the fifth consecutive analysis of SCRs by this research team, whatever the structural arrangements in future, the significant body of learning contained in this Triennial Analysis and the previous reports will remain an essential resource for everyone concerned to prevent and protect against the maltreatment of infants, children and young people.
In 2013 the NSPCC launched the national case review repository, in collaboration with the Association of Independent LSCB Chairs. The repository has over 600 case reviews and inquiry reports dating back to 1945. It provides a single place for published case reviews to make it easier to access and share learning at a local, regional and national level.
The NSPCC has also produced thematic briefings highlighting the learning from serious case reviews. Each briefing focuses on a different topic, pulling together key risk factors and practice recommendations to help practitioners understand and act upon the learning from case reviews. See detailed list of NSPCC Thematic Briefings posted on their website.
Serious Case Reviews and Thematic Reviews published by Croydon Safeguarding Children Partnership
Chid Y SCR
Croydon Safeguarding Children Board has today published the Serious Case Review of Child Y which was commissioned in September 2017.
Child Y, 15, was the victim of a fatal stabbing on 8 August 2017. Although the stabbing was deemed to be gang-related and a group of young people were convicted of his murder, Child Y was not thought to be connected to either of those gangs; he did have childhood friends who were said to be gang members.
Child Y had a close loving family, he lived with his hardworking father and devoted older sister, and his wider family provided unconditional support. His mother had long-term health problems which prevented her from looking after him during his childhood. His father described himself as strict and described Child Y as a fun-loving, affectionate and charismatic child who enjoyed spending time with his family.
During Child Y’s adolescence the father and son relationship came under real strain from a variety of incidents; which included Child Y coming into contact with the police, him going missing, suffering a stab injury and being excluded from school. Child Y became very disillusioned when he learned he could not return to his school and was transferred to a pupil referral unit.
Whilst Child Y is the sole subject of this serious case review, his whole life experience is reflected in the CSCB-commissioned Vulnerable Adolescents Review published in February 2019. The findings and recommendations of the Vulnerable Adolescents Review are relevant to him and are referenced within this review.
Di Smith, Independent Chair of Croydon Safeguarding Children Board, said:
“The tragic death of this child, who was dearly loved by his family, is so difficult for all to comprehend. In conducting this review in conjunction with the wider Vulnerable Adolescent Review we have sought to understand the factors that led to such devastating consequences for Child Y. Also to identify important lessons that will help services in Croydon keep children and young people safe.
“While many practitioners from different agencies worked to help Child Y and his family, there were some missed opportunities. More could have been done to support Child Y with preventative work at an earlier stage, and build on his strong family network.
“Later, certain events were of pivotal importance – for example, his exclusion from mainstream school – and we must ask what interventions might have worked more effectively at these key points to deter him from his trajectory.
“It is not possible for us to say what difference it would have made to Child Y. But
both the case of the Child Y and the Vulnerable Adolescents Review clearly highlight the importance of strengthening families, building their resilience at an early stage and the importance of education in children’s lives.
“The learning from both will be invaluable as we go forward, as a strong and cohesive partnership determined to take a preventative approach by strengthening families and helping our young people to make positive choices.”
Child Q SCR: “Where were you when I was six?”
Croydon Safeguarding Children Board has today published the Serious Case Review of Child Q which was commissioned in September 2017.
Child Q, 16, suffered fatal injuries in a road traffic collision between a moped and a police car in the early hours of 16 July 2017. Tragically, he died in Croydon University Hospital the following day. At the time of his death, he was looked after by Croydon Council, living with extended family in the Midlands.
Child Q was known to social care agencies from a young age. During his childhood he experienced many moves, living with different family members and foster carers. He attended numerous schools, and ultimately, pupil referral units.
Child Q was deeply loved by his family, and well-liked by professionals. He excelled at football and was a likeable engaging boy. At age 13 he was a victim of crime after which he committed his first offence.
As he grew older, he regularly came into contact with the police and was subject to criminal convictions. Agencies assessed him as a gang member. It became a significant challenge to keep him safe within the community.
The aim of this serious case review was to understand the factors that led to such devastating consequences for Child Q and also to identify important lessons that will help services in Croydon keep children and young people safe. Whilst Child Q is the sole subject of this serious case review, his whole life experience is reflected in the CSCB-commissioned Vulnerable Adolescents Review published in February 2019. The findings and recommendations of the Vulnerable Adolescents Review are relevant to him and are referenced within this review.
Di Smith, Independent Chair of Croydon Safeguarding Children Board, said:
“This was the tragic death of a child, who was deeply loved by his family, and well-liked by professionals. This review asks; ‘could more have been done to keep him safe?’
Child Q’s childhood experiences shaped his pathway and services were unable to provide the support to address or change this trajectory.
By the time Child Q reached adolescence, his behaviour was high-risk and challenging and the situation changed constantly, leaving agencies struggling to keep pace.
Whilst the professional network had a wealth of experience, skills, knowledge and expertise, they were frequently not equipped with the tools they needed to keep him safe, at the time they needed them. For example, there was a particular challenge in obtaining secure placements for highly vulnerable children like Child Q.
This review questions whether more could have been done to support and divert Child Q at an earlier age, and there were times during his early years, and his education, when his needs were not met. As a young child he did not experience stability at home or in education; during his primary school years he did not receive the mental health support he needed. During his adolescence he did not receive the treatment and care he needed.
It is not possible for us to say what difference this would have made to Child Q. However, both the case of the Child Q and the vulnerable adolescents review clearly highlight the importance of strengthening families, building their resilience at an early stage – and the pivotal importance of education in children’s lives.
The learning from both will be invaluable as we go forward, as a strong and cohesive partnership determined to take a preventative approach by strengthening families and helping our young people to make positive choices.”
Download here: Child Q SCR (published May 2019)
Vulnerable Adolescents Thematic Review 2019
Statement from the CSCB Independent Chair – Di Smith
The Vulnerable Adolescents Review was commissioned in Summer 2017 following the tragic deaths of three young people in less than a month. The aim of the review was to understand the factors that led to such devastating consequences and to identify important lessons that will help services in Croydon keep children and young people safe and reduce the risk of future harm.
The CSCB made the decision to widen the scope of the review to get a broader understanding about the lives of vulnerable young people in Croydon. In addition to the three young people who died, the review also included 57 vulnerable young people who were identified as being of concern, including those particularly at risk from violence and exploitation.
This is the largest piece of work undertaken by the Board to date and it demonstrates the determination of partners to improve and deepen their understanding of the lives and experiences of vulnerable young people, the community in which they live and the services they have received. The review brings together information from their families, social care, schools, health, police, youth offending, community organisations and, where possible, the young people themselves. The review considers the support they received and the effectiveness of multi-agency working.
The findings highlight a high proportion had experienced paternal absence (72%), exposure to domestic abuse (42%), homelessness (28%) and maternal absence (27%). All 60 were known to social care – more than half of them by the age of five – and 70% had been referred to child and adolescent mental health services.
The review particularly emphasises the pivotal importance of education in young people’s lives. It also highlights the impact of exclusion. Of the 19 young people in the cohort who received a fixed term exclusion in primary school, all went on to receive a criminal conviction.
Young people’s safety is a particular concern at the moment and as a result there has been widespread interest in the Vulnerable Adolescents Review. In Croydon, the learning will be invaluable as we go forward, as a strong and cohesive partnership, to take a preventative approach to youth crime, strengthening families and to helping our young people make positive choices. We hope this review will also be of some value to other areas facing similar issues both here in London and beyond.
It remains for me to thank all those across the partnership for their great commitment in gathering evidence for the review; to express a deep gratitude to the young people and families who have shared their experiences; and finally, to thank Charlie Spencer, Bridget Griffin and Maureen Floyd for the passion, drive and sensitivity they have brought to this ground-breaking piece of work.
Child A & Baby N – published 22nd February 2019
On 15 March 2016, Baby N, at 2½ weeks old, was admitted to hospital in a critical condition having suffered a cardiac arrest. He was transferred to a specialist paediatric unit but sadly died on 21 March 2016.
The preliminary results of a specialist post mortem indicated that Baby N’s death was associated with a severe head injury. The circumstances were considered to be suspicious and a police investigation commenced.
Prior to Baby N’s death, his older sibling, Child A had been presented to hospital with head injuries on two occasions, one of which required inpatient admission. Children’s Social Care were notified of the admission, but it was not progressed beyond a contact to a referral.
Child A is safe and well and living with the wider family. The Police investigation is complete and no criminal charges have been initiated.
Di Smith, Chair of Croydon Safeguarding Children Board, said: “This is a very sad case where a very young child – Baby N – tragically died after sustaining a severe head injury.
“Prior to his birth, the family had come into contact with agencies. When their older child, Child A, attended hospital with head injuries, child protection procedures were triggered. However, agencies did not adequately share information; decisions were not timely and reasons for decisions were not adequately recorded.
“We cannot say whether the death of Baby N could have been predicted or prevented. However, this case review has identified a number of issues relating to information sharing, record-keeping, compliance with child protection procedures, and professional curiosity. In addition, this case emphasises the significance of head injuries in pre-mobile children, which need to be recognised and acted upon. .
“Local agencies support the findings and the learnings from the review, and have strengthened their procedures across all these areas as a result.”
Child ‘L’ – SCR published 22nd August 2018
Croydon and Lambeth Local Safeguarding Children Boards (LSCBs) have published the Serious Case Review (SCR) of Child L which was jointly commissioned by both LSCBs in September 2016 and led by Croydon LSCB. The link to the full report is below.
L was the subject of a Child Protection (CP) Plan in Lambeth since before his birth in July 2015. He remained on a child protection plan and the family received support from Lambeth agencies until May 2016, when the case was transferred to Croydon where he was living with his mother.
In July 2016, aged 11 months old, L was taken to hospital by his parents. He was in cardiac arrest as a result of cocaine ingestion. Child L survived the incident, he was made the subject of care proceedings and is now safe.
The publication of this report was delayed in order to avoid any conflict with the criminal proceedings brought against both parents in June 2018. Both parents were found Not Guilty.
Di Smith, Interim Independent Chair of Croydon LSCB, said:
“Child L was made subject to a Child Protection Plan in Lambeth from before his birth. His parents had a volatile relationship with allegations and counter-allegations of domestic abuse, assault and apparent mental ill-health. He lived with his mother who was from Croydon, and housed in homeless accommodation across Lambeth and Camden before returning to live in Croydon. His father often stayed with the family.
In May 2016 the family moved to Croydon who took over responsibility for his Child Protection Plan. In July 2016, at the age of 11 months Child L was taken to hospital by his parents as he was in cardiac arrest having ingested cocaine which was said to have been hidden in his cot. Thanks to speedy and intensive medical attention he survived the incident and is living permanently with other family members.
His father was known to have used drugs in the past. The risk that Child L was exposed to from parental drug misuse was not fully recognised in his child protection plan.
We always carefully and independently consider all such cases to assess whether more could have been done, and what can be learned. In this case, the conclusion is that this sad incident could not have been predicted. Nevertheless, this Serious Case Review highlights where more could have been done to promote his safety and wellbeing. The challenge of multi-agency working across three boroughs is recognised in the review as is the finding that some child protection standards were not met.
All agencies in both Croydon and Lambeth LSCBs are fully in agreement and committed to putting into practice the lessons highlighted in the SCR.”
Child “Joe” – SCR Published 26th February 2018
Croydon Safeguarding Children Board has published the Serious Case Review (SCR) of Joe which was commissioned by the CSCB in July 2016.
Joe was known to services in Croydon since before he was born, when he became subject to a Child Protection (CP) Plan. He remained on a CP Plan until January 2016 when he was two years and five months old. Following this he continued to receive support from local services through a Child in Need Plan.
In June 2016, aged two years and 11 months, Joe lived in temporary accommodation with his mother. On the day of the incident he was found home alone and suffering from life-changing burns. On the same day Joe’s mother was sectioned under the Mental Health Act. Subsequently, mother was found to be suffering from drug-induced psychosis. Joe is recovering, although he will need long-term treatment for his injuries.
Di Smith, Interim Independent Chair, said:
“This serious case review makes for difficult reading. We fully recognise that the practice in Joe’s case was not acceptable and the multi-agency processes in place to protect him were not effective. Whilst his injuries could not have been predicted, it is evident that more could and should have been done to protect his safety and wellbeing.”
“Agencies in our partnership have cooperated with the SCR and have accepted all of the findings. They are focused on improving child protection practice and are working hard to continue to strengthen our standards and processes in response to the findings of this review. We are determined to address the shortcomings in the child protection system that this sad case has brought to light.”
Child J and Child K – SCR Published 15th February 2018
Croydon Safeguarding Children Partnership (CSCP) has published a Serious Case Review (SCR) concerning a four year-old child (Child J) and their 16 year-old half-sibling (Child K). In November 2015 Child J was admitted to hospital with serious malnutrition. Child J had a positive response to intensive hospital treatment and now lives in a permanent home away from their family.
The CSPB commissioned an SCR to examine the children’s history and determine what had led to this event.
Di Smith, Chair of CSCP, said: “CSCP has undertaken rigorous examination of the events in this case as this child could have suffered even more serious consequences, were it not for swift medical intervention. It was important for us to be clear how this situation had come about and to identify what could be done differently in future. The SCR was robust in establishing how agencies had worked together and CSCP has implemented the learning immediately, introducing measures across the partnership to improve earlier identification of such cases.”