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10 Serious Case Reviews

Working Together 2013 outlines its expectations that LSCBs undertake reviews of serious cases and advise the authority and their Board partners on lessons to be learned.

A serious case is one where:

  1. abuse or neglect of a child is known or suspected; and
  2. either
    • the child has died; or
    • the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child

In addition LSCBs should consider conducting reviews on cases which do not meet the SCR criteria. They will also want to review instances of good practice and consider how these can be shared and embedded. The LSCB should oversee implementation of actions resulting from these reviews and reflect on progress in its annual report.

South Gloucestershire Safeguarding Children Board is committed to the promotion of learning and improvement based on local and national reviews of cases. During 2014 -15 South Gloucestershire LSCB did not undertake any new Serious Case Reviews.

However in June 2014 it published Serious Case Review Child C which was completed during the previous year but could not be published until the conclusion of criminal proceedings. This SCR resulted from the death of Child C at the age of 17 weeks; the death is recorded as due to unascertained causes. Mum and Dad of Child C were of similar ages and although the relationship was longstanding it was not continual and they had never lived together as a family.

Child C had a full sibling who was almost 3 years older than her. Mum met a new partner when Child C was approximately 5 weeks old, he was significantly older than her and he moved in to join the family shortly after they got together.

Child C had been receiving help during her short life from several agencies including Children’s Social Care.

There was a complex family history which wasn’t fully brought into focus by the agencies involved and Child C’s Mum was well known to caring agencies during her transition from childhood to adulthood. Child C suffered a series of injuries over the eight week period leading up to her death.  These were not fully known across the professional network.

The 2 men relevant to Child C’s life were not included in any assessment.

The significance of injuries sustained by Child C were not appreciated by the professionals to whom she was presented.

Significant progress has been made against both single agency and multi-agency action plans which have now been signed off by the Safeguarding Children Board.

A case review of Baby M was undertaken following a “hot debrief” model using the principles from systems methodology. Baby M was stillborn. Her parents were both using drugs and alcohol and involved in the criminal justice system. An action plan was developed following the review.

The monitoring of all action plans takes place within the Serious Case Review sub group. This group also examines SCRs from other LSCBs and promotes learning as appropriate.