Learning from Serious Case Reviews – Child N

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lscb 5 min briefing

Learning from Serious Case Reviews – Child N

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This short briefing summarises the findings and lessons from a Serious Case Review (SCR) into the death of Child N in Cumbria in 2012 – the SCR focusses specifically on how agencies worked together and individually between March 2011 and December 2012 just prior to her death.

A  Serious Case Review takes place “where abuse of a child is known or suspected; and either - (i) the child has died; or (ii) 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”.

If you work with children and families in Cumbria, there may be additional specific actions and recommendations for your agency and your role. Please ask your manager, or contact your representative on the Cumbria Local Safeguarding Children Board, to find out more.   You can read the full report at www.cumbriaLSCB.com


Child N’s story

Child N died in December 2012 aged 13 months. The post mortem x-rays carried out 2 days after Child N’s death revealed healing fractures to Child N’s tibia and fibula. The post mortem also revealed other possible injuries to Child N. During Child N's short life the family were only known to ‘universal’ services:  schools and a range of health services. Child N’s mother had a complex childhood and had been a looked after child herself because she was at risk of Child Sexual Exploitation.


THEME 1: Recognising and Assessing Risk and Need


Finding 1

Complexity of risk and need is not always obvious within a family. However Child N’s mother had experienced significant historical traumas and loss which were, in themselves, clear indicators that her parenting may have been compromised and that her children could be at risk.

Lesson to be learned

Professionals working with pregnant and new mothers need to consider the long term impact of unresolved childhood trauma and abuse on future parenting capacity.

How do you support your care leavers when they become pregnant?


Finding 2

The use of family history, chronology and genealogy to identify patterns of risk should be promoted through multi-agency partnerships and used at the earliest opportunity.

Lesson to be learned

Professionals should use family history, chronology and genealogy to identify patterns of risk.

Do you include how history and family context has been used in assessments?


Finding 3

Injuries to immobile infants were treated in isolation.

Lesson to be learned

When immobile infants are presented multiple times with what appear accidental injuries – professionals should consider further enquiries and/or a Child Protection Referral, and/or an Early Help Assessment (EHA). (It is worth noting that should an EHA be considered and parents/carers refuse to co-operate and any help and support offered that in itself may raise the level of concern).

Do you always assess the wider family circumstances when young children repeatedly attend with accidental injuries to children and consider if an Early Help assessment is indicated?


THEME 2: Responding to Risk and Need


Finding 4

In this case there was very little professional curiosity and scepticism around fathers and other males who associated with changing, high need or complex families particularly where there has been a history of sexual exploitation or abuse. 

Lesson to be learned

Multi-agency assessments should include understanding of the whole family and regular visitors to the home, alongside observations of multi-agency professionals who are involved with the family. A full & detailed history on fathers, partners (male and female) & other significant adults (male and female) in the family should be sought when gathering information.

Do you always make a record of family members and regular household visitors; remember to always update as circumstances change in particular and when there is a new partner?


THEME 3: Support and Supervision


Finding 5

In this case there was little understanding of the need and risk in women with complex profiles, such as mothers who have own child removed and a large number of subsequent children.

Lesson to be learned

Complex profiles need to be discussed through supervision and reflective support. Use reflective techniques in supervision to ensure that complex and changing family dynamics are continually considered.

Do you receive regular supervision? Do you discuss complex and changing family dynamics and do you make use of family chronologies in your supervision?


The LSCB will conduct a number of workshops and a conference to raise the profile of the lessons in this and the other SCR being published.

Sharing learning from serious case reviews in order to improve safeguarding practice is vital. We use the recommendations from case reviews to improve safeguarding of children & young people.

If you would like to discuss this briefing or any of its contents then please speak to your line manager, your representative on the LSCB or contact the LSCB Office. 1st Floor - Lower Gaol Yard, The Courts, Carlisle, Cumbria, CA3 8NA Email LSCB@cumbria.gov.uk

5 minute briefing