Learning from Serious Case Reviews – Children P

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lscb 5 min briefing

Learning from Serious Case Reviews – Children P


Cumbria LSCB commissioned a Serious Case Review (SCR) regarding Children P who are a pair of siblings who became the subject of interim Care Orders in July 2013 and placed in foster care due to longstanding concerns of sexual abuse and neglect.

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 here

Children P’s story

In April 2015, Cumbria LSCB began a Serious Case Review (SCR) in relation to the services that were provided to Children P and their family. Children P were two siblings born in 2007 and 2009 and resided with their maternal grandmother and her partner until July 2013. The family was well known to a considerable number of agencies because of issues related to a serious history of inter-generational sexual abuse, alcohol and drug misuse, domestic violence and mental ill health. The mother and her siblings had been subject to child protection plans during 2005 under the category of sexual abuse and neglect.

If you work with children and families in Cumbria, there may be additional specific actions and lessons 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.  

Lessons from Children P

  1. When a child protection plan category changes it is incumbent upon the conference chair to ensure that the new plan takes account of the history and any outstanding actions including assessments that have not been addressed within the previous plan. This case highlights the importance of clear, full and accurate recording of the history of the child or young person, including their understanding and knowledge of their family. Transfer summaries and chronologies are essential tools for workers and their supervisors to rely on.
  2. Practitioners and managers must equip themselves with up to date knowledge of child sexual abuse including age appropriate sexual behaviour in children.
  3. A history of sexual abuse must be taken into account in risk assessments to determine the carer’s ability to keep children safe.
  4. Parental alcohol and substance misuse assessments should be multi-agency and practitioners must ensure that resultant plans are child focussed, timely, address the risks to children in order to effectively safeguard them.
  5. This case highlights the importance that assessments relating to drug and alcohol misuse in respect of the parents and other care givers must include a thorough analysis of how their substance misuse poses a risk to the children. In addition, other known risk factors of parental emotional and physical ill health and domestic violence should be examined in relation to substance misuse.
  6. Practitioners should consistently use chronologies and LSCB Neglect Tools to understand and assess the emerging pattern of risks over time.
  7. Risk assessment, analysis and decision making in cases of neglect must be child focussed.
  8. Where private law orders are supported by a local authority, managers and practitioners must continue to assess whether the order remains in the child’s best interest and should this position alter, timely action must be taken to inform the court of the revised position.
  9. Multi-agency meetings are an essential part of the child protection planning process and therefore multi-agency professionals must ensure that the child protection plan is child focussed and implemented as a detailed working tool.
  10. Practitioners should assess the risk of domestic abuse in teenage (under 18) intimate relationships to take account of factors such as: intergenerational domestic abuse, older partners, teenage parent’s exposure to sexual, physical, emotional abuse and neglect. Where the victim of domestic abuse is a teenager under 18, professionals should always consider  a  referral to Early Help or MARAC, and MARAC decision-making must reflect the increased risk for this age group
  11. Any frontline agency representative that undertakes a risk assessment with a domestic abuse victim, and thereby determines that their case meets the high risk threshold, can refer a victim’s case to a local MARAC. The threshold for MARAC is high risk with 14 or more ticks on the SafeLives-DASH Risk Indicator Checklist or where professional judgment warrants a MARAC referral.
  12. Professionals working with parents who are under 18 years of age should use family history, chronology and genealogy to identify patterns of risk to ascertain whether the parent should have their own plan addressing their needs as an individual child beyond an assessment of their parenting capacity – threshold decisions must be documented for both the parent and their child(ren).
  13. This case highlights the need for practitioners to understand and consider the impact of trauma and abuse on young parents.

Dissemination of Learning

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, Cumbria House, 117 Botchergate, Carlisle, CA1 1RD.

Email LSCB@cumbria.gov.uk