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Today the CSCP have published Local Child Safeguarding Practice Review Leo.
The full report along with the CSCP response can be accessed on our website here.
A Local Child Safeguarding Practice Review (LCSPR) is a locally conducted multi-agency review in circumstances where a child has been abused or neglected, resulting in serious harm or death, and/or there is cause for concern as to the way in which agencies have worked together to safeguard the child.
The purpose of a review is to establish whether there are lessons to be learned about the way in which local professionals and agencies work together to safeguard children; identify what needs to be changed and, as a consequence, improve inter-agency working to better safeguard and promote the welfare of children.
The statutory guidance for Child Safeguarding Practice Reviews can be found in Working Together to Safeguard Children 2023.
Leo was 4 months old when he died, he lived with his mother, father and sibling. Leo's mother was care experienced and receiving leaving care services at the time of Leo's death. Leo's father had a history of experiencing abuse and poor mental health.
At the time of Leo's death his family was not in receipt of early help services , neither Leo or his sibling were subject to a statutory plan (CIN,CP).
Information Sharing
There were missed opportunities to share and seek information, which meant all the risks weren't identified and understood. There is both local and national guidance to support information sharing and seeking. The DfE Information Sharing advice for practitioners document has been updated in May 2024 and can be found here. The local CSCP Information Sharing protocol can be found here
Recognising Parental Substance Misuse
Following Leo's death evidence gathered showed that parents were using a number of substances. It is important that frontline practitioners working with parents understand the prevalence of misuse of prescription drugs and are able to identify and respond to parental substance misuse and that of prescription drugs. Recovery Steps Cumbria are providing Parental Substance Misuse Training to the partnership, which will explore the impact of substance misuse on adults and children, details can be found on the CSCP website
Professional Curiosity of Male Care Givers
Leo's father was described as taking an active role in caring for the children.
The absence of knowledge about the father’s poor mental health, history of trauma and substance misuse resulted in him being seen as an able ‘stay at home’ father rather than a parent whose vulnerabilities could impact on his parenting. The father’s role as a main carer did not prompt professional curiosity about his capacity to care full time for two children under 2 years of age.
Risks to infants (children under 2 years old) and identified complicating factors identified in research should be considered when assessing need and risk. although Leo's Father was not invisible further information can be found in the The Child Safeguarding Practice Review Panel "The Myth of Invisible Men" Safeguarding children under 1 from non-accidental injury caused by male carers 2021.
Cumbia Safeguarding Adults Board (CSAB) and the CSCP have developed a Quick Guide to professional Curiosity and a recorded Lunch and learn session on Professional Curiosity both can be found here
Responding to Babies needs
It was known that Leo did have feeding difficulties and although a number of attempts was sought to enable support for Leo and the family, it needs to be recognised by practitioners the potential impact of feeding difficulties on safety in families where there are predisposing factors which heighten risk, especially for care experienced parents and where there is no opportunity to take a break and utilise safe wider family members for support. Information on ICON can be found on the CSCP website here
Missed appointments are known indicators of risk and it is known that Leo was not taken to appointments . All practitioners should consider the risks where children are not taken to appointments and ensure this is raised with the appropriate organisation where they have missed appointments.
Sharing learning from safeguarding practice reviews in order to improve safeguarding practice is vital. We use the recommendations from practice reviews to improve safeguarding of children and young people.
Research indicates that children under the age of one year old are the most vulnerable cohort of children.
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 Safeguarding Children Partnership, to find out more.
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