Transcript Learning Lessons

Serious Case Reviews and
Domestic Homicide reviews

Key themes arising from reviews; some of these are
reoccurring themes, how do we break the cycle locally?
What needs to happen

Public perception between children and adult reviews:
Are there differences? What are they? What factors
influence this?

How can local safeguarding boards improve support for
staff, professionals and families involved in Children or
Adult Reviews?

How to best engage local staff / professionals in
dissemination of learning from reviews: What methods
should be used?
 Determine
what lessons can be learnt about
how professionals/ agencies (individually and
together )work to safeguard children or
adults at risk.
 To
review the effectiveness of local
safeguarding procedures (multi-agency and
single agency)
 Inform
and improve local inter-agency
practice
 Regulation
5 of the Local Safeguarding
Children Boards Regulations 2006: the
requirement for LSCBs to undertake
reviews of serious cases in specified
circumstances.
 Care
Act 2014 – enacted April 2015,
requires Local Adult Safeguarding Boards
to arrange a Safeguarding Adults review
Hamzah’s decomposed body was found by police in the home,
almost two years after he starved to death. The Serious Case
Review in Bradford, identified some of the key events prior to the death:

Mother was late notifying her pregnancies, history of alcohol misuse

Mother victim of repeated Domestic Violence incidents, but refused
to formally complain to police about her partner.

GP & Health Visitor: children’s access to immunisations health
appointments was a problem. Hamzah was described in the report
as an “invisible child” to agencies.

Older sibling distressed following DV incident, reported this to the
police in 2006. Child returned home after initial assessment by
Children Social Care.

Missing from home incident reported to police with older sibling.



School attendance problems with children.
Communication across agencies not always effective
sharing information.
Home conditions very poor.
Lessons learnt:
 Importance of listening to children
 Good assessment practice needs to be based on good
theoretical understanding of concepts such as
vulnerability and neglect. Long process of multi-layered
issues
 Importance of “think family” and providing early help to
family and children in need
 Importance of good information sharing across agencies
Daniel was starved and beaten for
months before he died in March 2012
at his Coventry Home.
The SCR report says that the boy appeared ‘invisible’ to the
authorities, who “demonstrated a failure of the most basic aspect
of child protection work”.
A midwife with serious concerns was persuaded by a social worker
not to refer the case to the children’s services at Coventry City
Council, for example.
Teachers saw Daniel scavenge for food from bins, and police
received 26 reports of domestic abuse at his home, but no-one got
to the bottom of what was going on in time to save his life

Dangers of Silo Practice – children not always taken into account
within adult assessments for services. Importance of “think family or
whole family approaches” flagged.

Importance of taking forward early help / CAF to support families,
when required.

Importance of listening to the voice of the child; supporting them with
communication when English not main language. Child observed
repeatedly scavenging food, underweight.

Importance of information sharing and collating information across
agencies

Importance of escalation and challenge

Domestic Violence, parental substance misuse, mental ill-healthhigh risk factors. Collectively referred to as “toxic trio” represented
in many SCR’s.

Domestic Violence- separation does not always mean safety, risks
may increase, i.e. stalking behaviours.

Importance of escalation; if a child or adult is in need of
safeguarding and there are concerns about an agency response.

Collation of information and the importance of understanding the
“history”- use of chronologies.

Importance of pre-birth assessments.

Communication and information sharing between local children
and adult services- often a gap

Hostile or avoidant behaviours, can divert professional attention
to the adults, away from children or vulnerable adults in the
home.

Dangers of “hidden” adults gaining access
to children who pose a risk – Baby Peter died 2007.

Dangers of professional “rule of optimism” and not
being child focused.

Immobile babies and unexplained bruising –
importance of demonstrating “respectful uncertainty”.
Safeguarding referral procedures not followed. Child
Z Leicester City LSCB (2013)

Impact of accumulative community anti-social behaviour
on vulnerable adults – importance of reviewing all
information and risk assessment of these on the individual
Pilkington Leicestershire (2008).

Importance of collating and reviewing safeguarding
concerns when they arise in a single provider settingSummervale, Leicester (2012).

Importance of sharing relevant information about
vulnerable adults, at points of transfer of care. Applying
the Mental Capacity Act 2005 working with vulnerable
adults in residential settings. Leicester, JG SILP (2012).

Sourcing appropriate care arrangements when agencies
remove main carer, MS Review (2010).
Winterbourne View Hospital was a
Private hospital providing long term
care for adults with Learning
Disabilities and autism.
An undercover BBC reporter secured
employment as a support worker at
Winterbourne View Hospital. Who
filmed colleagues tormenting,
bullying and assaulting patients.
Findings were exposed on Panorama
11 care workers who admitted a total
of 38 charges of neglect or abuse of
patients at a private hospital have
been jailed.
SCR taken forward by Gloucestershire SAB, Independent Author
Margaret Flynn

NHS commissioners -there was no overall leadership. Even
though the hospital was not meeting its contractual
requirements in terms of the levels of supervision provided
to individual patients, commissioners continued to place
people there.

Families felt dis-empowered: influencing placing decision
making.

Mental Capacity Act 2005 principles not followed,
particularly for adults not detained under the provisions of
the Mental Health Act 1983.

Whistle-blowing: concerns were not addressed by
Winterbourne View Hospital nor Castlebeck Ltd

Clinical leadership and professional responsibility, Low
threshold for detaining patients under section 3 Of the
Mental Health Act and the safeguards of a second,
Independent doctor supporting the application and the
independent decision by an Approved Mental Health
Professional were overridden.

Volume and characteristics of safeguarding referrals
Which were known to South Gloucestershire Council Adult
Safeguarding were not treated as a body of significant
concerns.
Recognition and response to other alerts: notifications
to the Health and Safety Executive; the hospital’s
inattention to the complaints of patients or relatives;
restraint incidents excessive; high level of police presence
responding to incidents and repeated absconding.

Joint LLR Agency Winterbourne action plan
across local agencies:





Commissioning of placements for adults with long term
disabilities being more community focused.
Active review of quality of local learning disabilities
services.
Whistleblowing procedures – reinforced embedded
Large Scale Safeguarding Investigations – procedures in
place
Empowerment and advocacy for service users.
Stephen Hoskin:
died 2006 Cornwall
A 39 year old man with learning
disabilities – his “friends” beat
him, imprisoned him, drugged
and tortured him. His body was
found at the base of railway
viaduct.
Over 40 missed opportunities
across agencies to protect him.
Gemma Hayter:
died 2010 Warwickshire
Had a significant learning
disability, was found dead on a
disused railway embankment.
Gemma considered the 5
convicted of her murder as
“friends”.
They had forced her to drink urine
from a beer can, beaten with a
mop and stripped before being left
for dead.
DHR’s were established on a statutory basic under section
9(3) of the Domestic violence, Crime and Victims Act
(2004).Came in force April 2011, a DHR should be taken
forward when:

Death of a person aged 16 years or over has, or appears
to have, resulted from violence, abuse or neglect by

a person to whom s/he was related or with who s/he
had been having an intimate personal relationship or
A member of the same household as himself, held with
a view to identifying the lessons to be learnt from the
death.
Between 13 April 2011 and 31 March 2013, 54 completed
reports were received by the Home Office. The emerging
themes:

The importance of a consistent approach to risk identification,
assessment and management for all professionals was
identified in a number of reports. DASH risk assessment needs
to be applied consistently across agencies.

Agencies need to make informed decisions – preferably with
victim consent - to share information and only share when it is
safe to do so, to ensure that the victim is not placed at higher
risk. Importance of staff understanding good information
sharing practice.

Domestic Violence and abuse were not always identified agencies were focusing on addressing, for example, the
mental health or substance misuse of the adult, identifies the
importance of asking questions about DV during assessment.

Inadequate information sharing between agencies -where a
perpetrator is released on bail or from prison. Some reviews
highlighted the importance of compliance with existing
processes and procedures specifically in relation to bail
management ( including breach of bail ) as this is critical in
protecting victims and managing suspects.

In a smaller number of reports there were cases where
opportunities were missed to refer cases to Children’s
Services. This included those cases where children were in
households where domestic violence and abuse occurred
between adults but the impact on the children was not
necessarily considered.







Community Safety Partnerships have reviewed the report and local position
and are strategically leading the DV agenda.
Ensure that staff in your agency or service have the appropriate training in
Domestic Violence to include risk assessment and management.
http://www.caada.org.uk/marac/RIC_for_MARAC.html
Royal College of General Practitioners have developed a DV e-learning
training course for GPs. http://elearning.rcgp.org.uk/course
The National Institute for Health and Care Excellence (NICE) guidance on
preventing domestic violence, 2014 Vulnerable groups | Guidance and
guideline topic | NICE
Training tools are being developed for health visitors on domestic violence
and are expected to be launched in 2015.
The NOMS Multi-Agency Public Protection Arrangements (MAPPA) team plan
to observe level 2 and 3 meetings on Category 2 violent offenders to look for
best practice of risk assessment risk management planning and sharing of
information and this will include management of offenders with complex
needs.
Midwives should undertake routine enquiry by asking all pregnant women
whether they are at risk of, or are suffering/suffered from domestic violence.
 What
are the legal powers?
 What does my agency AND inter-agency
policies and safeguarding procedures tell me?
 What are my civil duties?
 What do information sharing protocols or
agreements allow me to do?
 Am I carefully balancing the rights of adults
and children?
 What are the best interests of child or adult?
 Do I need legal advice?
 Good
assessment, information sharing and
review of information
 Accessing good supervision
 Early intervention and support
 Following local multi-agency procedures
 Effective partnership working
 Good risk management and review
 Working within Legal Frameworks
 Good Record Keeping Standards.

Hull Safeguarding Adults Partnership Board. A decade of serious case
reviews: our vision for adults safeguarding: 2014
www.safeguardingadultshull.com

Manthorpe J & Martineau S, First Annual Report: national panel of
independent experts on serious case reviews adult safeguarding 2014
Kings College London

OFSTED, Ages if concern: learning lessons from serious case reviews: a
thematic report of Ofsted’s evaluation of serious case reviews (april 2007 to
March 2011). 2011 www.ofsted.gov.uk

Home Office, Multi-agency Statutory Guidance for the Conduct of Domestic
Homicide reviews: revised, august 2013 home office

For SCR or DHR reports referenced log onto relevant LSCB or SAB
website.