Transcript Learning from Case Reviews

Learning from Case Reviews
Caroline Tote
Head of Service Children’s Safeguarding Leicester City Council
Donna Thomson
Detective Chief Inspector Leicestershire Constabulary
Adrian Spanswick
Consultant/Designated Lead Safeguarding LLR Cluster/Honorary Principle
Lecturer DMU
Content of the session
• Introductions, aims and ground rules
• Case review processes – Serious Case Review and Serious Incident
Learning Process
• Case summaries
• The Big Picture – Presentation by Donna Thomson
• Break
• Systems: Developing Practice – Presentation by Adrian Spanswick
• What does this mean for you and your agency/organisation?
• Feedback and questions
• Evaluation
• Close
Aims and Ground Rules
Aims
• Understanding the process
• Broad understanding of the cases
• Lessons learned
• Themes
• What this means for our own practice
Ground Rules
• Confidentiality
• Understanding the emotional impact
• Understanding each others roles
• Taking responsibility – not blaming
• Learning lessons
The purpose of a Serious Case Review
• To establish whether there are lessons to be
learned about the way in which local
professionals and agencies worked together to
safeguard children
• To identify clearly what those lessons are, how
they will be acted upon and what is expected
to change as a result
• To improve inter-agency working and better
safeguard and promote the welfare of children
Serious Case Reviews are not:
• Inquiries into how a child died or was
seriously harmed, or into who is culpable.
These are matters for coroners and criminal
courts, respectively, to determine as
appropriate
• Part of any disciplinary inquiry or process
relating to individual practitioners.
When should an LSCB undertake a
Serious Case Review?
• When a child dies (including death by
suspected suicide) and abuse or neglect is
known or suspected to be a factor in the
death
• When a child dies in custody
When should an LSCB consider
undertaking an SCR?
• A child sustains a potentially life-threatening
injury or serious and permanent impairment
through abuse or neglect
• A child is seriously harmed as a result of sexual
abuse
• A parent has been murdered and a domestic
violence homicide review is being initiated
• A child has been seriously harmed following the
violent assault by another child
And
There are lessons to be learned about interagency working to protect children
The SCR Process
• The LSCB needs to decide whether or not a
case should be the subject of a SCR
• The LSCB should establish a Serious Case
Review Panel
• The Local Authority should inform Ofsted of
the LSCB decision
• The LSCB can consider alternative review
processes if not undertaking an SCR
The SCR Process
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Trawling for information
Individual Management Reviews
Overview
Action Plan
Executive Summary
Submission to Ofsted
Evaluation
Links to the criminal and coronial processes
Publication
Dissemination
Serious Incident Learning Process
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Decision made to undertake a SILP
Initial work as with an SCR
Panel Chair and Overview Report Writer
Agency reports commissioned
Learning days
Action Plan
Links to the criminal and coronial processes
To publish or not?
THE
BIG PICTURE
Donna Thomson
Detective Chief Inspector
Leicester City Safeguarding
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PERSONAL
RESPONSIBILITY
• Ownership.
• Co-ordination.
• Which other agencies or individuals need to be
informed.
• Which other agencies or individuals need to be
involved.
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IN FOCUS?
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THINK FAMILY
• Support networks.
• Hidden males, friends and
associates.
• Lifestyle – What is happening
in this house with this family?
• Keep the focus on the child
whilst considering the needs
of adults in the household.
• What other services are being
provided by agencies to the
whole family?
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CULTURAL ISSUES
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Race.
Ethnicity.
Religion.
First language.
Social isolation.
Immigration status.
Role of UKBA.
ASSuME (relationship status)
Fear of being perceived as racist
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CO-MORBIDITY OF ISSUES
‘The Balcony View’
Drugs.
• Alcohol.
• Parental mental ill health (anger management, self
harm, suicidal thoughts, depression).
• Domestic violence.
• Other (socio-economic factors etc)
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HEALTHY SCEPTICISM
Detectives ABC
• Accept Nothing.
• Believe Nothing.
• Check Everything.
Aka…..
• Corroborate
• Challenge.
• Speak to the child and others
that speak on their behalf.
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DASH
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Separation.
Stalking and harassment.
Pregnancy and new birth.
Suicidal thoughts and depression.
Escalation.
Isolation.
Strangulation.
Sexual assault.
Use of weapons.
Child abuse.
Animal cruelty.
Drug and alcohol use.
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NATIONAL DECISION
MAKING MODEL
Gather
Information and
Intelligence
Assess Threat
and Risk
and Develop a
Working Strategy
Take Action
and Review what
happened
Policing Mission,
Values, Risk
and Protecting
Human Rights
Identify Options
and
Contingencies
Consider
Powers and
Policy
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GATHER INFORMATION
(Beware Silo Working)
• What current and historic
information is held within my
agency?
• Which other agencies or
individuals may hold current or
historic information?
• What are the inconsistencies?
• Cross border information
• Where are the gaps? …..
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INFORMATION FROM PARENTS, CARERS
AND SIGNIFICANT OTHERS
• Ask the right
question...
• Motivation to be open
and honest.
• Goals.
• Credibility of
information.
• Inconsistencies in
information.
• Corroboration.
• Challenge.
• Gaps in information.
and I will give you the right answer
iRobot Vikki
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INFORMATION
(HEARING THE VOICE OF THE
CHILD)
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INFORMATION – (HEARING THE
VOICE OF THE CHILD)
• Listen to the voice of the child.
• What are their goals?
• Listen to the story of those that
speak on behalf of the child.
• Thinks about the context in which
they are sharing information.
• What is their motivation to be open
and honest?
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ASSESS THREAT
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ASSESS THREAT AND DEVELOP
A WORKING STRATEGY
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What are we concerned about?
Who is at risk?
What are they at risk from?
Who are they at risk from?
When are they at risk?
What needs to change?
How quickly does it need to change?
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POWERS, POLICIES AND
PROCEDURES
• What are my legal powers?
• What do my agency AND inter-agency policies
and 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 is in the best interests of the child?
• Do I need legal advice?
• Over reliance on criminal proceedings
(bail conditions)
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IDENTIFY OPTIONS AND
CONTINGENCIES
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Failing to decide
Do nothing (inaction is still action)
Share and gather information.
Speak to family, relevant others and witnesses.
CAF.
S17.
S47.
Agreements.
Accommodation.
Police Protection.
Legal action.
What is Plan B?
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TAKE (SMARTER) ACTION AND ASSESS
• What action does each agency need to
take in order to mitigate or manage the
identified threat?
• Who needs to take it and when?
• Check understanding of parents/ carers
–(straight-forward language)
• Agreement of professionals and
parents/carers
• How will we know that the actions are
working?
• What will we do if it does not work and
when will we do it?
• What will trigger re-assessment?
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REVIEW
• Is it working?
• How do we know that it is
working?
• Has what we are concerned
about gone away?
• Has what we needed to
change to be ‘good enough’
changed?
• Have I informed agencies and
individuals of material
changes circumstances?
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RECORDING
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Full
Factual
Accurate
Timely
Reasonable judgements and
defensible decisions
• Legal disclosure
• Hand-written notes
• Sharing information internally
and externally…….
(photos/diagrams/full description and size of injuries etc)
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OUTCOMES
• LSCB Procedures for informing agencies of
outcomes.
• Dissemination of Child Protection Conference
meetings and other minutes.
• Single record of strategy meetings.
• Personal contact with agencies not represented
when significant issues have arisen.
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Thank you for your attention.
[email protected]
Telephone 0116 222 2222 x 4348
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LEARNING LESSONS
DEVELOPING PRACTICEs
Developing Practice
Adrian Spanswick
Consultant / Designated Lead Safeguarding LLR Cluster /
Honorary Principal Lecturer DMU
March 2012
A Reality Check!
• “At the ‘sharp end’ of the system, practitioners
interact with children and parents.”
• “Effective help or error arises from the
interplay of the difficulties presented by
families problems and the expertise and
resources of practitioners”.
» (Munro, 2005)
What do you really know?
• “from a single action you draw an entire universe”
» Kwai Chang Caine
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Local Serious Case Reviews
What are we not learning?
• Importance of social history
– Practice Note: Clearly the existence of previous evidence of
poor or inadequate parenting should not militate against the
possibility of change, but any assessment should take account
of past or potential patterns of behaviour or concerns.
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» Research Report DCSF-RR129 Brandon et. al 2009
Drug and alcohol misuse (‘Hidden Harm’)
Parental mental ill health (‘Hidden Harm’)
Domestic violence
Differential diagnosis
Professional disagreement
Local Serious Case Reviews
What are we not learning?
• Minor injuries / non-mobile babies / shaken
babies
• Delay / possibility of deliberate harm
• Lack of information sharing (intra and interagency)
• Poor communication between professionals
• Measurements – metric and centile
• Gender / cultural assumptions
• Ethnicity not recorded
• Communication including use of interpreters
• Employment / allegations against staff
Local Serious Case Reviews
What are we not learning?
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Poor living Conditions
Anger Management issues
Lack of whole family perspective
Thresholds
Information systems
Lack of consideration in regard to use of a CAF
Warning signs / Risk factors Child Sexual Exploitation
Dangers from inappropriate child care arrangements
Not becoming complacent regarding children in care
Lack of multi-agency risk assessment.
Parental Substance Misuse
(Research Report DCSF-RR129)
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Parents’ substance misuse was sometimes closely linked to the child’s death or
serious injury (and as we mentioned earlier was a feature of some of the cases
where the child had died through ‘overlaying’). A small number of deaths (fewer
than six) were as a result of the child ingesting their parent’s drug, most often
methadone. Sometimes the ingestion was accidental but in one case a father
admitted to giving his baby methadone.
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Following D’s death, post mortem showed ingestion of drugs. .. Father has
admitted to giving the baby methadone, but not immediately before death.
Reason was to calm the baby.
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In the area where this review originated, LSCB literature was updated to provide
information making it clear that giving babies or children methadone is highly
dangerous and may cause serious harm or death. It was also noted in this report
that giving babies methadone:
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“appears to be acceptable practice within the drug community to calm babies
down”.
Mongolian Blue Spot
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common birthmark.
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blue-grey markings
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usually lower back and buttock
region.
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The affected skin is not thickened
or changed in any way other
than in colour.
• Feels normal
History
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Lack of explanation
Inconsistent explanation
Does not fit with the developmental age of the child.
Time delay without appropriate explanation
Inappropriate child/carer response
Age of child – (remember immobile infants)
Previous history of unusual injury
Known to children’s social care
Repeated attendance due to neglect or abuse
Repeated DNAs
Social history.
Information and Communication
Technology (ICT) Systems
• Do staff find that the existing ICT systems make it
easy to record, retrieve and print relevant data?
• Are there aspects of the ICT system that militate
against the recording of data and/or analysis that
would assist in decision-making and case planning?
• Are there any additional functions that it would be
useful for the ICT system to be able to do?
• Are flags on systems to alert others (should others
know what you know to inform decision making?)
• Remember – “Computers have a lot to offer, but
their use so far has been problematic.” (Munro,
2011)
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Context in which Professionals Operate
Secure Work Setting:
• Adequate training
• Regular supervision and support
• Clear procedural guidelines
• Adequate funding and staffing
• Low staff turn over
• Optimal caseload
• A stable organisation
• Good secretarial back-up
» Reder et. al. (1993)
Supervision
• Does supervision provide practitioners with
supportive challenge to their thinking and
reasoning in relation to particular cases?
• Are supervisors helped to develop and sustain
their supervision practice?
• Does the organisation provide clear expectations
about levels of competence, appraisal and
supervision?
• Use of ‘signs of safety’.
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Professional Network Relationships
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Closed Professional Relationships
Polarisation
Exaggeration of Hierarchy
Role Confusion
» Reder et. al. (1993)
Practice note
• “When professionals with low levels of
confidence consider a child is at risk of harm
and others do not, they will struggle to
challenge the decisions and behaviour of their
multi-agency colleagues”.
» Research Report DCSF-RR129 Brandon et. al 2009
Professionals Networks
Inter-agency Organisations:
• Pivotal worker absent
• Weekend Phenomenon (out of hours)
A. Is recipient there to receive message?
B. Use of special patient notes (Central Notts.
Clinical Services – CNCS).
Have an Opinion!
‘Efforts Not To Be Judgmental Become A
Failure To Exercise Professional
Judgement’
(Research Report DCSF-RR129 Brandon et. al 2009)
Professional Challenge and Curiosity
• Lord Laming (2009) highlighted the
importance of ‘respectful challenge’ of
parents colleagues and professionals in other
agencies.
• Needs to be an integral part of professional
practice both within your own team,
organisation, agency and with inter-agency
partners.
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Signs of Safety
• The only avenue toward lasting protection of
children except the extreme measure of
permanently removing them from the home –
depends on establishing a co-operative
relationship between the parent (s) and the
case worker.
» (Weakland and Jordan, 1990)
Practice Principles that Build Partnerships
• Respect service recipients as people worth
doing business with.
• Cooperate with the person not the abuse.
• Recognise that cooperation is possible even
when coercion is required.
• Recognise that all families have safety.
• Maintain focus on safety.
• Learn what the service recipient wants.
Practice Principles that Build Partnerships
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Always search for detail.
Focus on creating small change.
Don’t confuse case detail with judgements.
Offer choices.
Treat (contact) interview as a forum for
change.
• Treat the practice principles as aspirations, not
assumptions.
Risk Assessment
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“Life can only be understood backwards, but must be lived forwards”.
Soren Kierkegaard.
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“You have to make a judgement, but you can never know the final judgement”.
Tony Cooke, West Australia.
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“If I had said my dog was blue. I would have meant it was sad, but they would have
thought I painted it” Victorian Child Protection Service Recipient.
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“Do we see risk or do we risk seeing?” Nicki Weld, New Zealand.
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“Safety is regarded as strengths demonstrated as protection over time”.
L. McPherson and N. Macnamara, Victoria.