Transcript SIDS Update - Coventry SCB

Learning from Serious Case Reviews
Lessons from national studies
In my report I have referred to, but not dwelt upon,
the impact of the reorganisation [upon the front line
workers] and the part this may have played in certain
failures in supervision. Every field-level [practitioner]
was placed at risk of such a tragedy by the
organisational upheaval consequent upon the
reorganisation and the sharp increase in the volume
of work…
It is to be hoped that X’s death and the grievous
distress that it has caused… will prompt urgent
consideration of the stresses upon the profession and
the ever-increasing expectations of it, especially
since we are now in the throes of yet more
reorganisation1
Are they all the same?
Holly Wells Jessica Chapman
Peter Connolly
Jasmine Beckford
Kyra Ishaq
Victoria Climbie
Heidi Koseda
The purposes of SCRs
• establish what lessons are to be learned from the
case about the way in which local professionals and
organisations work individually and together to
safeguard and promote the welfare of children;
• identify clearly what those lessons are both within
and between agencies, how and within what
timescales they will be acted on, and what is
expected to change as a result; and
• improve intra- and inter-agency working and better
safeguard and promote the welfare of children.
Evaluating SCRs
• Are we better safeguarding and
promoting the welfare of children?
• Are we implementing actions to
safeguard children?
• Are we identifying lessons about
safeguarding children?
Serious Case Reviews, 2005-10
Fatal assaults 1975-2005
Deaths per 100,000 population
Source: ONS Registrar General
Violent child deaths, 2009-10
Age
SCR Data
N (Rate)
ONS Data
N (Rate)
Home Office
N (Rate)
<1
23 (3.46)
10 (1.51)
16 (2.41)
1-4
18 (0.71)
14 (0.55)
13 (0.51)
5-9
6 (0.21)
6 (0.21)
4 (0.14)
10-14
9 (0.30)
6 (0.20)
4 (0.13)
15-17
6 (0.31)
18 (0.93)
15 (0.77)
Total
62 (0.56)
54 (0.49)
52 (0.47)
CDOP
N
47
Violent Child Deaths, England,
2005-9
Rates per 100,000
Patterns of fatal maltreatment,
England 2005-9
Categories of Fatal Maltreatment
A
B
C
D
E
Infanticide and “covert” homicide
Severe physical assaults
Extreme neglect / deprivational abuse
Deliberate / overt homicides
Deaths related to but not directly
caused by maltreatment
Patterns of fatal
maltreatment, 2005-9
Violent deaths in children
• Rates and numbers of violent infant deaths have
decreased by at least 50%
• Rates and numbers of violent child deaths have
decreased
• Rates of violent adolescent deaths have
remained static or risen
• There are currently between 20-60 violent infant
and child deaths per year in England & Wales
A pyramid of severity
Severe,
deliberate &
persistent
Inflicted physical or
emotional abuse
Neglect, poor physical care,
emotional unavailability
Casual attitudes, carelessness,
poor parenting
Children subject to child
protection plans, 1988-2009
NSPCC national prevalence study
Evaluating SCRs
• Are we better safeguarding and
promoting the welfare of children?
• Are we implementing actions to
safeguard children?
• Are we identifying lessons about
safeguarding children?
Evaluating SCRs
• Are we better safeguarding and
promoting the welfare of children?
• Are we implementing actions to
safeguard children?
• Are we identifying lessons about
safeguarding children?
An overemphasis on actions
• Practitioners and their managers told the review
that statutory guidance, targets and local rules
have become so extensive that they limit their
ability to stay child-centred.
• The demands of bureaucracy have reduced their
capacity to work directly with children, young
people and families.
• Services have become so standardised that they
do not provide the required range of responses to
the variety of need that is presented.
SCR Recommendations
• Recommendations should usually be few
in number, focused and specific, and
capable of being implemented. (WT 8.40)
• 2009-10 review of 20 SCRs
– Total of 932 recommendations
– Average 47 (range 10-94)
Common themes in
recommendations from 20 SCRs
• Training and awareness
raising (20)
• Information sharing
between and within
agencies (19)
• Quality of recording (18)
• Management and
supervision (18)
• Clarification of staff roles
(16)
• Ascertaining the ‘whole
picture’ as regards the
child/family (16)
• Referral process (16)
• Audit (15)
• Responsibility for case, or
avoiding case ‘drift’ (14)
• Use of Common
Assessment Framework
(13)
SMART Recommendations?
• “organisations must
• “to review the health
ensure that staff
visitor caseload
working with children
weighting tool, which
always focus on the
should reflect
needs of the child, and
vulnerability and
never allow themselves
disadvantage not
to be distracted by the
numbers of children.”
problems of the
adults.”
Evaluating SCRs
• Are we better safeguarding and
promoting the welfare of children?
• Are we implementing actions to
safeguard children?
• Are we identifying lessons about
safeguarding children?
Evaluating SCRs
• Are we better safeguarding and
promoting the welfare of children?
• Are we implementing actions to
safeguard children?
• Are we identifying lessons about
safeguarding children?
Common themes in SCRs
• The ‘invisible’ child
• Limited inter-agency co-operation and lack of service
integration
• Poor communication both between and within
agencies
• A failure to interpret information gathered
• Poor recording of information and decision making
• Uncertainty in decision making
• Different perceptions of the thresholds
New and emerging themes
• Importance of an ecological framework for
understanding the complexity of child abuse
• Mirroring of behaviour in the family and in the
agency responses
• “Fixed thinking”
• “Start again syndrome”
• The “rule of optimism”
• “Authoritative” child protection
Authority
‘The authoritative intervention is urgent,
thorough, challenging, with a low
threshold of concern, keeping the focus
on the child, and with high expectations of
parents and of what services should
expect of themselves’
Haringey LSCB, 2010, p24
•What does a child
need in order to grow
and develop?
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Dimensions of Parenting
Expectation
• Nurture
• Provision
• Response to needs
• Emotional warmth
• Stimulation
• Opportunities
• Boundaries
• Discipline
High Affection
Affection
High Expectation
Low Affection
Low Expectation
Authoritative Child Protection
• Authority
– Confidence and Competence
• Empathy
– Child Centred
– Family Focused
• Humility
– Recognising limitations
– Acknowledging strengths
– Seeking to improve
Authority in Safeguarding
• Confidence and Competence
– Knowledge, skills and attitudes
– Appropriate training
– Supervision and support
– Ability to challenge (parents and services)
– Requires the application of appropriate
evidence, combined with the experience of
the practitioner and their responsiveness to
the current context
Evidence Based Practice
• Evidence based practice is the
conscientious, explicit and judicious use
of current best evidence, integrated with
relevant expertise and an understanding
of the context, to guide decision making
in relation to individual cases
Sidebotham, 2009 Based on Sackett, 1996
Empathy
• Child Centred
– A rights-based approach
– Listen to/for the voice of the child
• Family Focused
– See things from the family’s perspective
– Avoid collusion/prioritising the parents’ needs
above those of the child
• Being ourselves
– It is possible to be thorough and systematic yet
sensitive
Empathy
‘Authoritative practice will have high
expectations of parents, will provide the
support to enable them to try and meet
those expectations, and will be prepared
to challenge and act when they are
unable to do so.’
Humility
‘A positive quality that enables
practitioners to recognise their own
limitations, to acknowledge and use their
skills and strengths, and to seek to
improve their practice.’
Humility
• Recognising limitations
– Interagency working
– Working within our expertise
• Acknowledging skills and strengths
– Be confident in what we do well
– Celebrating success
• Seeking to improve
– Continual professional development
– Supervision and support
– Reflective practice
Working Together, 2013
Learning Lessons
• Broader emphasis on regular learning
– Culture of learning and improvement
– Range of approaches
– Involvement
• Emphasis on systems approach
– Not just what, but why?
•
•
Emphasis on actions resulting in lasting
improvements
Transparency and independence
Local learning
• Is most effective when embedded in the
process of conducting the SCR
• Can be enhanced by keeping the emphasis
on learning lessons
Local Implications
• Develop a more participative approach
• Include plans for learning in the scoping
of the review
• Include practitioner/manager support in
scoping
• Clear methodology and briefing
• Learning lessons and taking action are
complementary