Transcript Serious Case Review Reflection Session

Safeguarding
and the city
Welcome to the
Safeguarding in the City
Conference 2012
September 2012
Organised by the Leicester Safeguarding Boards
Leicester Safeguarding Adults and Children Board Conference 2012
Safeguarding
and the city
Aims of the Conference
To enable workers from services for adults
and children to understand the wider
safeguarding picture in Leicester
To offer opportunity for reflection on how
services can work more effectively together –
domestic violence, mental health, substance
abuse
Raise awareness about LSAB and LSCB
Leicester Safeguarding Adults and Children Board Conference 2012
Safeguarding
and the city
Main Functions of The Boards
Agree policy – assessment and response
Co-ordinate investigations and delivery
Facilitate joint training
Monitor and review effectiveness
Children Act 2004, Section 13
No Secrets guidance 2000
Leicester Safeguarding Adults and Children Board Conference 2012
Today’s Timetable
9:30/1.30
Welcome and Introductions – phones on silent please!
9:50/1.50
Mythbusting – interactive session
10.05/2.05
Families with multiple needs – Mental Health, Substance Misuse
and Domestic Violence
10.50/2.50
Refreshments
11.05/3.05
Keynote – Safety and Respect – using professional judgement
12.00/4.00
Self harm, suicide and familicide (filicide) – issues for children
and adult services
12.20/4.20
Summing up and going on
12.30/4.30
Conference ends
Safeguarding
and the city
Mythbusting –
So how much do you
know about Adults
and Children
Safeguarding?
With Stephen Vickers
Head of Service - Safeguarding Adults
Leicester City Council
Leicester Safeguarding Adults and Children Board Conference 2012
Safeguarding
and the city
Who are these
people?.................
Leicester Safeguarding Adults and Children Board Conference 2012
•
•
This person was part of a Serious Case Review Published in Nov 2011
They were a victim of multiple Hate Crimes, by so called ‘friends’
•
They were known to services and were referred to MH services in 2007, evicted from private
shared tenancy in 2008, and involved with the Police (2-4 contacts per month) during 2010
On 8th Aug 2010, they went to their ‘friends’ flat and was subjected to serious assaults over a
period of 4 hours including being head butted fracturing her nose, hit with a mop and forced to
drink urine out of a lager can
•
•
•
On 9th Aug just past midnight all of the youths were caught on CCTV leaving the flat
That evening they were subject to further assaults resulting in death. She was stripped of her
clothes which were set on fire along with her other belongings, had a black bin bag put over
her head and was also stabbed in the back of the neck
Materials provided for Stephen Vickers
by Julie Chapaneri ©
Safeguarding Adults Trainer
• Murdered aged 27
• No single agency had a
full picture
• A number of missed
opportunities
• blockage of her airways by blood as a result of
severe facial trauma
• significant impact to Gemma’s nose, in which
the bone was almost completely severed.
• struck repeatedly with a rod or something
similar.
• naked and badly-beaten body
• hair had been shaved
• stabbed in the upper back
• a total of 55 external injuries including 17 to her
face head and neck which included widespread
and extensive bruising, areas of grazing and
cuts
• further bruising and grazing to her body, legs
and arms
Materials provided for Stephen Vickers
by Julie Chapaneri ©
Safeguarding Adults Trainer
•
•
•
•
•
•
This child was part of a Serious Case Review published in February 2009
The child’s mother was born in Leicester, within a violent family and when her parents split,
she moved to London. She’d also suffered post natal depression with all her children
This Child was know to be on the child protection Register since Dec 2006 and between being
born in Mar 2006 and their death in Aug 2007, there were over 11 Conference Meetings and
review of Conference meetings regarding the child.
Between Mar 07 and Aug 08, the SW, Police, FWA visited/ had seen the child over 20 times
Between Mar 07 and Aug 08 this child was seen by the GP, A & E, Walk-in clinic and various
health professionals over 13 times
This child was admitted to hospital and died within the hour on 3rd Aug 2007. The child was
seen to have bruising to the body, a missing tooth, a torn frenum. A tooth was found in the
child's colon along with 8 fractured ribs and fractured spine.
Materials provided for Stephen Vickers
by Julie Chapaneri ©
Safeguarding Adults Trainer
• Died aged less than 15
months
• No single agency had a full
picture but had suspicions
• A number of missed
opportunities
• Bruising and grab marks to the body
• A torn frenum
• Marks to his head, infection and head
lice
• Missing tooth which was later found in
his colon by the post mortem
examination
• 8 fractured ribs on his left side
• A fractured spine
Materials provided for Stephen Vickers
by Julie Chapaneri ©
Safeguarding Adults Trainer
•
•
This person was part of a Serious Case Review Published in April 2002
Sheltered housing staff had some concerns about their poor diet, lack of money and the
standard of cleanliness in her home was not good.
• Fire services attended to 10 separate minor fires in their home over 10 years
• Their grandchildren would visit and argue with them and other residents. This person also
reported to sheltered housing staff that the grandchildren had hurt their arm.
• They had moved from sheltered accommodation in June 2001 to their son-in-law's home
and did not want any contact with social care which didn’t take place until 2 months before
her move from sheltered housing. 5 weeks later she was dead.
• After her death in 2001, a post-mortem found 49 injuries on her body including cuts probably
made by a razor blade and cigarette burns. But as the cause of her death could not be
established, no one was ever charged.
Materials provided for Stephen Vickers
by Julie Chapaneri ©
Safeguarding Adults Trainer
• Margaret died aged 78.
• She had moved to live with her son-in-law and her
teenage grandchildren.
• A post-mortem revealed a horrific catalogue of
more than 60 injuries including
• razor-blade cuts to her stomach and chest
• cigarette burns to her back and armpits
• black eyes
• There were so many bruises a pathologist could
not count them all
• Although her son-in-law and 2 of his sons were
arrested on suspicion of murder, it could not be
proved who was responsible for Margaret’s
injuries and no-one was ever prosecuted
Materials provided for Stephen Vickers
by Julie Chapaneri ©
Safeguarding Adults Trainer
•
•
•
•
•
•
This person was part of a Serious Case Review Published in April 2001
They were brought to this country by a relative for ‘a better life’ but ended their 11 months
stay the victim of unimaginable cruelty.
They were known to 3 housing authorities, 4 social services deps, 2 child protection teams of
the Met Police, a specialist centre part of NSPCC, and was admitted to 2 different hospitals.
There were 12 key occasions when relevant services had the opportunity to intervene
including several further other opportunities. Not one of these required great skill or would
have made heavy demands on time to take some form of action.
Ironically, the LA formally closed her case on the very day they died.
She was admitted to North Middlesex Hospital on 24 February 2000, she was desperately ill,
bruised, deformed and malnourished. Her temperature was so low it could not be recorded on
the hospital’s standard thermometer. Post mortem revealed over 128 separate injury sites.
Materials provided for Stephen Vickers
by Julie Chapaneri ©
Safeguarding Adults Trainer
• Victoria was 8 years old and had only lived in
this country for 11 months.
• Victoria was seen by dozens of social workers,
nurses, doctors and police within 10 months
but all failed to spot and stop the abuse as she
was slowly tortured to death.
• A number of missed opportunities.
• Nothing more than a manager reading a file, or
asking a basic question about whether
standard practice had been followed, may
have changed the course of events.
• When Victoria died, on 25 February 2000, she
had 128 separate injuries on her body,
including cigarette burns, scars where she had
been hit by a bike chain and hammer blows to
Materials provided for Stephen Vickers
her toes.
by Julie Chapaneri ©
Safeguarding Adults Trainer
Group Discussions……
In your group, take a few moments to discuss the
following questions……
1. How do you think cases are perceived between Adult
Social Care and Children's Services through the
Media?
2. What messages are portrayed to the public and
professionals within these services?
3. What impact have Serious Case Reviews had on
legislation/ changes in policies if any?
Materials provided for Stephen Vickers
by Julie Chapaneri ©
Safeguarding Adults Trainer
Safeguarding
and the city
Families With Multiple
Needs Mental Health,
Substance Misuse and
Domestic Violence
With Professor Julie Taylor,
Head of Strategy and
Development (Physical Abuse
In High Risk Families).
NSPCC
Leicester Safeguarding Adults and Children Board Conference 2012
The Dangers of Multiple
Adversities: The Risks for
Children
Julie Taylor: Head of Strategy and
Development (Physical Abuse in High Risk
Families). NSPCC
[seconded from the University of Dundee]
Leicester Safeguarding Boards Joint
Conference
28th September 2012
Who are these families?
There is now compelling evidence
that families whose children are
involved with statutory child
protection services have multiple
and complex needs, and that the
level of complexity increases
across the spectrum from referral to
placement in out of home care.
Multiple Adversities
Abuse and neglect often co-exist alongside
a range of family problems and adversities
Frequently compounded by issues such as
poverty, house moves and eviction.
Cumulative harm
A ‘wicked problem’
Reconceptualisation?
Bunting and Toner (2012); Devaney and Spratt (2009)
Intergenerational Cycles of
Violence and Abuse
Early trauma and abuse
Sequelae
Environment and parenting
Risk taking behaviours
Stress responses
The ACE Study
(Adverse Childhood Experiences)
Adverse Childhood Experiences and their
relationship to Adult Health and Well-Being
Child abuse and neglect
Growing up with domestic violence, substance
abuse, mental illness, crime
18,000 participants
10 years
Anda, R., & Felitti, V. (2010) The Adverse Childhood Experiences (ACE) Study: www.acestudy.org
Some findings so far…
Increased risk of lung cancer
More auto immune disease
Increased prescription drug use
Increased COAD
Poorer health related QoL
Children Living with Domestic Abuse Experience
Children may:
Be in same room when the incident is taking place
Hear events as they unfold from another room
Witness physical damage to an adult or property following an incident
Be hurt accidentally while trying to intervene
Be used as a pawn to bargain or threaten with, particularly post
separation
Become the direct subject of abuse, which may be physical, sexual, or
emotional or a combination of these
Children Living with Domestic Abuse Experience
And the effects…
Disruptive behaviour; difficulties at school
Sleep disturbances
Bed wetting and nightmares
Guilt, confusion, sadness, self blame
Depression, resentment, anger
Physical injury
Sense of loss
Children as carers
PTSD
Legacies of secrecy
Rates of physical child abuse and neglect in families where DA is an issue
are 15 times higher than the national average
Drug and Alcohol related problems
+ 300,000 children in the UK (Scotland 59,600)
Conflation of ‘substances’
1100 children pa die as a direct result
Children four times more likely to develop a dependency
Prevalent in cases of DA and child protection
Strong links between alcohol and violence
Little evidence that substance use alone is a risk factor
SG Statistics (2011); Best (2011) Scottish Drug Recovery Consortium; ACMD 2007; Forrester and
Harwin (2008)
Problem Substance Use
Effects on Parents
Physical ailments (e.g. infections, injuries)
Psychological impairments:
withdrawal symptoms
psychoses
serious memory lapses
Most short lived
Manifestation: mental state; physiological impact of
drug; self-expectations; personality; type, dosage,
admin method.
Problematic Substance Use: Children
Neglect
Physical abuse, sexual abuse etc
Exposure to dodgy adults
Unstable and violent environment
Feel second to drugs
Exposure to noxious hazards
Criminality
Hindered schooling
Developmental and health problems
Own addictions
Mental Illness: Scale of the problem
About one in four adults is affected by mental illness
Most cases will be mild or short-lived
Sometimes severe (e.g. schizophrenia or manic depression)
Many more live with a long-term personality disorder or longterm depression
40-60% of people with a severe mental illness have children
Around a third of children on CPR or with CPP are there
because of parental mental ill health
Parental Mental Illness
Effects on Parents
Employability, poverty
Linkages with substance misuse and violence
Strained relationships
Parental Mental Illness: Effects on
Children
Constant separation
Insecure relationships
Hindered schooling
Neglect
Hit or maltreated
Carer role
Upset, frightened, ashamed
Bullied
Hear unkind things
Risk of mental illness
Revenge killings
Serious Case Reviews
Common Themes in SCRs of serious
and fatal maltreatment
Family characteristics
Minority previously known to CPS
The invisible child
<Service integration, co- operation, communications
Failure to interpret the information
Poor recording of information and decisions
Decision making
Relations with families
Thresholds
Sidebotham, P. (2012) What do serious case reviews achieve? Arch Dis Child 97 (3): 189-192
Risks posed by significant males not always identified
Mental health issues significant feature
Poor housing, frequent moves, homelessness prominent
Listening to children, seeing unusual behaviour
Struggle to balance children’s and adults’ rights
Lack of clarity about what information can be shared
Scarcity of resources in small and/or rural authorities
<Systems for managing risks by young sex offenders
Vincent et al (2007) A review of Child Deaths and Significant Child Abuse Cases in Scotland
New Themes Emerging
Importance of ecological frameworks and niches
Heterogeneity
Mirroring: families and agencies
Exclusion of fathers
Fixed thinking
‘Start again syndrome’
The rule of optimism
Silo practice
Disguised compliance
Vulnerability of older children and adolescents
Sidebotham, P. (2012) What do serious case reviews achieve? Arch Dis Child 97 (3): 189-192
The world is a dangerous place to live. Not
because of the people who are evil, but
because of the people who don’t do anything
about it
(Albert Einstein)
Thank you for listening
[email protected]
Acknowledgements:
Lisa Bunting
Kathleen Turner
Sherene Thananjayarajasingam
Kristi Herd
Safeguarding
and the city
10 minute break
Leicester Safeguarding Adults and Children Board Conference 2012
Safeguarding
and the city
The importance of
Professional
Judgement
With Dr David N. Jones
Independent Chair,
LSAB and LSCB
Leicester Safeguarding Adults and Children Board Conference
JOINT LSAB AND LSCB VALUES STATEMENT
The values that the Leicester Safeguarding Boards are committed to are as follows:
• All people of Leicester have the right to:
– dignity, choice and respect
– protection from abuse and/or neglect
– effective and co-ordinated work by all agencies to ensure a holistic child/person centred
response
– the best possible outcomes, regardless of their age, gender, ability, race, ethnicity,
religion, sexual orientation and circumstances
– high quality service provision
• Safeguarding the wellbeing of children, young people and adults is a responsibility we all
share.
• Openness, transparency and sustainability will underpin the work of the Boards.
• Participation by children, young people and adults is essential to inform services, policies,
procedures and practices.
• Services to meet the individual needs of children, young people and adults aspire to reach the
highest standards.
• Celebration of strengths and positive achievements is important to the Boards, as is the
commitment to a process of continuous development and improvement.
• Constructive shared learning to protect children, young people and adults will be integral to
the Boards’ business.
Safety and Respect
Safeguarding context
Law Commission and safeguarding
Working Together consultation
and Munro implementation
Performance Management & Inspection
Setting the context
Adult safeguarding - Personalisation and dignity
-
Law Commission report on adult social care
Stoke-on-Trent hospitals, food, Summervale, Pilkington, Hoskins
Old age, disability, learning difficulties, mental health
Child safeguarding – assessment & communication
-
Munro Report, Baby Peter, Victoria Climbié,
Working Together revisions
Common themes
-
Mental health, drugs, alcohol, communication breakdowns,
Rights and responsibilities
Social context changes
• Increase in very young and very old
• Rising unemployment and family poverty
• Benefit changes – potential migration and
housing pressures
• Increase in social pressures and suicide
• Continued high level of demand for health and
social care
• Pressure on ‘preventative’ services
• Rising expectations & growing concern
Agency changes
• City Council – city mayor, public health – H&WBB
• Children’s services - structural changes, budget
reductions, demand
• Schools – academies, changed accountabilities
• NHS – CCGs, budget pressures, markets
• Social care - budget pressures, markets, demand
• Police – Commissioner elections, structural
changes, budget reductions
Agency changes
• Voluntary sector – budget pressures,
commissioning changes and insecurities
• Housing – benefit changes,
• Probation – service review
• CAFCASS – DfE to Justice, private law
pressures, reduction in legal aid
• Connexions – major restructuring and wind down
Law Commission recommendations
•
•
Consolidated statute for adult social care
Individual well-being basis for all decisions and
actions
• Decisions to be based upon the individual
circumstances of the person
• Local Adult Safeguarding Board to be made
statutory
• LA duty to investigate safeguarding risks
• Duty to cooperate enhanced
Government response positive BUT
Delays due to funding care crisis – Dilnott?
Munro report recommendations
1. Regulations – separate rules and ‘advice’ – encourage
local creativity
2. Inspection – examine effectiveness of all local services
3. Inspection framework - child’s journey
4. Nationally collected & locally published PIs benchmark performance
5. Annual report to Chief Execs of LA, health & police
6. LSCBs - local need, value for money of preventative
services
7. Evaluate impact of health reforms on services for
children
8. SCRs – system methodology – accredited
practitioners, etc
Working Together consultation
Munro implementation
• Working Together consultation - radical reduction in
regulation – revise statutory framework – focus on direct
work (by 12/2011) - remove timescales and distinction
between core and initial assessments
• Joint inspection consultation - new inspection
framework - experiences of children and young people
• SCRs - Systems review methodology
• Interim NHS guidance - ensure continued
improvement of safeguarding in health reform
• Practice - quality of relationships between social
workers and young people core of effective child
protection - support work to develop the knowledge and
skills of the profession – SWRB, CIB
Performance Management & Inspection
• Criticism of target driven performance management
• New emphasis on quality of practice – professional
‘discretion’ and judgement
• Annual Report
• Revised approach to inspection
• Peer review – regional programme
• More qualitative focus on practice
Monitoring outcomes is becoming the main task
Individual practice
• New focus on quality of practice – less on
targets – evidence based
• Not a free for all – ‘do what you like’
• Know and follow the procedures
• Inform managers when lack of resource or
service quality is risky
• Assess with care – in partnership with service
users and family
• Evaluate and document risks
• Form and implement professional judgement
Individual practice
Never
‘Common Sense’
Always
Respectful, informed
Good Sense
Safeguarding
and the city
Trends and issues in self
harm, suicide and familicide
(filicide) across Childrens
and Adults Services
With volunteers from Leicester
Samaritans and Dr Jenna Ward
Snr Lecturer Organisational
Behaviour DeMontfort University
Leicester Safeguarding Adults and Children Board Conference
Suicide: a social perspective
Dr Jenna Ward
De Montfort University, Leicester
What does all of this really mean?
Suicide: a dirty word in a dirty world?
• Social stigma of suicide – but why?
• Emile Durkheim (1858-1917)
•
Social breakdown – organic solidarity
Safeguarding
and the city
Summary and Closing
Address
Leicester Safeguarding Adults and Children Board Conference
Safeguarding
and the city
Thank You For
Attending
Please complete feedback
forms in your packs to help
shape our future events!
Leicester Safeguarding Adults and Children Board Conference