Transcript Biennial Analysis of Serious Case Reviews 2005-7

Biennial Analysis of Serious Case
Reviews 2003- 2005 and 2005-7
Ruth Gardner
University of East Anglia (with University of Warwick)
A typical serious case review
(death or serious injury of a child where abuse or neglect is a factor)
“[mother] had a series of violent partners…,
suffered with mental health problems, anxiety
and depression and was misusing alcohol.
The family changed address frequently….all
three children witnessed serious domestic
abuse… [mother] failed to attend a number of
medical appointments with the children.”
• Biennial Analysis of Serious Case
Reviews 2003-5 (161 cases) and 20052007 (189 cases)
Research Questions (2005-7)
•
•
•
To identify common themes and trends across
review reports, using an ecological-transactional
approach and drawing out the implications for policy
and practice;
To explore the way in which reviews are
commissioned and scoped, how they are published
and how key messages are disseminated locally;
discover what mechanisms are put in place locally to
implement the findings and to monitor their
implementation;
To capture the learning from this first phase so that it
can feed into a longer term project to develop and
implement a revised method of conducting national
reviews.
The SCRs - 189 cases (2005-7) & methodology
Layer 1 = 464
All notifications to child
protection database
CSCI/DCSF
Layer 1. Find the SCRs
Layer 2 = 189
all SCRs
Minimal information about
each case from
DCSF/CSCI
Layer 2. Describe the
cases
Layer 3 = 40
Small sample
Overview reports, chronologies,
sometimes IMRs
Layer 3. Examine 40 cases in detail. 24
Interviews about SCR process.
Layer 1: Which cases become serious
case reviews?
189 SCRs – where from? (2005-7)
Type of notification (as stated on
national child protection database reports)
464*
“Death of a child looked
after”
“Serious Harm to a
child”
124
SCR
?
No
101
SCR
13
54
?
10
No
43
SCR
7
?
4
“Serious Case Review
possible but not yet
confirmed”
151
No
81
SCR
42
?
28
“Serious Case Review
confirmed”
135
No
4
Yes
127
?
4
Findings: Layer 2 cases
161 cases 2003-5, 189 cases 20005-7
Death or serious injury cases?
• 66% death
Reason for SCR: A’s stepfather had a criminal record and was in
care of the council when younger. The council also wants to
ensure the circumstances of death undergo a thorough review.
(suicide)
• 34% serious injury
These children are (now) subject to full care orders. There is a
long history of neglect and concern that the developmental delay
experienced by these children could have been minimised if
agencies had worked together earlier and worked effectively. The
SCR will investigate the concerns raised in the course of care
proceedings.
Same proportions of death/ serious
injury 2003-5 and 2005-7
Age of child at time of incident
2005-2007
2003-2005
age categories
<1yr
1-5yrs
6-10yrs
11-15yrs
>16yrs
11%
age categ
<1yr
1-5y
6-10
11-1
>16
9%
11%
16%
46%
47%
10%
7%
23%
20%
Ethnicity 2005-7
Ethnicity
White
Mixed
Black/Black British
Asian/Asian British
Other Ethnic Group
2%
5%
8%
13%
72%
Similar ethnic proportions in both studies, but fewer Black/ Black
British children 2005-7 than 2003-5, more mixed race children.
92% of ethnicity recorded 2005-7, 84% in 2003-5.
Child Protection Plans/ Legal Status (2005-7 n=189)
• 17% of children with a cp plan at time of incident
(12% in 2003-5).
- 11 physical abuse, - 7 sexual abuse - 7 emotional
abuse - 30 neglect. (Some children in combined
categories).
• In 1/3 of families either the index child or sibling
had current or past cp plan.
“L was living with mother and three older half siblings,
history of domestic disputes with ex-partners and of
substance misuse by mother.” (at home with CP plan)
• 11% on a care order, 2% supervision order , 5%
‘looked after’
Analysis: Layer 3 cases
40 cases (2005-7) 47 cases (2003-5)
Interacting factors 2003-3 (n=47 )
Child factors and
experiences
Family and
Practice/professionals,
environmental factors agency factors
Very young babies
(prematurity,
admissions to
hospital, types of
injury)
Middle years children
largely missing
(protected?)
Older child, hard to
help (self neglect,
chronic illness, sexual
exploitation, ‘going
missing’,bullying,
Suicide
Co-morbidity of
Domestic violence,
Substance misuse,
Mental ill health
Fathers, hostility,
criminal convictions
Patterns of hostility
and cooperation
Family History, eg
neglect, previous child
death,
Poverty, poor living
conditions,
Frequent moves
accidents, fires
Child not seen/ heard
Agency context, capacity,
‘organisational climate’
Preoccupation with
thresholds e.g. CP
threshold not met
Professional anxiety,
reluctance to act and
challenge
Supervision
Ethnicity challenges
Neglect, ‘start again
syndrome’
Keeping track of families
inter acting factors 2005-7 (n=40)
Family and environmental
factors
Practice/professionals,
agency factors
Chaos, overwhelmed families with
low expectations
Unsupported families or negative
support
“toxic trio” (dv, mental ill health,
substance misuse etc)
Overwhelmed workers, low
expectations
Unsupported workers, Professional
uncertainty
Men: Good dads, bad dads, men not
known about
‘Accidents waiting to happen’
House fires, multiple moves, poor
living conditions
Large families
‘other people’ are seeing the child
Efforts not to be ’judgemental’ ,
Fixed views, men, neglect
‘off the radar’ cases
Thresholds and boundary disputes
Lack of cultural sensitivity / over
sensitivity.
The missing child
• During both police and CSC enquiries into the
allegations it appears that the children were either not
seen or spoken to in any detail and no direct work was
undertaken during CSC involvement.
• The last date that X was seen by any professional prior
to her death (at age 11 months) was for her 6 week
check and first immunisations at her GP surgery.
Health professionals continued to visit the family home
seeing other family members, but not X.
• There were lost opportunities to speak to the young
person about his perceptions and feelings; therefore
there is little understanding of the “child’s world”. The
core assessment was not shared with (him), nor were
his views sought; he was of an age and understanding
to have the core assessment discussed with him
directly.
• Child also missing from the SCR – eg about MARAC or
MAPPA processes, not the child or child’s needs.
Child factors/experiences
• Child missed, lost , isolated, assaulted
• ‘Ecological niches’ for children of different
ages
• Prematurity, low birth weight, neonatal
abstinence syndrome
• Illness, complex health needs, disability
• ‘Hard to help’
• Suicide
• Unhappiness not known about
• Bullying
• Risk taking behaviour, substance misuse,
sexual exploitation
• History of neglect and rejection
Children: Ecological Niches
1. a pre-school, family based environment, with a neo-natal
sub-environment;
2. a middle childhood, somewhat protected, mixed school
and family niche;
3. an adolescent, risk exposed, transition to adulthood
niche.
Helps us understand risks of harm/ protective factors from
the environment, from others, and also for the older
children, from within themselves.
“The types of homicide suffered by children are related to the nature
of their dependency and to the stage of their integration into the
adult world. Among the factors that may well change across
childhood and across these niches are the victim-offender
relationship, the locale where the homicide occurs, the nature of the
weapon, the motives involved, and the contribution the victim
makes to the crime in terms of risk taking and provocation. These
homicide variations provide a good case for assuming the
importance and utility of a developmental perspective on child
victimizations…” (Finkelhor 2008:40).
Pre School Age Niche
• 26 children – 17 babies. This age group most vulnerable to
death from abuse (internationally).
• Physical vulnerability of these young children mean that
many die from force and violence that would not kill an older
child. Older children, no longer so dependent, can physically
move, run out of the way or fend for themselves.
• 1/3 born premature – lasting impact. 6:17 babies had
hospital admissions (1 x 9), 3 to A&E at least once.
“ Pre-school victims of homicide appear to be mostly cases of
fatal child abuse that occur as a result of a parent’s attempts
to control a child or angry reactions to some young child’s
aversive behaviour – uncontrollable crying, hitting parent or
siblings, soiling himself or herself, or getting dirty, for
example (Finkelhor 2008:39).
Middle Childhood
• 4 children aged 6-10 (2 known to CSC)
• Small number reflects the lower level of emotional and
physical demands children of this age make on their
caregivers.
• Higher level of protection offered by their environment school.
• But: children of this age at A&E most often with
unexplained injuries linked to maltreatment (Woodman et
al 2008). Rarely subject of SCR but still maltreated.
• Some history of problems with eyes, ears, speech and
language. Not uncommon - but delay in treatment
causes problems. Some links between hearing problems
and behavioural difficulties, particularly in combination
with other family problems.
Adolescence
• 10 young people aged 11-17 years. 7
suicides.
• Patchy school attendance - numerous house
moves, truancy or school exclusions (2 had
left school)
• 5 with low level services: eg carer for disabled
brother at home, and struggled at school and in
home community where he was bullied.
• 5 well known to agencies and had profiles
characterised by risk taking behaviour,
substance misuse and sexual exploitation.
inter acting factors 2005-7 (n=40)
Family and environmental
factors
Practice/professionals,
agency factors
Chaos, overwhelmed families with
low expectations
Unsupported families or negative
support
“toxic trio” (dv, mental ill health,
substance misuse etc)
Overwhelmed workers, low
expectations
Unsupported workers, Professional
uncertainty
Men: Good dads, bad dads, men not
known about
‘Accidents waiting to happen’
House fires, multiple moves, poor
living conditions
Large families
‘other people’ are seeing the child
Efforts not to be ’judgemental’ ,
Fixed views, men, neglect
‘off the radar’ cases
Thresholds and boundary disputes
Lack of cultural sensitivity / over
sensitivity.
Chaotic families: Professional responses & behaviour
Fixed views about
Family, men, neglect
silo practice.
Overwhelmed,
chaotic families,
‘negative’ family support,
drugs, violence,
mental ill health,
criminality.
Invisible children
Efforts not to be judgemental,
whole picture not seen, separate
‘specialisms’ offer support.
Too much to achieve,
low expectations, ‘success’ is
getting through the door,
muddle about confidentiality
Known to children’s social care?
2003-5 (n=47)
• 55%
2005-7 (n=40)
• 53%
•Family known in past:
87%
•Family known in past:
78%
•NB Almost half not
known to CSC at time
of incident in both
studies
“Child protection does
not come labelled as
such” (Laming 2003)
Efforts not to be judgemental
“ a tendency towards justification and reassurance
that all was well, rather than more objective
consideration and investigation of what had
occurred”
• “x presented as a pleasant young woman who had
complex needs and professionals felt
compassionate towards her and she was given
repeated chances to improve matters and to
reduce and manage her drug use”
There is no reason to doubt her honesty in terms
of her intentions. It is right that professionals
should be supportive of such intentions. However
such support should be matched by a critical
awareness of the difficulties facing a person with a
dependency on drugs in reducing their
consumption”
Fixed views
• ‘Neglect case’ as a mindset – physical
injury missed (eg case 03 two s47 enquiries for physical injury)
• Men - ‘good’ dads or ‘bad’ dads (eg father’s
concern about ex wife’s parenting discounted no checking of
‘improvement’ in spite of past history of
extreme dv, (start again syndrome)
• Uncertainty (confidentiality), assumptions
that others are seeing the child
• rigid specialisms, silo practice
• These preoccupations shift the focus
away from the child/ren
Additional theme:
SCR doesn’t provide enough information to
decide – ‘was it preventable’? Why aren’t
the right questions asked?
• Limited information about the family (eg
parents’ past)
• Limited information about the family’s
environment eg poverty
• Limited information about the agencies’
capacity and ‘climate’
• Limited information about the child
Layer 3 contd: The serious case review
process
The SCR process - delay
• Only 2 of the 106 reviews from 2005-2006 were
completed within 4 months. Not a manageable time
scale
• Challenging court proceedings as a reason for delay:
- LSCB has authority to insist that SCR should not
be held up, and to assert that the SCR process is an
important part of its safeguarding role.
- A presumption that the SCR process go ahead, and
be published, unless discussions with CPS and
coroner reveal a good reason for delay.
- If delay is reasonable, negotiations should allow
action plan to be implemented (although report
publication might be delayed).
- The agency that requires the delay (eg CPS) should
provide written reasons for submission (to
GO/Ofsted).
Negative SCR cycle
Deference to media.
SCR as PI
Lack of supervision
Blame culture returns
Child largely
absent &
out of mind
Practitioners
& families
excluded from
SCR process.
Fear of families/
blame/
litigation
Defensive practice &
SCRs
Impact of SCR on Practitioners (from regional seminars)
• Feelings of failure, guilt or being made a
scapegoat (21)
• Fear, anxiety (20)
• Threatening, threatened (8)
• Stressful (6)
• Emotional impact ( 8
• ‘upset’, ‘traumatic’, ‘devastating’, ‘under
scrutiny’ and ‘vulnerable’
• Added stress of media involvement; “the
media wants a scapegoat, but we want
lessons learned”.
Impact on practitioners (contd)
 The impact is profound and long lasting.
I am emotionally scarred by this.
 Loss of professional confidence
I guess, initially, it made me completely
lose all my confidence. It made me
question my trust in any of my
judgements. I almost started to doubt my
clients’ histories, and became quite
suspicious, although that has improved
over time.
 Good support valued “what helped was
just being able to share with colleagues”.
A positive SCR cycle
Publication of exec
summary.
Media strategy.
Creative ways of
disseminating learning
‘Open to learning’
Agency context
included.
Full information –
agency context, family,
household.
Child at
heart
of the SCR
Involvement of
practitioners,
&
families.
Impact on practitioners
• Restored professional confidence and
ability to challenge:
It is every professional’s responsibility to
say “No, I disagree”.
Wherever they sit in the hierarchy, at the end
of the day they are just a person. And at
the end of the day it is about the child.
• Practitioners/clinicians feel excluded
(practitioners) are excluded from the whole
process, our actions are scrutinised
(which is understandable) and then we're
left to get on with it, with little support
during the process and at the time the
report is published.
A Positive practice cycle
Good working relationships
with children & families.
Reflective,
challenging supervision.
Support and trust
in teams
Clear lines of communication
with other agencies.
Child seen,
kept in mind,
understood
Confident professional
judgement
and sustained challenge
Conclusions
• There are no simple or easy answers to
the challenge of protecting children, only
a relentless focus on doing the best we
possibly can, at every level and in every
service. But Laming’s full and frank
analysis does not provide a guarantee
against the combination of failings and
circumstances that led to the death of
Baby P. The unpredictability of human
nature and the restrictions on the current
system mean the scale of the task is
immense. (Eaton, Bromley-Derry, Myers
The Guardian 2009)
Conclusions
The children
• …the more you try to see the world from the child’s point of
view and the safer you make him feel, the better his
behaviour is likely to be and the more likely you are to find
ways of further improving it’ Perry and Szalavitz 2008:245
The workers
• One of the greatest lessons I’ve learned in my work is the
importance of simply taking the time, before doing anything
else, to pay attention and listen. Because of the mirroring
neurobiology of our brains, one of the best ways to help
someone else become calm and centred is to calm and
center ourselves first – and then just pay attention’ (Perry
and Szalavitz 2008:244-245)
• “..ultimately the safety of a child depends on staff having
the time, knowledge and skill to understand the child or
young person and their family circumstances.” (Lord
Laming 2009:10)
Tomorrow’s SCR?
• Same issues locally and nationally eg
loss of focus on the child; drift; neglect not
regarded as significant; poor quality control.
Questions to get us going
? What was “true for you” in these findings
? How could case R/V ( inc SCRs) be used
HERE & NOW for more effective learning
? Revision of WT- how could SCRs be
improved
ISSUES/STRENGTHS/GAPS/ACTIONS