Transcript Slide 1

Lessons Learned from Case Reviews &
Cases of Concern 2011 to 2013
Learning Outcomes
• Raise awareness of how case reviews are carried out
in Salford
• Understand the key themes and recurring themes
from Salford’s Case Reviews
• Recognise what has been done so far and what still
needs to be done
• Discuss how to keep you informed about case review
recommendations and implementation
CRSG Membership
The following agencies/services are represented:
• Children’s Services- Head of Safeguarding, Head of CIN & CP (Vice
Chair), Assistant Director for Universal Services and the Deputy Head
of the Youth Offending Service
• Health Services- Designated Nurse for Safeguarding Children (Chair),
CMFT Head of Psychology, GMW Safeguarding Children
Practitioner, NHS Salford Consultant in Public Health and SRFT
Safeguarding Supervisor
• Housing- Safeguarding Lead
• Greater Manchester Police- Serious Case Review Team
• Greater Manchester Probation- new representative to be identified
• SSCB Business Manager
• SCC Legal Services
SSCB Case Review Policy
Revised in September 2012. Changes made include:
•One referral form for all case reviews
•Guidance on seeking the views of the family members
•Guidance on the use of SCIE Systems Methodology
Case of Concern review criteria made more explicit“an agency raises a serious concern about the way a service
has managed/is managing a case. The case should be where
a child/children have been at risk of serious harm but an
incident (or incidents) has not occurred which takes it to the
level of an SCR. The case should be one where lessons can
be learned and practice improved for the benefit of other
children and families”.
Case Referral Process
Any agency can refer a relevant case
Referral form included in policy
CRSG considerations:
• Is a Screening Panel required?
• Does the case meet the criteria for a Case
of Concern review?
• Review methodology
• Other actions required e.g. single agency
actions.
Criteria for Serious Case Review
Working Together to Safeguard Children 2013
SCR criteria:
(a) abuse or neglect of a child is known or
suspected; and
(b) either — (i) the child has died;
or (ii) the child has been seriously
harmed and there is cause for concern as to the
way in which the authority, their Board partners or
other relevant persons have worked together to
safeguard the child.
Case 1
Lindsay Barrett, Safeguarding Lead Officer
(Housing) & Pat Dugdale, Safeguarding
Childrens Team Supervisor (Health)
Background
• Oct 06 – Couple approved as foster carers, with one biological
child. Mr A was the main foster carer as Mrs A had physical
health problems
• From Nov 06 to Mar 10 – 5 children were fostered
• Aug 07 – the 2nd foster child placed, male aged 2 days
• Dec 07 – incident Mr A angry towards birth mother of foster
child no. 2
• Jan 08 – Mr & Mrs A wants to be considered for adopting
foster child no.2
• Feb 08 – incident Mr A displayed aggressive behaviour
towards the birth mother of foster child no. 2
Background
• Jun 09 – Approved to adopt foster child no.2
• Jun 09 – Mrs A reports behaviour changes in Mr A, query
epilepsy?
• Oct 09 – Self harm incident by Mr A, subsequently admitted
to mental health in patient unit
• Dec 09 – Mr A re-admitted to inpatient unit 2nd time
• Feb 10 – Mr A re-admitted to inpatients unit for 3rd time
• Jun 10 – Mr A arrested after attempting to suffocate Mrs A
and re-admitted to inpatient unit
• Jul 10 – Mr & Mrs A de-registered as foster carers
Methodology
• Decision to use the ‘systems’ model to analyse the case - SCIE
(Social Care Institute of Excellence) Systems Approach
• Sub-group members formed the review team
• Case group members were all practitioners directly involved in
the case
• Initial introductory meeting
• Conversations with case group members
• Follow-on meetings
• Recommendations & action plan
Key Practice Episodes
•
Foster Panel approve Mr and Mrs A as Foster Carers – not all
information available to the Panel
•
Foster Panel re-approves Mr and Mrs A as Foster Carers – not
all Childrens Services information was collated
•
Adoption and Permanence Panel approves Mr and Mrs A as
Adoptive Parents for foster child no.2 – incidents of anger
issues not explored
•
Incident in which concerns about Mr A’s behaviours resulted
in an admission to an inpatient mental health unit – no
formal multi-agency risk assessment and appropriate
safeguarding of the children
Lessons learned
• Practice was not sufficiently child focussed i.e. the full impact
of Mr A’s deteriorating mental health on the children
• Assessments lacked comprehension
• Overly optimistic assessment of the carers
• Over-reliance on self–reporting without verification
• Lack of appropriate communication and information sharing
Recommendations and Action Plan
• 12 single agency recommendations for:
Childrens Services
Health Services
Adult Mental Health Services
• 1 multi-agency recommendation
• Themes – assessments, communication & information sharing
• All recommendations on the action plan have now been
completed and signed off accordingly
Discussion Forum
1. Prior to today were you aware of this case?
2. Were you aware of the recommendations
and action plan from this case review?
3. Can you see if any of these actions have been
implemented in your agency?
Case 2
Sharon Hubber, Head of Safeguarding,
Salford City Council & Julie Moss, Head of
Child in Need & Child Protection, Salford
City Council
• Female
•DOB – 9/05/2001
•White British
•Lived with 3 Adults
•Adult 1 – Mother
•Adult 3- Maternal Grandfather
•Adult 4 – Maternal Grandmother
Adult 1 – requested support with daughters self esteem and
bullying.
School
Joint visit
Educational Welfare
Officer & School Nurse
This visit upset
all the family
and further
arranged
meetings then
cancelled by
Adult 1
Bullying
GP
Numerous
appointments
Poor school
attendance
2007
(CAF)
Moved Primary
School
OCD
EWO
Adult 1
banned from
school
premises
due to
behaviour
Shouting swearing
Spill things
Remove clothing
Nervous breakdown
SHA
DNA (closed in
line with old
policy)
Adult 1 unhappy
with seeing a
trainee psycologist
Clinical meeting
held (no
safeguarding
discussion
(EIP)
FAM
Unhappy about psychology
wanted psychiatry (DNA
closed in line with old policy)
CAMHS
GP
Food intolerance
Viral
Food refusal
Not leaving home
Poor self esteem
Bullying
Adult did not
attend
2009
SHA
Professionals’
meeting held
Referral to CSC
Core Assessment
(but no other
professional
involved)
Poor
School
attendance
Refused to allow
information
sharing
Surgery discussed
issues but no
outcome logged
Home educated (end
of 2009) never
returned to mainstream
education
Unhappy about
discussing child’s 2
weight
GP
CAMHS
Self
esteem
2010
Unhappy given
appointment to see
psychiatrist
Did not want to
see a male
psychiatrist
Bullying?
CSC
Section 47
Removed
4 appointments 2 seen by adults 2
child/4th appointment child gave
abuse allegation
Safeguarding
never really on
agenda
No risk
assessment
No escalation of
same presenting
problem
Poor response in
2009 Inadequate
Core Assessment
Challenging
aggressive
adults
Voice of child
not in the
case
Barriers
No follow up of
Professionals’
Meeting
Refused to
allow
information
sharing
Complexity of
Health Services
DNA Policy
CAMHS
Fabricated and
induced illness
not considered
Removed from mainstream
education left her vulnerable
Some delay
following allegation
Detailed Multi
Agency
Chronology
Mum not
allowed to
intimidate
Good Multi
Agency
response
following
allegation
Good
Practice
Escalated
appropriately
following case
conference
Procedure
followed when
Manager in
CAMHS became
aware of
allegation
Discussion Forum
1. Prior to today were you aware of this case?
2. Were you aware of the recommendations
and action plan from this case review?
3. Can you see if any of these actions have been
implemented in your agency?
Break
Case 6
Melanie Hartley, Designated Nurse for
Safeguarding Children, NHS Salford Clinical
Commissioning Group
Case 6 Review
This complex case was referred to the CRSG by
Greater Manchester Police in November 2012
Complex family unit formed in 2007
Family comprised of 2 adults caring for 5 children:
• 1 aged under 2 years- birth child of the 2 adults
• 2 teenage children- birth children of one adult
from a previous relationship
• 2 teenage children- second adult was the legal
carer of these children.
Referral followed a serious assault by 1 teenager
on another teenager in the family unit.
Agency Involvement
Child F – Victim of
Incident
Agencies involved:
School 2
GP
Child G
Agencies involved:
HV
GP
Child D
Agencies involved:
School 2
GP
Adult A:
Legal Carer of
Child E and F
and mother of
Child G
Adult B:
Father of
Child C and D
and Child G
Child E
Agencies involved:
School 2
School Nurse
GP
Child C –
Perpetrator of
Incident.
Agencies involved:
School 1
CAMHS
IYSS
EIP
School Health
Advisor
Community
Paediatricians
GP
Case 6 Review
• Case discussed at a Screening Panel meeting
in November 2012
• Recommendation made to SSCB Chair that the
case did not meet the criteria for a Serious
Case Review and that a Case of Concern
review should be undertaken
• SSCB Chair agreed to this and decision made
to undertake this review through an externally
facilitated Multi-agency Learning Event
• Event held in February 2013
• Action plan from this case review currently
being implemented.
Case 6 Review Methodology
• Innovative “whole system” review
methodology
• Externally facilitated
• Full day Learning Event
• Representatives from all agencies
working with the family involved
• Detailed chronology reviewed, agency
involvement discussed and lessons learnt
identified.
Case 6 Review - Lessons Learnt
Communication/Information sharing:
• Some examples of good communication and
information sharing
• Cross border issues
• No practitioner had a full understanding of
the concerns held by all the agencies
• No practitioner had a full understanding of
the complex history of the family.
Case 6 Review- Lessons Learnt
Challenge and escalation:
• Individual practitioners did challenge both the
parents/carers and other agencies
• Attempts to escalate were complicated by the
information sharing issues
• Agency attempts to escalate were based only on
the information and concerns known to them about
the family members they were working with.
Case 6 Review- Lessons Learnt
Voice of the Child:
• Practitioners working with the individual teenagers
listened to and believed them
• Trusting relationships were established
• Disclosures did not result in escalation of the case.
Why?
• - some retraction of statements
• - number of different practitioners involved.
Case 6 Review- Lessons Learnt
Emotional abuse thresholds:
• Further clarity required about thresholds
Risk management of complex cases where there are no
child protection plans in place:
• Case managed at TAC level
• Multi-agency level of risk not determined and no
risk management plan in place.
Practitioner Feedback
• “It was a useful event for me. It was very useful learning
further information on the case and how we can improve
some of the services”.
• “It was a draining and exhausting day listening to very
disturbing information regarding the children and the family
dynamics. The staff needed to express their emotions.
However they did appreciate the event and recognised the
importance of bringing agencies together”.
Practitioner Feedback
• “Lot
of agencies involved, very sad and
information there that I didn’t know”
• “Lot I didn’t know, one piece of information
is a surprise and should have known about
it”
• “Professionals go to homes not knowing
what situation they may find. They take the
information given by mother as truth”.
SCRs AND
ENHANCING CHILD PROTECTION
RAY JONES
PROFESSOR OF SOCIAL WORK
35
SCRs AND
ENHANCING CHILD PROTECTION
• MY EXPERIENCE
• SOME OF THE BARRIERS
• SOME OF THE ENABLERS
• WHAT MAKES FOR GOOD CHILD PROTECTION
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SCRs AND
ENHANCING CHILD PROTECTION
MY EXPERIENCE
•
•
•
•
•
•
SOCIAL WORKER AND MANAGER
DIRECTOR OF SOCIAL SERVICES 1992-2006
INQUIRIES X 3
LSCB CHAIR
CIB CHAIR X 5
RESEARCH
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SCRs AND
ENHANCING CHILD PROTECTION
BARRIERS TO LEARNING FROM SCRs
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•
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TOO MANY SCRs
TOO TIME CONSUMING AND COSTLY
THE BLAME CULTURE AND DEFENSIVENESS
CASE RATHER THAN CONTEXT
WHAT RATHER THAN WHY
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SCRs AND
ENHANCING CHILD PROTECTION
BARRIERS TO LEARNING FROM SCRs
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TOO MANY RECOMMENDATIONS
ACTION PLANS NOT SMART
TOO MUCH FOCUS ON PROCEDURES NOT PRACTICE
NOT REACHING WHERE IT NEEDS TO REACH
MOVING ON TO THE NEXT SCR
LEARNING AND IMPROVEMENT NOT EMBEDDED
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SCRs AND
ENHANCING CHILD PROTECTION
ENABLERS FOR LEARNING AND IMPROVEMENT
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•
•
•
•
•
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PRACTITIONER PARTICIPATION THROUGHOUT
REFLECTION NOT ONLY DESCRIPTION
CONVERSATIONS AND COMPREHENSION
SMART RECOMMENDATIONS/ ACTION PLANS
THEMES AND MESSAGES
SYNTHESISE AND SIMPLIFY
REALISTIC AND RELEVANT
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SCRs AND
ENHANCING CHILD PROTECTION
ENABLERS FOR ENHANCEMENT AND IMPROVEMENT
•
•
•
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TARGETING MESSAGES AND LEARNING
FOR PRACTITIONERS AND MANAGERS
FOR DIFFERRENT AGENCIES AND WORKERS
BUT ALSO LEARNING TOGETHER
PROCEDURES AND TRAINING
BUT ALSO CULTURE AND BEHAVIOURS
LEADERSHIP AND CHAMPIONS
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SCRs AND
ENHANCING CHILD PROTECTION
ENABLERS FOR LEARNING AND IMPROVEMENT
• THE IMPORTANCE OF SUPERVISION
• THE PRIMACY OF FRONT-LINE MANAGERS
• PROMOTE PROFESSIONAL IDENTITY AND VALUES
• REPEAT AND EMBED
• AUDIT AND CHECK ON IMPACT
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SCRs AND
ENHANCING CHILD PROTECTION
WHAT MAKES FOR GOOD CHILD PROTECTION
•
•
•
•
•
•
A STABLE FRONTLINE
COMPETENT AND CONFIDENT PRACTITIONERS
WHO KNOW EACH OTHER ACROSS AGENCIES
RELATIONSHIPS, RELATIONSHIPS, RELATIONSHIPS!
WHO KNOW THEIR LOCALITIES AND NETWORKS
WITH ALL SERVICES CHILD AWARE AND FOCUSED
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SCRs AND
ENHANCING CHILD PROTECTION
WHAT MAKES FOR GOOD CHILD PROTECTION
• STABLE FRONT-LINE MANAGERS
• WHO ARE EXPERIENCED AND SUPPORTIVE
• WITH REFLECTIVE AND CHALLENGING SUPERVISION
• APPRAISING OPTIONS
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SCRs AND
ENHANCING CHILD PROTECTION
WHAT MAKES FOR GOOD CHILD PROTECTION
ALL THE ‘I’s
•
•
•
•
INVESTIGATIVE
INQUISITIVE
INTRIGUED
IMAGINATIVE
• INGRAINED [ TO BE CHILD-FOCUSED]
• INSPIRED AND INFUSED [TO THINK AND TO ACT]
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SCRs AND
ENHANCING CHILD PROTECTION
WHAT MAKES FOR GOOD CHILD PROTECTION
• TOP MANAGERS STAYING CLOSE TO THE FRONT LINE
• WHO THEMSELVES :
–
–
–
–
HAVE EXPERIENCE AND EXPERTISE
HAVE CONFIDENCE AND WISDOM
ARE OPEN TO FEEDBACK AND SEEK TO STAY INFORMED
RECOGNISE A COLLECTIVE ENTERPRISE WITHIN AND
ACROSS AGENCIES
46
SCRs AND
ENHANCING CHILD PROTECTION
WHAT MAKES FOR GOOD CHILD PROTECTION
EMOTIONAL INTELLIGENCE
AS WELL AS
INTELLECTUAL INTELLIGENCE
47
SCRs AND
ENHANCING CHILD PROTECTION
WHAT MAKES FOR GOOD CHILD PROTECTION
AND TIME AND SPACE
TO PRACTICE WELL!
48
Discussion Forum
How can we cascade the lessons
learned more effectively to front
line practitioners?
Lessons Learned from Case Reviews &
Cases of Concern 2011 to 2013
Thank you for your participation today
Please complete the Post-Evaluation and
collect your certificate