interpreter being provided Overview report can be found at: 3 01/16 12/13 Enfield AX of a 17-year-old boy of heritage on 3 December 2013 following an altercation with three other adolescents. Courts later found that the three assailants were acting in professionals responding to discrete episodes of anti-social behaviour as opposed to addressing the broader concerns around an increasingly dangerous lifestyle; the failure of youth offending teams to update assessments as new information emerged; a lack of information sharing between schools and youth offending teams; and a failure to properly monitor and enforce attendance and curfew orders. Review mechanisms for sharing intelligence between agencies and put mechanisms in to allow the prompt and effective transfer of oversight and supervision of young people on court orders who move between boroughs. adolescent deaths risk-taking neglect Overview report can be found at: 4 01/16 11/15 Unnamed Board Child U, B & V Death of a baby boy and neglect of his older half-siblings (13 and Ambulance service was called by parents on 29 the needs of adults dominated the work undertaken; increasing concerns about the children's wellbeing failed to trigger intervention via the Common (LSCB) to review and report on the effectiveness of early intervention; LSCB to ensure commissioning arrangements for assessing substance misusing parents are in place and a clear infant deaths child neglect alcohol misuse early intervention fathers Caribbean
November 2015 as Baby V was not breathing. Parents had been drinking heavily. Both parents pleaded guilty to child neglect and received a custodial sentence. Assessment Framework (CAF); adults' accounts were accepted without reference to other available information pathway to accessing services for families; and all agencies to consider information on fathers and other significant males during assessments. Overview report can be found at: 5 02/16 11/13 Thurrock Megan Chronic neglect of a 17-year-old girl who was admitted to intensive care after collapsing at home Megan and her sibling spent periods subject to child protection plans because of physical abuse and neglect and as Children in Need. Family issues included: chronic neglect, domestic violence, housing eviction, poor home conditions and financial problems. lack of effective information sharing and analysis lack of professional understanding of adolescent neglect; lack of professional consideration of Megan’s lived experience professional focus on the level of service provided to the family as opposed to the impact of services. Adolescents Neglect Impact Information sharing Overview report can be found at: 6 02/16 - Oxford Child J Murder of a female by her who received a life sentence in 2014. Child J had recently told her ex-partner she thought she was pregnant with his child, resulting in him threatening her. Child J was often viewed as “difficult” and not as a child in need of safeguarding; processes and procedures for victims of domestic abuse were still under development; local safeguarding children board (LSCB) and Community Safety Partnership to act as a strategic lead on domestic abuse to ensure a unified approach to young victims and/or perpetrators; schools to cover healthy relationships in the context of domestic abuse; adolescents; murder; domestic abuse; risk assessment; relationships missing partner
grievous bodily harm but no convictions resulted. Both children were subsequently permanently removed from their care drug misuse by parents and maternal grandmother; mental health; and unstable housing arrangements leading to frequent moves. role of staff supervision across agencies. Local Safeguarding Children Board to review the sharing of domestic abuse notifications between the police and partner agencies; promote the family" approach ensure that multi-agency training covers the impact of domestic abuse, mental health and substance misuse on parenting. Overview report can be at: 11 03/16 08/14 Lancashire - Child O Death of Child O in August 2014 at the hands of their mother who then killed herself. A post-mortem concluded mother and child died of carbon monoxide poisoning. parents were separated and mother and Child O had moved to a number of places around the country. At the time of their death in Lancashire, they were not known to any statutory or other agencies within the county. Father had made an application for contact with Child O and a Cafcass children’s guardian was working with the family. Mother had made unsubstantiated allegations to Devon and Cornwall police of domestic violence and sexual abuse against Child O’s father. The coroner’s inquest there were organisational weaknesses in the approach to working constructively and proactively with fathers; professionals needed to be encouraged to balance respect for who talk about domestic abuse with appropriate scepticism curiosity where allegations are denied. developing knowledge and awareness of the nature of homicide in the context of parental conflict. deception; family courts; family violence; fathers; infanticide; suicide; wrongful accusation of child abuse
social media and or 'Pro-Ana' websites. Overview report can be at: 13 03/16 10/14 Cheshire West and Chester – Child A Serious head injury of a child in October 2014. family had significant contact with a wide range of agencies and were receiving support from a Team Around the Family (TAF) due to concerns about home conditions and the children’s failure to thrive. Mother had a history of childhood sexual abuse, a lack of emotional warmth towards her children and suspicion of services and professional involvement with her family. Father had a history of alcohol misuse, domestic violence and controlling behaviour. parents were able to dominate and manipulate TAF meetings by disputing points, creating diversions and feigned compliance with recommendations; no formal parenting assessment was made of parenting capability or motivation to change; professionals struggled to distinguish between parental neglect and emotional abuse; assessment tools were not always used effectively; escalation policy was not used by professionals to challenge decision making following referrals. head injuries, child neglect, emotional disguised compliance Overview report can be found at: 14 04/16 Spring 14 City and Hackney - Child H Death of a baby in Spring 2014 caused by inflicted injuries. Following a review of the evidence, parents were informed they family had been referred to children's services but were not assessed as in need of intervention. Parents and Child H lived with the mother's adoptive parents. Mother had a history of: childhood abuse and neglect failure to share information about bereavement and illness in mother's family, which should have led to a re-assessment of parenting capacity; confusion around whether the mother was infant deaths; adults abused as children; mental health; learning disabilities; parenting capacity aged
not be the subject of any further enquiries. which resulted in her being taken in to care, anger management issues, mental health issues and special educational needs. eligible for support from the Learning Disability Service; over-estimation by social services of the role of the hospital's psychosocial meetings with mother in monitoring the family's support needs; incomplete record keeping within children's services. Local Safeguarding Child Board to promote understanding of adult learning disability and eligibility for services Local Authority should ensure its quality assurance arrangements are sufficiently robust. Overview report can be found at: 15 06/16 10/13 Sutton – Child D Death of a 6-year-old girl in October 2013 from a head injury. Father was charged with her murder and child cruelty. Mother was charged with intending to pervert the course of justice and child cruelty. D had previously been on the child protection register under the category of physical abuse, after being hospitalised with head injuries in February 2007. Child D's father was convicted and Child D was placed in the care of her maternal grandparents. Following new medical evidence, father's conviction was quashed and a high professionals to: focus on the child's needs and experiences at all times, regardless of how demanding the parents are; when working with independent social work agencies, consider issues around quality assurance of practice, accountability, how they are selected and how they work in a context. physical abuse; family reunification; independent social workers; judges; expert witnesses; kinship foster care; legal judgements
not received medical treatment. The Crown Prosecution Service (CPS) decided not to prosecute the parents and an inquest reached a verdict of open conclusion. their children. Family had a history of: mother’s deteriorating mental health; father’s poor health and combined role as a home educator and carer for his wife and children; longstanding litigation claims against mother’s former employer; reclusive lifestyle; and lack of engagement with agencies. Welsh government to consider changing legislation to require parents to register children receiving home education with the local authority on an annual basis and to ensure the children are seen and spoken to and their wishes recorded annually. Overview report available at: 20 09/16 12/14 Brighton and Hove - Child E Death of a boy from injuries sustained by hanging in December 2014. Coroner returned an open conclusion on whether E’s death had been an accident or suicide. the local authority looked after E from when he was in a ‘Family and Friends’ placement with his maternal aunt and her partner. He spent time in respite foster care and before his death moved to the same area as his father. Family history includes: mother’s mental health and substance misuse difficulties; mother’s death from an overdose when E was 8-years old and absence of E’s birth father for much of his childhood. E faced difficulties including: emotional distress; challenging behaviour at home; being known to the tension between the roles of the local authority as corporate parent and ‘Family and Friends’ carers who can be seen as ‘parents’, this can result in blurred boundaries and difficulties asserting the local authority’s statutory responsibility for a child when this is needed. Due to inconsistent standards in transfer summaries and chronologies, new social workers did not always receive enough background information to gain an holistic understanding of the needs and risks facing young people and their carers. adolescent boys; kinship foster care; children with a mental health problem; suicide
and given custodial sentences. offending behaviour and cannabis use by partner. Overview report can be found at: 23 2016 02/15 Cheshire West and Chester - Bryony Death of an adolescent girl from an overdose in February 2015. There were no suspicious circumstances surrounding Bryony’s death and she left a note expressing her distress and desire to take her own life. Bryony was subject to a Child in Need plan and spent time in foster care placements under Section 20 arrangements. Before she died, Bryony had returned to live with her mother under a care order. Family history included: domestic abuse and mother’s disability resulting in Bryony spending a lot of time caring for her. Bryony faced difficulties including: severe emotional distress; self-harm; offending behaviour; school refusal; going missing; and risks around child sexual exploitation and harmful sexual behaviour. A number of services supported the family including: children’s services and Child and Adolescent Mental Health Services (CAMHS). the mindset of some professionals was skewed towards risk, resulting in them viewing Bryony as a perpetrator rather than a vulnerable child; there was a lack of focus on working with the whole family (including father and grandparents); a Bryony’s views were not sought consistently enough. LSCB to undertake focused work on bringing risk assessment, risk management and safeguarding practice together across children’s and adults’ social care. suicide, children with a mental health problem, adolescent girls, child sexual exploitation, harmful sexual behaviour, foster care, placement breakdown, parental illness 24 2016 2011-14 Bristol - Operation Brooke Sexual exploitation of children between 2011 and 2014. The police investigations, known as Brooke 1 and Brooke 2, investigation Brooke 1 involved the sexual exploitation of a 16-year-old looked after child and a further 3 children aged between 14 and 15-years-old. the system was not set up to respond quickly and flexibly to adolescents with complex needs; child sexual exploitation; organised abuse; sex offenders; children in care; alcohol misuse; substance misuse;
resulted in the successful prosecution of 15 offenders for crimes including rape, paying for the sexual services of a child and trafficking for sexual purposes Brooke 2 involved the sexual exploitation of 6 children. The perpetrators, who were all in their early 20s, used drugs, alcohol, money and the children themselves to attract and groom new victims. professionals struggled to distinguish between sexual abuse, sexual exploitation and/or underage sexual activity; working methods and recording systems did not reliably identify patterns in individual and behaviour which made it harder to detect victims and perpetrators of CSE. child abuse identification Overview report available at: 25 2016 06/11 Birmingham – BSCB Death of a boy from serious injuries in June 2011. Following the child's death, the mother's boyfriend was sentenced to 8 years for manslaughter and the mother to 15 months for child cruelty. Mother had recently moved out of maternal grandmother’s home into her own tenancy and her new partner spent significant amounts of time there. Mother had a history of: mental health problems, childhood sexual abuse and abusive relationships. Partner had a history of substance misuse. GPs didn’t consider safeguarding issues when treating parents of vulnerable children inadequate screening of referrals of concern to children’s social care Safeguarding should routinely evaluate measures taken by Children’s Social Care to improve the screening of referrals; the Mental Health Trust should promote guidance on protecting children and young people for doctors who treat adult patients. child deaths, physical abuse, referral procedures Overview report available at: