lessons learned from case reviews & cases of concern 2011 to 2013
TRANSCRIPT
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 MembershipThe 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 policyCRSG 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 2013SCR 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 1Lindsay 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.
2007
Bullying
School
GP
Numerous appointments
Poor school attendance
Moved Primary School
SHAShouting swearingSpill thingsRemove clothingNervous breakdown
CAMHS
DNA (closed in line with old policy)
Adult 1 unhappy with seeing a trainee psycologist
Adult 1 banned from school premises due to behaviour
EWO
OCD
This visit upset all the family and further arranged meetings then cancelled by Adult 1
(CAF)
Joint visitEducational Welfare Officer & School Nurse
2009
CAMHS
Unhappy about psychology wanted psychiatry (DNA closed in line with old policy)
Bullying
SHA
Surgery discussed issues but no outcome logged
Home educated (end of 2009) never returned to mainstream educationRefused to allow
information sharing
Poor School attendanceCore Assessment
(but no other professional involved)
Referral to CSC
Professionals’ meeting held
Adult did not attend
(EIP)FAM
Clinical meeting held (no safeguarding discussion GP
Food intolerance Viral Food refusalNot leaving homePoor self esteem
2010
GP
Self esteem
CAMHS
Unhappy about discussing child’s 2 weight
Unhappy given appointment to see psychiatrist
Did not want to see a male psychiatrist
Bullying?
4 appointments 2 seen by adults 2 child/4th appointment child gave abuse allegation
CSC
Section 47 Removed
Barriers
Safeguarding never really on agenda No escalation of
same presenting problem
Poor response in 2009 Inadequate Core Assessment
Challenging aggressive adults
Fabricated and induced illness not considered
Removed from mainstream education left her vulnerable
Some delay following allegation
DNA Policy CAMHS
Complexity of Health Services
Refused to allow information sharing
No follow up of Professionals’ Meeting
Voice of child not in the case
No risk assessment
Good Practice
Detailed Multi Agency Chronology
Good Multi Agency response following allegation
Procedure followed when Manager in CAMHS became aware of allegation
Escalated appropriately following case conference
Mum not allowed to intimidate
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 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 2007Family 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
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 EAgencies involved:
School 2School Nurse
GP
Child C – Perpetrator of
Incident.Agencies involved:
School 1CAMHS
IYSSEIP
School Health Advisor
Community Paediatricians
GP
Child F – Victim of Incident
Agencies involved:School 2
GP
Child GAgencies involved:
HVGP
Child DAgencies involved:
School 2GP
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 LearntCommunication/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 LearntChallenge 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 LearntVoice 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 LearntEmotional 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
• 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
• 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
• 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
• 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
• 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 PROTECTIONALL 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
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SCRs AND ENHANCING CHILD PROTECTION
WHAT MAKES FOR GOOD CHILD PROTECTION
EMOTIONAL INTELLIGENCEAS WELL AS
INTELLECTUAL INTELLIGENCE
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SCRs AND ENHANCING CHILD PROTECTION
WHAT MAKES FOR GOOD CHILD PROTECTION
AND TIME AND SPACETO PRACTICE WELL!
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Discussion Forum
How can we cascade the lessons learned more effectively to front line practitioners?