November 2015

Learning and Improvement SCR HN13

Background• Child H was 4 months old when she died. The cause of her

death is unknown but she had sustained a number of injuries of varying dates which are thought to be non-accidental

• She lived with her mother, mother’s partner and her sibling• The family had been known to a number of agencies as a

result of serious domestic abuse between mother and her previous partner, the children’s father

• There were concerns around mother’s mental health and questions were also raised around her use of alcohol

• Father was very well known to the police but not known to CSC in his own right

• Mother’s partner was known to CSC as a child

Methodology• The review was conducted using the Serious Incident Review

Process (SILP) led by an independent reviewer• Learning model which engages frontline staff and their managers,

focussing on why those involved acted in a particular way at the time

• The process aims to ensure that the perspectives and opinions of all those involved are discussed and valued

• NOTE: HN13 remains a serious case review - SILP refers solely to the methodology used

• Briefing event• Individual agency reports• Family engagement• Learning event involving practitioners, managers and

safeguarding leads• First draft of the overview report• Recall event involving the same group to study and

debate the first draft of the overview report • Final draft overview report circulated to commissioners • Final overview report signed off by NSCB• Dissemination of learning and publication

SILP Process

Key Learning

• The review concluded that the injuries to child H were neither predictable nor preventable

• A significant amount of good practice was identified within the review

• The importance of remaining child focused when parents have complex needs of their own

• Recognition of possible disguised compliance on the part of the parent

• Recognition of increased risks to children where there is domestic abuse together with other risk factors

• The need to reflect on the case as a whole to establish if the threshold is met for CSC services

• Effective information sharing when a significant number of agencies are involved with the family

Actions Taken

• NSCB has commissioned a multi-agency case file audit that focuses on children who are subject of a CAF (or early help plan) where domestic abuse is an issue

• In November 2014 NSCB/NCSCB published revised Domestic abuse practice guidance

• New training has been provided by NSCB including “Decision Making and Disguised Compliance” and “Working with Intimidation, Resistance and Avoidance.”

Questions

• How does this learning impact on our area of work?

• Are there any issues we need to consider in relation to our practice?