Introduction |
Child
H was born in 2005
and spent the first
48 days of his life
in hospital as a
result of neonatal
abstinence syndrome.
He died at just eleven
weeks of age.
Child
H’s sibling
was born in 2004,
and also spent the
first few weeks of
life in hospital
due to neonatal abstinence
syndrome.
Following
police enquiries
around Child H’s
death and injuries
found at post mortem
it was decided that
no charges would
be brought against
either parent. The
cause of death remains
unexplained.
During
both pregnancies,
the parent remained
a client of the Substance
Misuse Service, undertaking
a methadone programme. There
were no referrals
to Social Services
for pre-birth assessment
for either sibling. The
family was known
to Social Services,
Health, Police and
Probation Services. Purpose
of a Serious
Case Review
The
overlying purpose
of a Serious Case
Review is set out
in Chapter 8 of Working
Together to Safeguard
Children (HM Gov
2006):
“When a child
dies, and abuse or
neglect are known
or suspected to be
a factor in the death,
local organisations …..
should consider whether
there are any lessons
to be learned about
the ways in which
they work together
to safeguard and
promote the welfare
of children…”
Specifically
agencies should:
-
establish whether
there are lessons
to be learned from
the case about
the way in which
local professionals
and agencies work
together to safeguard
children;
-
identify clearly
what those lessons
are, how they will
be acted upon,
and what is expected
to change as a
result; and as
a consequence;
-
to improve inter-agency
working and better
safeguarding children.
|
Family
Composition |
|
Mother |
Born
1982 |
|
Father |
Born
1973 |
|
Sibling |
Born
2004 |
|
Child
H |
Born
2005 – Died
2005 |
Recommendations
for Individual
Agencies Leeds
Social Services
Department |
1 |
The
Line Manager with
responsibility for
the case should ensure
that in all cases
where Section 47
Enquiries are initiated
the proper procedures
should be followed
in accordance with
national and local
child protection
procedures and guidance. The
case should not be
closed until an assessment
has been completed.
|
2 |
The
Social Services Department
to review its training
with regard to supervision
and recording. Any
supervision training
needs to ensure that:
-
staff keep
a clear focus
on the child/children’s
needs including
the need for
protection
from harm;
-
planning and
decision making
in case management
are informed
by an assessment;
-
supervision
ensures the reviewing
of plans and
timescales;
-
parents are
fully informed
of any decisions
that are made
in relation to
their family;
-
all of the
above are adequately
recorded.
When any gaps are
identified in relation
to the above training,
the Social Services
Department should
produce an Action
Plan to be submitted
to LSCB.
|
3 |
The
Senior Child Protection
Co-ordinator should
review, with immediate
effect, whether when
a request is made
for the cancellation
of a Child Protection
Conference (except
where cases are subject
to Care Proceedings),
the Child Protection
Co-ordinator has
given due consideration
to this being the
appropriate decision.
|
4 |
The
Social Services Department
to review its training
in relation to the
significance of Domestic
Violence and Drug
Misuse as an indicator
of risk to children. Where
any gaps are identified
the Social Services
Department should
produce an Action
Plan to be submitted
to LSCB.
|
Leeds
Health
(incorporating
Leeds East PCT,
Leeds Teaching
Hospitals Trust,
Leeds Mental
Health Trust) |
1 |
A
protocol to be developed
to assist health
service staff supporting
substance misusing
mothers and their
children (including
unborn children)
to respond to non-
compliance and issues
of concern.
The protocol should
include:
-
the possible
need to hold
collective discussions
about case management
between health
staff;
-
the need to
ensure that a
child focus is
maintained;
-
give consideration
to the need to
request a Pre-birth
Assessment from
SSD
|
2 |
The
diagnosis of a lipoma
in young children
to be highlighted
in child protection
training information
for doctors
|
3 |
The
Neonatal Unit staff
should be assisted
to develop guidelines
around the management
of non attending
parents.
The guidelines should
include:
-
the need to
discuss non attendance
by parents with
the Named Child
Protection Professionals,
especially when
substance misuse
is prevalent;
-
when to refer
concerns to social
services;
-
how staff should
assess attachment
in these circumstances;
-
the need to
hold a discharge
planning meeting
which should
include parents
and the health
professionals
who will be providing
the family support
on discharge.
|
4 |
The
Associate Director
for Safeguarding
Children to ensure
that a specific basic
signs and indicators
of child abuse training
package is developed
for key staff.
The package to
include reference
to the notification
of unusual diagnoses,
the need to ascertain
more information
and need to challenge
if they disagree
with the findings;
this should also
include information
on lipoma and torn
frenulum.
|
5 |
All
existing training
packages, where signs
and indicators of
abuse are discussed,
to be updated to
include key messages
from the basic signs
and indicators package.
|
West
Yorkshire Police |
1 |
The
police had no involvement
with Child H prior
to his death and
the involvement that
the police had with
the parents was limited.
The review panel
agreed there are
no recommendations
for the police.
|
West
Yorkshire Probation
Service |
1 |
Probation reviews
its own information-gathering
process to ensure
that where wider
family members,
including children,
are referred to,
full details should
be recorded.
|
Recommendations
for Leeds Safeguarding
Children Board |
1 |
LSCB
ensures that the
differences between
Section 47 and Section
17 of the Children
Act are clearly referred
to in all interagency
child protection
training. In
doing this it may
support all professionals’ understanding
and thus enable challenges
to be made on decisions
that seem to lack
direction.
|
2 |
LSCB requests
that each agency
complete a review
of their internal
training with regard
to supervision and
recording of information. Lord
Laming referred to
lack of supervision
and recording in
his review of the
death of Victoria
Climbie. Where
there are identified
gaps it is expected
that each agency
should produce an
action plan to be
submitted to LSCB.
|
3 |
LSCB
to support the promotion
and delivery of conferences,
over the next 2 years,
to raise awareness
on the issues of
raising children
within a family who
are suffering domestic
violence, mental
health issues and
substance misuse,
and the impact that
this has on children’s
lives and their well
being. |
