Model: used the Significant Incident Learning Process (SILP) methodology.Keywords: physical abuse, infants, hospitals, child protection> Read the overview report, Abduction from the United Kingdom of an almost 3-year-old girl in December 2016. Someone may abuse or neglect a child or young person by inflicting harm, or by failing to prevent harm. Figures are rounded to the nearest 10. Attendance at physiotherapy, neurology and occupational therapy appointments was sporadic; he was not registered with a GP for two years before his death; correspondence was not received due to frequent house moves; evidence of the mother making decisions about treatment and medication.Learning: the need to record address, telephone number and GP details at every appointment; updating interagency cross authority procedures to provide more detail of medical neglect; changes to practices at the Trust including an end to the partial booking system for children and provision of a key worker to link between services.Recommendations: to strengthen cooperation between hospital services and general practitioners; to have policies in place to change ‘Did not attend’ records to ‘Was not brought’ to emphasise the child’s vulnerability.Keywords: absenteeism, child advocacy, children with physical disabilities, developmental disorders, disguised compliance, housing, multidisciplinary approach> Read the overview report, Death of a baby girl, Child K, who drowned in a bath in the presence of her older brother and sister. These include: professionals need to be confident to raise questions about family or household members who could pose a risk of harm to a child.Model: Social Care Institute for Excellence (SCIE) Learning Together model.Keywords: child neglect, children with a chronic illness, disguised compliance, health services> Read the overview report, Death of a boy aged less than 1 year from unknown causes. Child W and his sibling Q began behaving antisocially and became involved with Youth Offending Services. described the system as "broken" and said people who ended up in hospital were being failed. In 2016, an estimated 1,750 deaths were related to abuse and neglect of a child. > Read the overview report, Death of a 17-year-old girl by suicide in August 2017.Learning: assessing competence, resilience and emotional attachment disorder in adolescents and considering the impact of adverse childhood experiences (ACEs) and impact of cannabis use; using a holistic family approach to assessing children and young people where their parents have difficulties; recognising when young people are carers; the importance of reflective supervision.Recommendations: to work with the Safeguarding Adults Board to develop a ‘Think Family’ approach; review how practitioners are supported and trained in assessing adolescents who have complex and unresolved emotional issues, possibly coupled with drug use and impulsivity; promote awareness of and response to contextual safeguarding.Keywords: adolescents, suicide, adverse childhood experiences, drug misuse.> Read the overview report, Death of a 9-month-old child in February 2014 as the result of a hypoxic brain injury. The victims, Grace, Lisa and Carey provided evidence to convict the perpetrator, who was sentenced to 9 years imprisonment.Learning includes: mishandled or ineffective investigation of child sexual abuse is especially damaging for the victims and leaves them in greater jeopardy; presentation of perpetrators as pillars of the community and hiding in plain sight; role of local authority designated officer (LADO) has a significant role in regard to any criminal investigation, enquiries and assessment as to whether a child or children are at risk or in need of services. B was subject to a child protection plan for emotional abuse, later becoming a child in need and finally a vulnerable child, supported by universal services. An investigation into the abuse was launched after a former resident raised concerns with the Care Quality Commission in July 2011. Death of 11-year-old child with complex medical needs requiring a high level of input from a variety of practitioners and putting a high level of demand on those caring for the child, making it difficult to define the threshold for neglect.Key issues: Alex was diagnosed with cystic fibrosis (CF) at a year old. Learning includes: more preventive approaches are needed to support young people who are anxious and help prevent them acting on suicidal thoughts; more support should be available for young people to talk to others if they are feeling anxious or depressed.Recommendations include: raise awareness about the use of and impact of illegal drug use by young people; consider the role of drug and alcohol use in mental health assessments of suicidal young people; schools should ensure that a child’s vulnerabilities including mental health issues should be passed onto a new school when a child transfers.Keywords: suicide, mental health, adolescents, anxiety.> Read the overview report, Death of a 2-and-a-half-week-old boy in March 2016 due to a non-accidental head injury.Learning includes: agencies need to ensure that they record full details of both the baby’s father and all members of the household; Children’s Services need to ensure that they have understood medical information and not be entirely led by medical opinion; professionals in MASH need to discuss and evaluate information, not just share it.Recommendations include: ensure the participation of agencies in serious case reviews, both in relation to attendance at meetings and responding to requests for information; findings of research into head injuries in children to be included in inter-agency training; seek assurances from partner agencies that managers are equipped with the skills and knowledge to provide effective oversight of child protection cases.Keywords: decision-making; non-accidental head injuries; infant deaths; information sharing; managers; professional curiosity.> Read the overview report, Death of a 16-year-old boy following a road accident in 2017.Learning: to provide support to parents as early as possible in a child’s life paying particular attention to attachment in early years and experiences of separation and loss; equip children’s workforce to provide a trauma informed response to adults and children; Child Q’s behaviours were not adequately addressed in school, which led to exclusion; ensure that transfer or transition arrangements are as robust as possible; Child Q required intervention and treatment for various emotional and mental health issues, but treatment was unacceptably delayed.Recommendations: to strengthen working protocols between Adult Mental Health and Children’s Services to facilitate development of integrated whole family health care pathway; to influence the Department for Education (DFE) to review alternative education and agree a consistent methodology of working with high-risk pupils in a multi-agency context; join up multi-agency risk and safety planning forums to improve services for children at high risk in the community, such as gangs, serious youth violence, missing and all forms of exploitation.Keywords: early intervention, gangs, placement breakdown, preventive services, threshold criteria, young offenders.> Read the overview report, Death of an adolescent boy due to a fatal stabbing.Learning: early help and prevention is critical; schools should be at the heart of multi-agency intervention; disproportionality, linked to ethnicity, gender and deprivation, requires attention and action; an integrated, whole systems approach is needed across agencies, communities and families.Recommendations: review evidence-based practice to revise and publish Croydon’s model of intervention to effectively respond to vulnerable, risky, and gang-linked young people; review service arrangements and introduce support for mental health patients to support a child’s relationship with their parent and provide support to the care giving parent; ensure adequate sustainable resources are in place to support the multi-agency response to address gangs and serious youth violence.Keywords: gangs, school adjustment, weapons, violence, peer groups, social media.> Read the overview report, Thematic review of 60 vulnerable children known to Children's Services (23 girls, 37 boys) aged between 10 and 17-years-old following the deaths of three children.Learning includes:a holistic approach to the child and family is needed, complemented by an integrated multi-agency response; making a difference to children's outcomes cannot be achieved by professional intervention alone and there is a need to understand and embrace family, kinship and communities; schools should be equipped to respond to challenges presented by children with high risk behaviour and placed at the heart of multi-agency service provision.Recommendations include: consider how awareness raising about the impact of adverse childhood experienced (ACEs) will be built upon to include professionals, families and the community; establish a data set about the most vulnerable children in Croydon to inform risk management strategies and service provision; consider how the involvement of professionals, families and the local community might be achieved, to explore how to address disproportionality.Keywords: adolescents, adverse childhood experiences, children’s attitudes, education, gangs.> Read the overview report, Serious physical harm to a 10-week-old infant in September 2016.Learning: assessments are biased towards assessing mothers, rather than assessing both partners equally; there was an over-reliance on the Family Nurse Programme (FNP) by all partner agencies involved; processes designed to safeguard children were not followed when bruises and marks were identified.Recommendations: consider how to reduce professional anxieties around sharing information with partners; foster a culture where professional curiosity is increased; and assure that professionals’ response to indicators of domestic abuse is in line with policies and procedures.Keywords: adolescent parents, disguised compliance, infants, physical abuse, teenage pregnancy, unknown men.> Read the overview report, Emergency admission to hospital of a male under 18-years-old in 2016 with acute severe nutritional failure.Learning: inability to comply as well as enmeshed relationships should be considered if plans are not progressing as expected; there is a gap in the provision of multi-disciplinary intensive family home support exploring and challenging family dynamics; there is a vulnerability at transition into adulthood, despite Getting it Right for Every Child (GIRFEC) processes applying up to the age of 18, especially for those who leave school or who have complicated or challenging needs which do not fit into a medically defined category.Recommendations: children with severe obesity affecting functioning should be supported via the GIRFEC pathway; everyone with parental rights and responsibilities should be consulted with and recorded on all agencies' GIRFEC paperwork; the GIRFEC pathway should be followed during transition especially once a young person who has a child's plan has left school, to ensure ongoing support and planning.Keywords: nutrition, obesity, encopresis, attachment behaviour, professional curiosity, school attendance.> Read the overview report, Death of an 18-year-6-month-old male in May 2017. Physical abuse in a relationship is more than just battering. The joint working protocol for safeguarding children and young people whose parents/carers have problems with mental health, substance misuse, learning disability and emotional or psychological distress should be reviewed and made more accessible to practitioners from the multi-agency partnership.Keywords: child deaths, fathers, filicide, parents with a mental health problem, suicide> Read the overview report, Death of a girl aged 2 years-and-four-months in June 2015 caused by accidental ingestion of her mother's methadone. Her step-brother and his partner were convicted of her murder and manslaughter respectively. He had carers who came into his home three times a day, but his wife cared for him the rest of the time. Carolyn is 21-years-old, and autistic with moderate intellectual disabilities. The most high-profile case of recent years was Connor Sparrowhawk, who had learning disabilities and epilepsy, and died when he had a seizure alone in a bath at an NHS unit in Oxford in 2013. * Child Physical Abuse – statute of limitations is only 1 year after 18th bday. The official investigation in the Winterbourne View case also made warnings about the excessive use of restraint. Many are detained under the Mental Health Act. The children were not known to child protection agencies. At 6-years-old she was sexually abused by a member of the household and became a looked after child in the care of her paternal grandmother. There were concerns about domestic abuse, lack of engagement with services, mother’s young age and her mental health problems associated with childhood trauma.Learning: responses from children’s social care were incident-led. He was not known to any services. It is thought so many cases of physical abuse are missed simply due to the physician's failure to ask about it. Behaviour and attendance at school erratic, and several incidences of involvement with others in minor and serious offences, including rape of a 12-year-old and 14-year old. Healthcare Workers Arrested in Separate Elder Abuse Cases Date of Offense What Happened? After being treated in hospital he was taken into care due to concerns about his health and the cumulative effects of neglect.Key issues: Young Person lived with his mother and her partner, and did not know his father. abuse was uncovered at another hospital for people with learning disabilities. Whorlton Hall: Hospital 'abused' vulnerable adults - BBC News Learning: the difficulties faced by professionals in working with a family when FII is suspected.Recommendations: development and implementation of pathways for the early identification and management of perplexing presentations, including suspected cases of FII, and for the management of identified cases of FII, including those who are subject to child protection plans; the Department of Health and the Department for Education should be asked to commission national research to establish the prevalence, incidence and case characteristics and outcomes for children who have perplexing presentations or FII. Keywords: infants, physical abuse, non-accidental head injury> Read the overview report, The child sexual exploitation (CSE) of Child C and Child Q by Perpetrators A and B between 2010 and 2014. pregnancy, foster care, people with learning difficulties, placement, non-accidental head injuries, abusive parents. Find case reviews by subject, year or area. She attends a special school program to assist with her disabilities. He was assessed by a psychological therapist as being at moderate risk of causing himself harm.Learning: professionals working with the father needed to consider how his mental health problems might affect Child G and what her needs might be. Police investigation concluded with no further action taken.Learning: being actively curious about members of the household, family dynamics and actual, or potential, risks to children is an important consideration for practitioners; contemporaneous record keeping is an essential requirement following all appointments and contacts; ensuring fathers are given the same advice and support as mothers is important; ensuring new parents think about safer sleeping arrangements for the baby is a core task for all professionals.Recommendations: to review the current strategies and initiatives around safer sleeping advice, support and promotional materials and consider any changes which may promote knowledge and understanding.Keywords: infant deaths, sleeping behaviour, fathers, professional curiosity.> Read the overview report, Death of a 14-month-old girl in August 2019.Learning: considerations should be given as to how professionals engage with fathers. Carolyn Grant. Shi-Anne’s guardian was subsequently convicted of murder. It should be short. Physical Abuse - The boyfriend of a child's mother in Wilmington, Delaware, hit and killed a 16-month old girl because she wouldn't stop crying. Child A was in the care of her paternal aunt when the incident took place. In cases of alleged abuse, the judge will thoroughly investigate each claim before awarding custody or visitation. But it helps. Injuries include bruises, lacerations, blunt trauma, fractures, head trauma, shaking, burns, and poisoning. The injuries remain unexplained but were suspected to be non-accidental. Boise Police began an investigation in November of 29-year-old Angel Hibbard into the possible physical abuse of children under her care. She was abducted by her birth parents which is a crime as the Care Order meant the Local Authority shared parental responsibility for Child T.Learning: effective information sharing and communication are vital if children are to be safeguarded when their parents are involved in serious crime; practitioners working with LAC placed at home should be alert to their vulnerability and ensure they understand their responsibilities towards safeguarding them and meeting their needs; multi-agency practitioners need to ensure they are clear about the content of parental written agreements; always be alert to the possibility of disguised compliance even when parents present as fully engaged and working well with agencies.Recommendations include: Greater Manchester Police and Children’s Services should assure the LSCB that strategy meetings or discussions are always held when a child has been subject to a Police Protection Order; partner agencies to assure the LSCB that the learning from this review has been implemented and embedded into practice.Model: multi-agency concise review (MACR). Child E's step-father pleaded guilty to manslaughter and no inquest was carried out.Learning: a focus on the physical care of the children and home conditions diverted attention from other serious issues, including risk of being in contact with people who presented risks to the children; professional challenge and escalation is important in effective intra and inter-agency work; agencies that saw signs of concern dealt with them appropriately most of the time but some intra and inter-agency communication and information sharing could have been better.Recommendations: more training on neglect and its impact on children; more understanding of legal processes and what local authorities must evidence to secure statutory orders; raise awareness of the Escalation Procedure and the importance of robust, respectful professional challenge between and within agencies; consider the introduction of a panel, chaired by a different professional to take a “fresh look” at cases that are making insufficient progress.Keywords: assessment, child neglect, child deaths, home environment, optimistic behaviour, step-parents.> Read the overview report, Neglect of a 5-year-old girl in September 2015.Learning: the number of children in the family and the number and range of professionals involved posed a challenge to effective communication; professionals were not curious enough about Child Q’s experiences and too quick to accept parents’ explanations without considering the whole context of her life.Recommendations: develop a multi-agency policy for the management of non-attended appointments across multiple services; review of information sharing systems between hospitals, GP practices and child health professionals, focusing on communication; ensure that requirements for all children’s voices to be heard at child protection conferences are met and that those who cannot speak for themselves are adequately represented.Keywords: pre-school children, school attendance, malnutrition, child neglect, home environment, child protection registers.> Read the overview report, Death of a 1-year-old boy in November 2017 from unascertained causes.Learning: the child’s experience must run through all work undertaken with families and thresholds should be focused on the impact of parenting on the child; professionals need to use the neglect framework and practice guidance to help them identify neglect; if a parent voices concern about being a parent due to their childhood experiences of sexual abuse, specialist support should be made available; when assessing if an injury is consistent with the story provided by the parent, consideration should be given to the child’s developmental stage.Recommendations: to question how professionals in partner agencies make referrals that provide the evidence and information required when they have safeguarding concerns; to request assurance from partner agencies that professionals understand the risks of interfamilial sexual abuse and a parent’s adverse childhood experiences (ACEs).Keywords: adverse childhood experiences, father-child interaction, neglect identification, mother-child relationships, nutrition, sudden infant death.> Read the overview report, Bruising first reported on a 6-week-old boy in March 2016, with further bruising and fractures documented over the next month and six days.Learning: a hierarchical approach in the working environment leads to professional deference and makes challenging medical professionals and decisions difficult; child protection practice requires collaborative work and professional respect; needs of fathers must be properly assessed and engaged; change to modern service delivery models cannot guarantee continuity of care; service thresholds were applied that did not correspond to the needs described.Recommendations: all agencies must undertake a review of internal and inter-agency information sharing systems including use of electronic recording, flagging and coding systems; community health visiting and children’s social care services must incorporate a ‘think family approach’ as standard; the LSCB must develop and agree a protocol for responding to bruising in pre-mobile babies and disabled children who are dependent and unable to communicate.Keywords: adults with physical disabilities, father-child interaction, fractures, health visitors, medical assessment, optimistic behaviour.> Read the overview report, Death of a 14-week-old boy from serious non-accidental injuries in July 2016.Learning: failure of the systems and processes designed to safeguard children with inaccurate recording; the interface between Child in Need and Team Around the Child did not work well; system around midwifery care was disjointed with lack of communication between midwifery teams and midwives and GPs; insufficient focus of emotional impact of Elias and Child A’s diagnoses on their parents.Recommendations: health services should review documentation and assessment tools and include household composition and functioning of the household; to seek assurance from health and partner agencies of emotional impact of having a child born with any abnormality/disability features within consultations with recognition of any risks to the child; all GPs to be notified of the pregnancy of all women registered in their care; to seek assurance that the application of thresholds is now consistent.Keywords: bruises, burns, children with physical disabilities, congenital disorders, housing, murder.> Read the overview report, Death of an infant in November 2017 from injuries linked to being shaken three months earlier. The young person reported the assault in November 2015, at the age of 18.Learning: understanding of risk and how that can be managed needs to be better; agencies need to identify persons who present a risk to children and flag those persons within their agencies to enable them to be managed in a multi-agency fashion; parents and carers need to be equipped to identify grooming, especially when a risk is known or perceived.Recommendations: ensure that organisations can effectively flag and monitor persons identified as presenting a danger to children; ensure that staff feel confident in identifying and referring persons who present a danger to children; review how effective disclosures can be achieved from children and young persons where there is a lack of verbal disclosure.Keywords: child sexual abuse, disclosure, siblings, professional curiosity, information sharing> Read the overview report, Death of a 7-week-old infant from non-accidental injuries caused by shaking in February 2016. 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