Website Menu
LSCB, Bournemouth Learning Centre, Ensbury Avenue, Bournemouth, Dorset, BH10 4HG
01202  458873

Learning from National Serious Case Reviews

Two summaries of Serious Case Reviews have been produced:

Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011-2014 analyses 293 Serious Case Reviews (SCRs) relating to incidents which occurred between 1 April 2011-31 March 2014.

Pathways to harm, pathways to protection (July 2016)

NSPCC Review of Parents who misuse substances: learning from case reviews – Summary of risk factors and learning for improved practice around parents with substance misuse problems

The Bournemouth and Poole Local Safeguarding Children Board (LSCB) aim to facilitate learning from national serious case reviews. This page will be updated monthly to draw attention to the most recently published serious case reviews. Partner agencies are responsible for drawing their own learning and practice development from these reviews.

The Board hopes to receive feedback from individual agency learning and the survey below will capture this. Practitioners contributing will be offered acknowledgement of their continuous professional development. Collated feedback on learning and improved outcomes will be presented to the LSCB Executive Board on a 6 monthly basis.

click to access the feedback survey

Nationally, messages from serious case reviews are drawn into summary reports, some of which are linked below.

The four latest SCRs published on the NSPCC website (summarised below) include joined up risk management across children and adult services, learning about adult health providers’ role in children’s safeguarding, CSE and its relationship with CSA and underage sexual activity, the value of chronologies and holistic work with families, screening of referrals, the voice of the child and approaches used in child protection planning. Practitioners and Manager across Children and Adult Services are encouraged to read the SCRs and reflect on the learning from them. Please use the links below to access the full reports.

2016 – Birmingham – BSCB 2011-12/1
Death of a 21-month-old 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.
Background: 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.
Key issues: include GPs didn’t consider safeguarding issues when treating parents of vulnerable children and inadequate screening of referrals of concern to children’s social care.
Recommendations: include: the Safeguarding Board 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.
Response: Birmingham Safeguarding Children Board’s judged that the review was “unfairly unbalanced” and made the decision not to fully accept the review’s findings and recommendations.
Keywords: child deaths, physical abuse, referral procedures
Read the overview report

2016 – Bristol – Operation Brooke
Sexual exploitation of children between 2011 and 2014. The police investigations, known as Brooke 1 and Brooke 2, 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
Background: 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. 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.
Key issues: the multi-agency system was not set up to respond quickly and flexibly to adolescents with complex needs; 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 group behaviour which made it harder to detect victims and perpetrators of CSE.
Model: systems based approach based on the Social Care Institute for Excellence (SCIE) framework.
Keywords: child sexual exploitation; organised abuse; sex offenders; children in care; alcohol misuse; substance misuse; child abuse identification
Read the overview report

2016 – 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.
Background: 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).
Key issues: included 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); and Bryony’s views were not sought consistently enough.
Recommendations: LSCB to undertake focused work on bringing risk assessment, risk management and safeguarding practice together across children’s and adults’ social care.
Keywords: suicide, children with a mental health problem, adolescent girls, child sexual exploitation, harmful sexual behaviour, foster care, placement breakdown, parental illness
Read the overview report

2016 – Newcastle – Child J
Death of a 15-week-old baby girl, J, in May 2014. A post-mortem confirmed she died of a head injury and further tests concluded this was likely to have been as a result of shaking. J’s mother and her partner were convicted of causing or allowing her death and given custodial sentences.
Background: J was born prematurely with suspected foetal alcohol syndrome. A month before her birth, she and her 3 siblings were made the subject of child protection plans for neglect. Family had a history of: domestic abuse, alcohol abuse; animosity over contact arrangements; children’s social care involvement during mother’s and partner’s childhoods; and offending behaviour and cannabis use by partner.
Key issues: recording systems did not include fit-for-purpose chronology templates, making it harder for practitioners to understand a family’s history; standardised tasks and contracts of expectation were used too routinely and without consequence in child protection plans making them ineffective at tackling deep-rooted, learned behaviour.
Model: systems approach based on the Social Care Institute for Excellence (SCIE) framework.
Keywords: abused infants; alcohol misuse; head injuries; foetal alcohol syndrome; intergenerational transmission of abuse
Read the overview report