Recommendations: strengthen skills and knowledge base of the children’s workforce so that professionals are better equipped to recognise and respond to sexual abuse within the wider family; ensure that services to young children with harmful sexual behaviour are proportionate and timely; improve the effectiveness of multi-agency practice with adolescents who are at risk due to substance misuse and other risk taking behaviours and/or abuse and exploitation. If a father has not engaged, it should be clearly recorded that he remains an unassessed risk; if a parent does not consent to local authority support for a child in need, careful consideration should be given to escalating the protection provided; information about avoidant behaviour should be shared with all other professionals involved.Recommendations: ensure that the language change - 'was not brought' is reinforced across partner agencies and that practitioners are trained to realise 'medical neglect' and recognise missed appointments as an indicator. This placement broke down and Claire was placed in foster care. Baby Eliza was taken to hospital by ambulance where examination revealed unexplained cerebral bleeding thought to have occurred more than once.Learning: need for thorough assessment of mother’s and wider family history, including trauma when assessing parenting capacity rather than depending only upon presentation and observations; need to avoid misplaced sympathy; need to consider correlation between animal cruelty and child abuse; importance of following best practice and compliance with established procedures; need for professional curiosity and mutual challenge; need for full, precise and accurate information recording and sharing; persistence in encouraging GP involvement; professional enquiry about men (resident or not) whose relationship and conduct had an impact on the case; need for an effective system for identifying safeguarding supervision cases. When Hurricane Katrina hit St. Bernard Parish, Louisiana, in August 2005, a … Many states add other factors to the legal definition, such as the age of the abuser and the nature of the injury. In that time, substantiated cases of physical abuse decreased 56%, sexual abuse decreased 62%, and neglect decreased 10%. Keywords: addicted parents, assessment of children, children of addicted parents, parenting capacity, substance misuse, Subdural haematoma suffered by Chris, a baby under 6-months-old, in September 2015. Although there were concerns about his emotional wellbeing at home and school in December 2015, a referral to children’s social care was not made.Learning: the challenge for professionals working with families where members have a range of complex needs; need for coordination in provision of services across local authority boundaries; specific practice issues were found which highlight the dilemmas faced by front-line practitioners when exercising professional judgement in their safeguarding practice.Recommendations: to strengthen the sharing of information to ensure a whole family approach when working with children in blended families; to re-launch the CAMHS pathways within the borough; for the London Safeguarding Children Board to work with organisations across London to mitigate the risk to children where there is a lack of clarity associated with localised commissioning arrangements; partner agencies should be asked that contracts with service providers include an expectation that they should fully participate in any serious case review process.Keywords: child deaths, child mental health services, disguised compliance, emotional disorders, parents with a mental health problem, self harm> Read the overview report, Death of a baby girl under 2 months old of white British/Pakistan origin, in October 2015 as a result of fatal injuries received after falling from her car seat. Footnote 1; Nearly 61% of incidents of elder abuse were physical assaults against older adults, and 21% involved threats. Many are detained under the Mental Health Act. She was placed permanently with her aunt (her father’s sister) under an SGO, with support under a Family Assistance Order (FAO). The CQC gave Whorlton Hall a good rating after inspecting it in 2017. He had been placed in care at the age of 2 years as a result of severe physical and emotional abuse and neglect; his foster carers subsequently adopted him.Learning: effective communication and planning between professionals is an essential component of good multi-agency working; a professional resolution process would avoid drift and delay in care planning; professionals need to feel confident when working with parents who are perceived as challenging and be more empathetic in working with families; pathway planning for young people in care to consider their holistic needs, emotional resilience and learning ability; enabling young people to communicate what is important to them is not the same as repeating what they say.Recommendations: local authority training for practitioners on the legal framework for children in care, particularly where disruption is evident or does not share parental responsibility; produce good practice guidance to ensure focused supervision of practitioners based on high challenge and high support; all agencies to assure the LSCB on how the child’s voice influences their ability to ensure good outcomes for children in care taking into account the child’s lived experience.Keywords: anxiety, assessment of children, attention deficit disorder, emotional abuse, placement breakdown, professional collaboration> Read the overview report, Serious injuries to a 6-year-old boy following a road traffic collision in April 2017. Judges need support to deal with 'upsetting' child abuse cases. When discharged the twins lived with their mother and father, and older half sibling (Child I) and Mr B, Child I’s father who pleaded guilty to the manslaughter of Child G.Learning includes: evidence that there was a potential systemic weakness in the way that information about unborn babies is sought and shared; professionals should always be alert to the possibility that family members may not always tell the truth.Recommendations include: ensuring that staff use the correct unambiguous terminology; professionals should consider consulting with the GP's of parents as this will avoid missing information on parental mental health and parenting capacity; professionals should document and share any history of risk/vulnerability when making referrals and providing or seeking information.Model: sets out findings using the Welsh Model methodology.Keywords: infant deaths, premature infants, professional curiosity, non-accidental head injuries, family violence, disguised compliance> Read the overview report, Significant non-accidental head injuries to a 7-week-old infant in 2018, attributed to shaking.Learning: focuses on the following themes: preventing abusive head trauma; opportunities to consider safeguarding in health appointments pre- and post-birth; information sharing to enable wider safeguarding.Recommendations include: explore opportunities locally for professionals to be more aware of the significance of adverse childhood experiences and the importance of proactive professional enquiry regarding family histories.Model: uses the Welsh Child Practice Review model.Keywords: infants, shaking, physical abuse, adverse childhood experiences> Read the overview report, Death of a 14-year-old boy in January 2019. She filmed a number of shocking scenes where staff can be heard using offensive language to describe patients, while another calls the hospital a "house of mongs". Child S had serious health concerns from birth, eventually identified as cerebral palsy. .css-1xgx53b-Link{font-family:ReithSans,Helvetica,Arial,freesans,sans-serif;font-weight:700;-webkit-text-decoration:none;text-decoration:none;color:#FFFFFF;}.css-1xgx53b-Link:hover,.css-1xgx53b-Link:focus{-webkit-text-decoration:underline;text-decoration:underline;}Read about our approach to external linking. All the patients have been transferred to other services and the hospital closed down, Cygnet said. Registered charity number 216401. After that programme, the then prime minister, David Cameron, promised the mistreatment of patients would never happen again. The 17-bed hospital is one of scores of such units in England that provide care for just below 2,300 adults with learning disabilities and autism. Family protective services, at the order of the judge, may also become involved in the investigation. Key issues: the pre-birth decisions made about Shi-Anne’s care followed the same approach as decisions made for her older sibling, without considering whether this was also appropriate for Shi-Anne 5 years later; the assessments for the special guardianship order (SGO) were flawed and incomplete; professionals had little or no contact with Shi-Anne after the SGO; risk factors for the guardian’s reduced parental capacity, such as becoming pregnant and the breakdown of her relationship, were not recognised and acted upon.Learning: all relevant checks should be carried out and the need for a period of monitoring should be considered before a special guardianship order is finalised. An investigation into the abuse was launched after a former resident raised concerns with the Care Quality Commission in July 2011. those working with Child M and his mother had a limited understanding of possible risks to Child M; after the family moved to Oxfordshire no professional had a comprehensive knowledge of the mother’s mental health history as case transfer and closure summaries did not contain full details; there was no coordinated transfer with agreed objectives and plan, to consider whether the LSCB’s current threshold of need document places sufficient emphasis on the need to consider previous and historical concerns; that mental health service providers and GPs have adequate arrangements in place to identify and assess the needs of children of patients being treated for psychiatric illnesses; to ensure  staff have clear expectations for obtaining and reading case histories; to seek reassurance that implementation of GDPR has not led to inappropriate limitations on information sharing, professional curiosity, filicide, threshold criteria, information sharing, mothers, history. This includes: being hit, slapped, pushed or restrained; being denied food or water; not being helped to go to the bathroom when you need to; misuse of your medicines; Psychological abuse. VideoStreets of Beijing back to life after Covid, 'New York is not dead, but it is on life support', Rapper Pa Salieu wins the BBC's Sound of 2021, Six tips for success from the richest person on the planet, BBC Culture: Why being creative is good for you. Learning: The impact of time spent in hospital on ability to care for children.Recommendations: include: make training available to Children and Families staff regarding the effects of long term drug use on the brain and to consider the impacts on patient’s ability to care for their family after a discharge from intensive care.Keywords: sleeping behaviour, child neglect, depression> Read the overview report, Death of a 16-year-old Black British boy of West African parentage in a young offender institution (YOI). Healthcare Professional Involved June 7, 2012: report of patient's mouth being swollen and bruises and cuts on one side of the body. Six care workers also told the undercover reporter that they have deliberately hurt patients - including one who describes banging a patient's head against the floor, and another who speaks about flooring a patient with an outstretched arm, something he called "clotheslining". Family had contact with services including the GP, health visitors, midwifery and maternity services and the police. The Government definition includes so-called ‘honour’ based abuse, female genital mutilation (FGM) and forced marriage. You have X-rays taken, which show the leg is broken. Six of the siblings are now adults.Learning: the overwhelming nature of the complexity and scale of the problems and of the oppositional, hostile behaviour of the parents; responses from all agencies to concerns and interventions were generally short-lived and episodic; children's lived experience was not fully appreciated.Recommendations: develop a model for interagency practitioner supervision for complex cases where working together closely and consistently is of paramount importance; ensure that the use of the Public Law Outline is being used effectively to give local authority and social workers sufficient leverage with families who are deliberately obstructive by clarifying their concerns in a 'Letter before Proceedings' or further action.Keywords: Child neglect, child abuse, hostile behaviour, disguised compliance, voice of the child> Read the overview report, Death of a 3-month-old girl in March 2019. A mother brings her toddler to the emergency room, very concerned about the pain her child seems to be experiencing in his leg. An estimated 18,688 cases of physical abuse were substantiated in Canada in 2008, a rate of 3.1 cases of substantiated physical abuse per 1,000 children. He suffered from long-term asthma and severe eczema which was being treated at a satellite dermatology clinic. Examples of good practice were noted by the GP, the housing support worker and the health visiting service.Recommendations: reviewing procedures for children cared for by extended family members and undertaking a learning exercise to improve responses to injuries and bruises in young babies. There are no recommendations included.Keywords: child sexual abuse, enuresis, listening, parents with a mental health problem> Read the overview report, Death of an 18 month-old-girl from a white British and black African background in September 2015. Child E was born at home following a concealed pregnancy. Recommendations include: review commissioning arrangements for residential care to specify where a child/young person attends or is admitted to hospital, staff will accompany them with relevant health information; review policies in relation to children missing education and be clear about what action to take when young people are engaged in illegal work; arrangements for staff supervision to include opportunity to reflect on the emotional impact of work in complex cases and consider how assumptions and cognitive biases may be affecting practice.Keywords: child deaths, children in care, drugs, health> Read the overview report, Accidental death of a 7-year-old boy in July 2015.Learning: unrealistic expectation by agencies for mother to address her substance misuse in a self-motivated manner; Child R not referred for specialist assessment or counselling as a result of the domestic abuse situation between his mother and father; at age six and a half, Child R was found to have considerable attachment and emotional issues but appears not to have benefited from psychological assessment or professional therapy.Recommendations: to review, with South Yorkshire Police, the current design of the child protection incident form to ensure it captures essential data to discharge appropriate safeguarding responsibilities to a child; to ensure that children’s social care explores the need for specialist input into child protection conference proceedings, where the specialist is not currently engaged with the family and, therefore, not automatically invited.Keywords: substance misuse, child deaths, emotional disorders, family violence, threshold criteria, aggressive behaviour> Read the overview report, Life threatening and life changing neglect of a 3-year-6-month-old girl in September 2017.Learning: children who are suffering from neglect (and other forms of child maltreatment) may be ‘hidden in plain sight’; pre-birth planning and assessments offer early help and support to vulnerable parents and ensure the future safety and wellbeing of the unborn child; more needs to be done to promote collegiate working, respect and mutual understanding of others’ roles and responsibilities, including the limitations in practice; all those delivering care to children, young people and their families must have the relevant competencies to do so.Recommendations: seek assurances that practitioners are asking parents / carers why young children are not accessing early years provision; ensure that practitioners delivering care to children, young people and their families have achieved, as a minimum, the competencies set out in the relevant professional guidance, including oversight from an appropriately qualified professional.Keywords: child neglect, failure to thrive, malnutrition, parents with a mental health problem, maternal health services, assessment of children> Read the overview report, Fractured skull to a 13-month-old boy in March 2017. The family had professional involvement from specialist services in Bury. Voices. Child V’s father was convicted of manslaughter in December 2017.Learning: victims of domestic abuse often withdraw police statements, which complicates the prosecution process; professionals must question and challenge decisions and concerns directly with colleagues, irrespective of their professional background or status; the matter of language difficulties and consistent use of interpreters is an area for improvement.Recommendations: Norfolk LSCB and partner agencies need to develop a system to support non-engaging parents in domestic abuse offences and rape criminal cases; to have robust and easily accessible systems in place to support team functioning and staff wellbeing; ensure that the children’s services workforce understands the limitations of solution focused interventions for relationship counselling where domestic abuse is suspected; neonatal and maternity services should implement systems to routinely gather and share safeguarding / domestic abuse information.Model: uses the NSCB Thematic Learning Framework model.Keywords: abusive fathers, emotional neglect, premature infants, fractures, family violence, language> Read the overview report, Sexual assault of a 14-year-old male by a 20-year-old male care leaver in June 2016. The post-mortem gave the cause of death as “unascertained”.Key issues: parents were known to police due to the supply and use of drugs and related offences; the family was known to multiple agencies due to concerns about the neglect of 2 older siblings. +-Physical abuse Click to collapse Case Study 1: This is a story of a young adult who experienced physical and psychological abuse from a parent, and how he managed to break the cycle and have an independent and happy life. They call this "pressing the man button", something which causes her great distress. Police had recorded incidents of Billy and other children playing unsupervised on a busy dual carriageway in 2015 and referrals were made to Children’s Social Care.Learning: all children within a family need to be considered in assessments and plans; professionals need to identify when parental cooperation with a plan is superficial; the need to be curious about information held by other agencies and be proactive in sharing information that may improve the understanding of the child’s lived experience; consider the daily life of all the family through the child’s eyes when working with parents who misuse substances; view with respectful caution a parent’s self-report of their drug taking; good quality plans and reflective supervision is key to effectively recognising and challenging neglect.Recommendations: to consistently capture the voice of the child and lived experience with meaningful analysis; to request assurance from partner agencies providing early help about arrangements for reflective supervision for their practitioners; and how can the LSCB ensure that the impact on children of parental substance misuse is appropriately considered in multi-agency assessments and plans.Model: uses the Significant Incident Learning Process (SILP) methodology.Keywords: attachment behaviour, disguised compliance, neglected children, parenting capacity, substance misuse> Read the overview report, Death of 13-week-old infant due to non-accidental traumatic head injury in March 2017. Father was found guilty of murder of Child D in February 2016 and also found guilty of injuries caused to siblings DD and LD.Key issues: Child D was a twin who was born prematurely and spent 2 months in hospital after their birth. © 2021 BBC. Archie was fatally stabbed by another young person.Learning: embedded in the recommendations but also includes: impact of bereavement must not be underestimated.Recommendations: when a parent elects to home educate their child, the local authority should seek reassurances that the child is receiving a balanced education, including a home visit for an assessment by a trained professional; local authority must develop and communicate a clear escalation process for children not on school roll; ensure that structures are in place to assess, refer and intervene with vulnerable people who may be exploited by gangs and organised crime groups; implement child protection conferences that assess risk and develop plans in line with increased understanding of contextual safeguarding.Keywords: adolescent boys, child deaths, bereavement, child criminal exploitation, home education> Read the overview report, Death of an unborn baby due to suicide of the mother who was 37-week pregnant in April 2019.Learning: identifies strong practice, particularly in relation to prompt follow up when the mother did not attend or could not be contacted by the midwife, social worker and housing officer.Recommendations: substance misuse midwifery team should consider informing women on the substance misuse pathway that a positive toxicology result will lead to a referral to social care at the point of testing; conduct a review analysing current referral processes and pathways.Keywords: suicide, substance misuse, pregnancy, partner violence> Read the overview report, Death by suicide of a 17-year-old child in November 2019.Learning: education, health and care (EHC) plans and safeguarding of those with special educational needs and disabilities (SEND) need to be more aligned to ensure safeguarding issues are not minimised due to SEND; the emergency provision for young people following a suicide does not aid recovery for the young person or the family; and when a young person has highly complex needs, the focus can be entirely on the young person without consideration of the impact of issues on the wider family.Recommendations: review the offers of post-diagnostic support for autistic spectrum disorder; challenge agencies and partnerships in how they listen to young people around the transition to adult services; and ensure that a review by the SEND board takes place to address issues holistically before consideration of school exclusion.Keywords: autism, exclusion from school, parenting capacity, suicide, SEND, special educational needs and disabilities.> Read the overview report, Death of a 10-week-old baby boy in March 2017. This includes: emotional abuse ; threats to hurt or abandon you ; stopping you from seeing people ; humiliating, blaming, controlling, intimidating or harassing you Both received prison sentences.Learning: a decision that the injuries were due to a medical cause rather than non-accidental injury meant that professionals did not query an alternative diagnosis; deference to the medical clinicians involved made challenging medical professionals difficult. Having a child should not in itself be seen as a factor which can reduce a parent’s risk level.Recommendations: the safeguarding adults board and the safeguarding children board should develop a shared strategic approach to “Think Family”. A Boise woman was charged Thursday with six counts of injury to child. Maternal history of mental illness, self-harm, disclosed attempts to harm husband and attempted suicide.Key issues: include: management of screening for maternal mental health and domestic abuse not fully embedded in practice; lack of direct questioning regarding thoughts to harm others; professional decision-making impacted by affluence and status of family.Recommendations: include: strengthen professionals' understanding of the negative impact of professional biases and beliefs in safeguarding practice; review procedures to improve understanding of the child as a protective factor, risk of filicide and harm to others in cases of parent mental illness. Child L had contact with Child and Adolescent Mental Health Services (CAMHS) and Children's Social Care (CSC). Call us on 0116 234 7246 Physical Abuse - A 9-year-old was beaten by his mother's boyfriend in Lawrence, Massachusetts. 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. Findings include: resource pressures manifested in high thresholds; medical focus was necessary but an early consideration of home situation would have been appropriate; local authority transfer requests were not founded on the best interest of the child; lack of understanding of the lived experience of Child Z.Recommendations include: children who themselves have children should have their own social worker and their own separate plan for the avoidance of conflicts of interest.Model: uses a hybrid model based on the Welsh Model.Keywords: child sexual abuse, child sexual exploitation, teenage pregnancy, voice of the child> Read the overview report, Sexual abuse and neglect of three siblings by their father over many years. More females (12.8%) than males (4.3%) reported experiences of childhood sexual abuse. In July 2015 Salma was made subject to a Child Protection Plan under the category of neglect. 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