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Case reviews posted

A summary of the professional summaries or full overview reports of very severe case reviews, significant instance reviews or multi-agency son or daughter training reviews posted in 2020. The national repository to find all published case reviews search.

2017 – Stockport – Pip

Loss of a 15-year-old woman as an upshot of a collision by having a train in December 2015. The coroner’s inquest concluded that her death ended up being suicide.Learning: the requirement to realize that anorexia places stress not merely regarding the youngster, but additionally on the household and experts dealing with them; recognition that anorexia has safeguarding issues for multi-agency advice, not merely medical researchers; the necessity for all assessments carried off become coordinated into one record of proof.Recommendations: the growth of consuming condition paths; make sure that the views and emotions of young adults and their own families are thought; making use of nationwide guidance to aid medical training.Keywords: anorexia nervosa, adolescent girls, kid fatalities, despair in youth, consuming problems, household therapy> Read the overview report

2017 – Sunderland – Family X

A multi-agency approach is best delivered through a child protection plan that adopts SMART planning techniques; when working with chaotic families it is important for professionals to remain focused on the children and their voice.Recommendations: to develop a clear neglect framework, assessment tools, processes and practice models; to work with the Children’s Strategic Partnership to develop and implement a model for assessing capacity to change; to oversee the introduction of quality assurance processes which ensure that children subject to child protection plans remain categorised to the most appropriate source of risk; and in order to maintain a focus on the voice of the child in practice around neglect, findings of recently completed audits on the Voice of the Child and Section 11 must be acted on.Keywords: child sexual abuse, disguised compliance, listening, neglecting parents, optimistic behaviour, parenting capacity> Read the overview report in 2014 a large sibling group were removed from parental care because there were concerns they had been exposed to and were suffering from chronic neglect.Learning: better outcomes would be achievable for children at risk from neglect if multi-agency activity was underpinned by a common assessment tool; to focus on parental capacity for change to avoid drift in achieving positive outcomes for children; where children are at risk of harm

2017 – Sunderland – Young Person Rachel

Circumstances resulting in a girl that is 15-year-old positioned in a protected environment in summer 2015. Learning: better understanding by experts and professionals associated with the interplay between adolescent choice and risk, particularly in reference to intimate behavior and sexual exploitation; need for multi-agency assessments which concentrate on the child’s care and experiences; kid sexual abuse into the household will frequently arrive at the interest of solutions because of a additional presenting element; the number and nature of adolescent risks will vary to those dealing with younger kids while the old-fashioned reaction to such dangers doesn’t necessarily match young people’s lived experience. Guidelines: enhance skills and knowledge foot of the children’s workforce making sure that professionals are better equipped to recognise and answer abuse that is sexual the wider family; make sure solutions to young kids with harmful intimate behavior are proportionate and prompt; enhance the effectiveness of multi-agency practice with adolescents that are at an increased risk as a result of substance abuse along with other risk taking behaviours and/or abuse and exploitation. Keywords: adolescents, youngster intimate exploitation, danger using > Read the overview report website link

2017 – Surrey – Adult S and Child CC

Loss of a 14-year-old woman and her mom, have been both killed because of the girl’s daddy, who later committed suicide.Learning: supplied in the shape of analytical findings, such as: personal wellness solutions have now been reluctant to share with you information; police failed to check into the clear presence of kiddies when called towards the domestic punishment event; some missed possibilities were noted when controling exactly the same incident.Recommendations: authorities to analyse their reaction to domestic punishment incidents; community interventions making use of the notion of co-production become trialled; the separate school to incorporate domestic understanding in safeguarding domestic abuse; HM Government to produce statutory guidance to add personal health care bills and oblige them to take part in DHR procedure.Model: this might be a joint Domestic Homicide Review and Serious Case Review.Keywords: family physical violence, filicide, homicide, authorities, suicide> Read the report that is overview

2017 – Surrey – Child BB

Loss of a 23-month-old youngster in might 2014 as a result of non-accidental injuries.Key issues: Child BB had been taken up to medical center in a state of extreme physical collapse, with bruises and burn marks, and died the day that is following. Criminal charges were brought up against the mother along with her partner in March 2015, nevertheless the partner committed suicide prior to the test. Mom was found not liable.Learning: better interagency work and closer interaction between authorities, probation services and children’s solutions might have led to a significantly better knowledge of the behavior for the mother’s partner; safety communications on dating sites concentrate on the users’ individual security although not on potential dangers after a relationship is made.Recommendations: consist of: authorities, probation solution and children’s services to examine procedures for liaison about incidents and call-outs with regards to domestic physical physical violence; nationwide consideration be provided with to just exactly how moms are alerted towards the dependence on care when participating in brand new relationships with formerly unknown males, potentially by having an increased exposure of relationships made through internet online dating sites and social media.Keywords: kid deaths, real abuse, online safety, domestic punishment> Read the overview report