The Child Safeguarding Toolkit has been developed to raise awareness about the key risk factors identified in the analysis of Serious Case Reviews and the Child Safeguarding Practice Reviews (local and national) since they were introduced under Working Together 2018.
The risk factors apply to all contexts of child and family practice; mental ill health, domestic abuse, alcohol or substance misuse, and parental criminal records as well as other adverse childhood experiences featured strongly as contributing factors in these reviews. Domestic abuse and violence was a common finding and the levels of criminal activity and the violence witnessed or experienced by children was highlighted as a major concern.
The Child Safeguarding Practice Review Panel's first annual report 2018-19 shares information about the children who died or were seriously harmed.
Age of children for serious child safeguarding notifications to the national panel:
The Panel identified 21 adolescents from 17 localities who died or were seriously harmed within a context of criminal exploitation.
The following key practice improvement themes were highlighted:
The 2016 report entitled Sudden Unexpected Death in Infancy and Childhood: the Report of a Working Group, convened by The Royal College of Pathologists and The Royal College of Paediatrics and Child health, identified a list of non-exhaustive factors that could suggest a death was suspicious and could provide supporting evidence of Non-Accidential Head Injury (NAHI):
All of the surrounding evidence must be fully considered by a prosecutor before a decision can be made on the evidential sufficiency of any case in accordance with the Full Code test in the Code for Crown Prosecutors. Further details are available on this link.
NSPCC SCR summary identified the following risk factors and learning for improved practice:
1. Risks associated with premature births
2. Professional optimism may lead to risks being underestimated
3. Poor risk assesments
The following key points were identified in the most recent Triennial Analysis of SCRs:
Using research to benefit children
An animation, guidebook and set of videos about childhood trauma and brain development have been created by University College London (UCL) in a project funded by the Economic and Social Research Council (ESRC). The resources, which are freely available, can be accessed here.
There was evidence of neglect in nearly three-quarters (208 of the 278, 74.8%) of the reports examined in the most recent Triennial Analysis of SCRs. Features of neglect were apparent in 112 out of 165 (68%) fatal cases and 96 out of 113 (83%) non-fatal serious harm cases.
Categories of neglect featuring in SCRs
The following categories of neglect featured in the Triennial Analysis of SCRs:
The following reasons for undertaking SCRs into the serious harm of death of adolescents were associated with early or continuing physical and emotional neglect:
Published case reviews highlight that professionals face a big challenge in identifying and taking timely action on neglect. The learning from these reviews highlights that professionals from all agencies must be able to:
Learning related to neglect as a key factor
The NSPCC case summary review of key factors found that in the case reviews where neglect was a key factor children died or suffered serious harm in the following ways:
It was also found that:
Risk factors for neglect in case reviews highlighted
Learning for improved practice
Elective Home Education
The first annual report of the Child Safeguarding Practice Review, highlighted that a small number involved children who were educated at home. Four of those children died, and seven children suffered serious harm through neglect.
There is a consensus that attending school is a protective factor. School is a place where children are seen every day and by many different professionals and by peer groups and other families. It is a place where early indications of concern can build into decisive action because the concerns are in plain sight. When a child is educated at home, they become separated from the protective mechanisms which school provides. In these circumstances, it becomes even more critical that other indicators of concern from other agencies are properly connected.
Poverty and Economic Deprivation
The most recent Triennial Analysis of SCRs concluded that:
“Of particular note in this analysis were indicators of poverty or economic deprivation as a feature of the case. The detailed examination of neglect cases revealed the complex ways in which the links between domestic abuse, substance misuse and poverty are 17 often inter-dependent, so that addressing a single issue does not deal with the underlying causes or other issues present. Complexity and cumulative harm was almost invariably a feature of families where children experience neglect."
The Important Role of Fathers
The analysis of neglect cases underlined the importance of understanding the experiences of parents and the perspectives and role of fathers, as distinct from mothers, and other kin caring for the child.
Phyiscal abuse is defined as:
The classification of child deaths in the Triennial Analysis of SCRs uses a ‘best fit’ assignment of where the information is pointing towards the following types of fatal physical violence against children and makes a distinction of whether there was ‘intent’ or not and follows a severe or fatal physical assault, whether intra-familial or extra-familial harm, and whether ‘overtly’ or ‘less overtly’ violent means were used.
Categories of physical abuse and violence featuring in SCRs
Challenging parents and hearing the child’s voice
Although it is very rare, parents can sometimes be deceptive or manipulative when reporting children’s health problems.
Children rely on their parents and carers to take them to medical appointments so missed appointments are always a cause for further action. From a child protection perspective, it is no longer felt that it is appropriate to use the term ‘Did Not Attend’ (DNA) when describing a child’s non-attendance to an appointment. Because it is not a child’s responsibility to attend clinic (it is their parent’s responsibility to take them), it would be more appropriate to say that the child was not brought to the appointment.
Case example from the NSPCC SCR repository
"Death of an 11-year-old boy in May 2017. Parents called an ambulance because Child X was suffering with a chest infection. Paramedics attempted to take him to the nearest hospital but parents refused and he was taken to a hospital further away. Child X suffered cardiac arrest en route and died. Child X had complex health needs since birth including cerebral palsy and epilepsy. His parents cared for him full time. He was admitted to hospital twice in May 2015 and Father questioned treatment. A Section 17 assessment was triggered in July 2015. Section 47 enquiries were initiated in January 2016 which led to Child X being made subject of a Child Protection Plan for neglect, later stepped down to a Child in Need plan. Several professionals reported aggressive behaviour by Father and parents were difficult to contact and displayed challenging behaviour. Family are Black/African Caribbean and Jehovah's Witnesses.
Lessons learned include
The NSPCC summarised the following SCR learning to improve practice with the overriding principle of GPs and other health professionals having a family focus:
"Knife crime affects people of all ages and backgrounds across the country, and all too often both perpetrator and victim are young people. However, throughout our inquiry we heard evidence that a young person’s risk of getting involved in knife crime is dramatically different between different groups of young people. Young people who for example experience mental health issues, adverse childhood experiences, have learning difficulties, live in poverty or are excluded from school are more likely to be vulnerable to involvement in knife crime."
"Education has a major role to play in tackling knife crime. Not only through teaching the dangers, risks and consequences of involvement in knife crime but also to facilitate contact with the local police and through safeguarding a child who may be at risk".
Key learning points
The NSPCC case repository include the following recent cases:
Death of an adolescent boy due to a fatal stabbing.
Death of a 15-year-old boy in May 2019 as a result of being stabbed.
Case reviews highlight that the warning signs of teenage suicide are often overlooked as typical adolescent behaviour. This means that young people are not always receiving the help that they need. The learning from these reviews highlights that professionals should take young people talks about suicide seriously and work hard to engage with and support young people.
Suicide is rarely triggered by a single event. It is the result of an accumulation of adversities over time. Issues often referred to in cases included:
Case reviews involving suicide nearly all related to adolescents, and the majority related to boys.
The case reviews identified a number of warning signs that a young person was considering suicide. These included:
Every warning sign of suicide should be taken seriously and acted on accordingly.
The first annual report of the Child Safeguarding Practice Review panel highlighted the following learning from Rapid Reviews:
The triennial analysis of SCR highlighted that:
"One example of neglect and subsequent suicide included in the reviews is that of an adolescent who took a fatal dose of opiates aged 15 years. Born with serious narcotic withdrawal symptoms into a family with a long history of substance misuse, sex work, alcohol-fuelled violence and domestic abuse, the harmful influence of the family shaped this child’s life. Signs of distress and self-harm were first identified by a schoolteacher when the child was 12 years old. When asked about the cuts on her arms the teacher reported being told ‘when I am feeling this pain, I am not feeling anything else’. Examples of self-harm escalated to the extent that prior to the fatal overdose, 32 episodes had been recorded. Although all the professionals working with this child were aware of her extreme vulnerability, there was little recorded of what life was like for her or her perspective, views and wishes, in the SCR."
The vulnerability of babies and the significance of injuries to this age group was listed as key learning in numerous survey responses and interviews with professionals involved in the management of serious child safeguarding incidents, and examples to address this were:
The Royal College of Paediatrics and Child Health (RCPCH) refers to the systematic review on abusive and non-abusive bruising in children (2016), and findings included:
RCPH expects designated and named professionals to be key partners in formulating local safeguarding procedures on the issue of management of bruising in pre-mobile infants, and suitably qualified healthcare professionals to be present at all strategy discussions/meetings about potential inflicted injury.
The consultant paediatricians’ role in contributing to the assessment of potential inflicted injury in pre-mobile infants is an essential one, bringing to bear their clinical knowledge and experience of accidental injury as well as inflicted injury, along with a knowledge of potential underlying medical causes which may require further intervention.
The NSPCC case review repository abstracts summaries the following SCR key learning for practice improvements:
Summary of risk factors and learning for improved practice around child sexual abuse
The learning from the NSPCC case reviews briefing looks at case reviews published since 2017, where children experienced sexual abuse. The reviews suggest that professionals are sometimes slow to identify sexual abuse as an explanation for a child's behaviour or medical presentations – particularly when other explanations are offered. The learning highlights the importance of:
Case study from the Triennnial Analysis of SCRs (2014-2017):
Stacey is a White British girl aged 15. She lived with her mother and stepfather who was a known and convicted sex offender. The stepfather was involved with the family for 10 years and sexually assaulted Stacey on two occasions. She had poor school attendance from the age of 5 years (at times as low as 50%), unspecified behaviour issues and experienced bullying at school and in the community. The GP saw Stacey for a number of minor illnesses and her school mistakenly believed that her poor attendance was because of various illnesses. There was no school/doctor liaison.
The mother suffered from a chronic but manageable illness, which she exaggerated, and Stacey worried about her dying. Both the mother and maternal grandmother had experienced sexual abuse. Children’s social care were involved with the family for eight years during which time they drew up four written agreements: 1. After stepfather indecently assaulted a child related to Stacey, the mother had to promise she would not allow unsupervised contact between Stacey and her stepfather (they all lived in the same home).
Mother physically assaulted Stacey and she had to promise not to use physical punishment. Stacey had an unexplained bruised eye and a third agreement specified similar actions to the ones above. The fourth written agreement was drafted without regard to the knowledge that all previous agreements had been breached. Stacey was assumed to be safe staying with her maternal grandmother who undertook not to allow stepfather contact with Stacey.
Life for Stacey continued to be the same despite written agreements and agencies being aware that agreements were not adhered to. CSC closed her case, preventing effective monitoring of agreements whereas the intended consequence of non-compliance with the agreements was that an initial child protection conference would be convened.
Other agencies were reassured by a written agreement and saw it as evidence of parental commitment to keep the child safe. The mother and stepfather later said that they did not understand the agreements as they were not explained in terms they could understand.
Key learning points:
Between 29 June 2018 and 30 June 2020, the Child Safeguarding Practive Review panel received 757 rapid reviews relating to child abuse and neglect. Of these:
This lead to a national review of Safeguarding children at risk from sudden expected infant death, which is available here.
The Royal College of Pathologists SUDIC multi-agency guidance for care and investigation is here.
The Safeguarding children at risk from criminal exploination
The national review sets out recommendations and findings from government and local safeguarding partners to protection children at risk of criminal exploitation. It involved 21 cases from 17 local areas regarding children who died or experienced serious harm where criminal exploiation was a factor.
The national Panel's Safeguarding children at risk from criminal exploitation report can be accessed here.
The NSPCC summary report can be accessed here.