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SCR E-Learning

 Introduction to the e-learning

The e-learning course is hosted on the Virtual College free e-learning courses web page, and can be accessed here.

Course description

This Learning from SCR course will equip all those who come into contact with children with the knowledge and understanding they need to respond to neglect, abuse and extra-familiar harm to help prevent future serious child safeguarding incidents. It takes a child centred approach which means keeping the child in focus when making decisions about their lives and working in partnership with them and their families, to ascertain what life is really like for them on an everyday basis. This is illustrated through the real lived experiences of children who have experienced neglect, abuse and extra-familiar harm and feature in SCRs published in the last 2 years. It is designed to support all practitioners working across the partnership, embedding the knowledge and understanding of legislation and related guidance and protocols.

How was it developed?

The content was developed by safeguarding professionals in the London Borough of Sutton as a joint project with Virtual College - a digital training provider with more than 25 years’ experience behind them. They work closely with a number of Local Safeguarding Children Partnerships (LSCPs) across the country.

 What does it include?

The course modules contain up to 10 case scenarios based on the following eight SCR themes:

  • Brain injuries in infants ('shaken baby')
  • Neglect
  • Physical injuries
  • Complex health needs
  • Fatal stabbing
  • Injury in pre-mobile babies
  • Self-harm and suicide
  • Child Sexual Abuse

Each course scenario is followed by a range of exercises to apply the learning - the responses draw on the learning from published SCRs and makes reference to legal requirements set out in Working Together to Safeguard Children 2018 and Keeping Children Safe in Education 2020

Who is it for?

The target group for the course are the following roles:

  • Social workers
  • Teachers
  • Health professionals
  • Police
  • Probation officers
  • Housing officers
  • Youth workers
  • Safeguarding leads
  • CAFCASS roles
  • Students
  • Academics
  • Commissioners
  • Others who have a role to promote the welfare and safeguard children

What levels of training needs will it address?

The course allows learners to select the level of training which best matches their training needs based on relevant levels of responsibilities. Anyone can progress to the next level to advance their knowledge and understanding.

Introduction (for everyone) -contains a shaken baby animated case scenario followed by a “what happened next” animation of the serious child safeguarding incident process. It has a downloadable flowchart for the management of serious child safeguarding incidents.

Level 1 - where you only need to know how to identify needs, respond and refer safeguarding concerns

Level 2 - where you have safeguarding responsibilities within your organisation that requires awareness rather than specialist knowledge and skills

Level 3 - where you are in frequent or direct contact with children who may require a child in need assessment, or already have assessed needs; and you may be, or regularly attend multi-agency planning or review meetings in your professional role

Level 4 - where you have a specialist safeguarding role, or an operational or strategic decision making role, and/or are involved in research, quality assurance and practice development work
What impact will the course have?
The course is intended to raise awareness about the critical learning from Serious Case Reviews - potentially it can help save lives by equipping those who come into contact with children with the knowledge and understanding they need to identify and refer concerns, assess and intervene and work effectively within the multidisciplinary safeguarding system.
What learning objectives will be achieved?
After completing the e-learning module you will have learnt:
  • To recognise the most common risk factors relating to neglect, abuse and extra-familial harm that feature in serious child safeguarding incidents;
  • How you have a role to promote the welfare and safeguarding of children within the context of multi-agency working;
  • Why the 10 key principles of learning from SCRs are critical to keeping children safe, and how they apply to your role;
  • Why children's rights to have their wishes and feelings listened to in decision making that affect their lives matters;
  • The importance of knowing and understanding the legal and policy frameworks, to fulfil statutory responsibilities;
  • How the management of child safeguarding incidents process works, from the point of an incident notification to undertaking a Child Safeguarding Practice Review (local and national)

How will I be able to evidence the learning?

After the completion of this course, a self-printed certificate will be issued to evidence the learning.

How do I access the free e-learning course module?

The e-learning course is hosted on the Virtual College free e-learning courses web page, and can be accessed here.




Matthew, a six-month-old twin baby, is admitted to hospital with a fractured skull and is in a critical condition. The paramedic described the baby as ‘floppy’ and unresponsive when called to the home address. Matthew was assessed by the paediatrician in the emergency department (ED) and the initial assessment identified a significant brain injury. There was no forensic evidence or witnesses to assist the investigation, however, the paediatrician felt that the likely mechanism was ‘shaking’. 

Matthew’s mum Chiara, discharged herself from hospital the day after the twins were born. The twins had been born prematurely and were diagnosed as having neo-natal abstinence syndrome, described as a group of problems that occur in a newborn exposed to addictive opiates while in the womb. They received appropriate treatment, including use of morphine. Chiara visited regularly and provided care. 

During this period the first Child Protection Conference (CPC) review made the decision to remove all four children's names from the Child Protection plans (CPP) and step down to Children in Need. 

The twins were discharged to the family home to live with Chiara and their siblings. The discharge plan outlined the required pattern of visiting by agencies, including an Early Help worker to support with practical tasks. Chiara's brother and her adult son were regarded as playing a significant role in supporting her in caring for the four children.

Concerns were raised when Chiara left the twins in the care of others, who were regarded by agencies as unsuitable carers. It also became known that Chiara was again using heroin and close family members raised concerns about her drug use. They shared information about one of the twins falling from her knee while she was injecting.

Prior to the incident, it is known that five people had, or potentially had, care of him in the previous 24 hours. 

The other children were removed into care following medical opinion that the injury was a non-accidental injury. Following Matthew’s discharge from hospital, he joined his three siblings, who had remained in the care of a family member. 

The relationship between Chiara and the twins' father had ended before their birth. It is unclear as to whether he ever lived in the same house as Chiara. 

The older children were described very positively by their teachers. However, it was known that they had been exposed to domestic abuse and had lived with adults, including their mother, with problematic drug use. There is information to suggest that they had seen their mother injecting. Information indicates that she had, at times, found it impossible to prioritise the needs of her children.

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Billy was involved in a road traffic collision, and the Police and Ambulance services attended the incident. He had suffered a significant head injury and the ambulance crew needed to support his breathing at the scene of the accident. 

Billy also suffered a fracture to his left leg and was admitted to paediatric intensive care. He required surgery and medical treatment for the injuries he had sustained. 

He was known to Children’s Social Care and an urgent strategy meeting was held. 

In the meeting, the social worker reported that Billy’s mother, Maureen, had a long history of substance misuse, and that there were three children within the family. All children were on a Child Protection Plan (CPP) after the birth of the youngest sibling. As part of the CPP, Maureen was referred to the substance misuse services to help her meet the health needs of the youngest child. Children’s Social Care had difficulty completing an assessment and actioning a risk management plan. Professionals were unable to persuade Maureen to access services to address her longstanding drug problem. 

The Police had previously responded to two incidents when Billy, and other children, were found on the busy dual carriageway unsupervised. The Police returned the children home and gave Maureen advice about safety and supervision. A referral was made to the Multi-Agency Safeguarding Hub (MASH) on both occasions, but it was assessed as not meeting the threshold for statutory intervention.

Following the second incident, the Early Help team initiated an early help assessment which focused on Billy’s behaviour, concerns for the safety of the children, parenting capability, and the family’s finances.

Maureen approached school around the same time, because she was concerned about Billy’s behaviour at home. She said he was not listening to her, playing away from the house, and getting into fights. The school allocated a Parent Support Advisor (PSA) to give practical advice on good parenting, for example, how to set clear boundaries for behaviour. The PSA also provided Billy’s mother with a ‘golden book’ so she could record positive comments about Billy. This was to help reinforce good behaviour and encourage adherence to the newly established boundaries. However, the book was never completed.  

Prior to the last incident, the Family Practitioner had found Billy with two younger children ‘wandering’ unsupervised. The family was no longer open to the Early Help team due to Maureen withdrawing consent. Billy was returned home and the worker spoke with Maureen and advised her that she would make a MASH referral, which she did the same day. 

When it was assessed that the referral did not meet the threshold for statutory intervention, it was passed to the Early Help officer in the Multi-Agency Safeguarding Hub (MASH) who supported the school to organise a Road Safety Officer to work with Billy either on a 1:1 basis or in a group at school. It was also suggested that the school forge links between the Police, Road Safety Officer and Maureen. 

Billy’s behaviour both at home and school continued to deteriorate. He had poor focus in class and started to arrive at school tired and with dark circles under his eyes. Prior to the road accident, he had been observed to be unsupervised on the dual carriageway and was seen in the company of three older boys.

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Daisy was the youngest of five children. She was described by a number of  professionals  as lively and sociable. When Daisy was two years old, an ambulance was called to her home, and on arrival she was found to be blue, not breathing and in cardiac arrest. Paramedics commenced resuscitation. 

The crew were informed by the family that Daisy had consumed some of her mother's, Chloe’s, methadone. There was a suspicion that there was a delay in seeking medical attention. Her mother had attempted to make Daisy vomit before she lost consciousness. 

Daisy had been born at home, but was subsequently admitted to the hospital for a paediatric assessment, as she had a cleft lip, a tremor, and a raised temperature. She was diagnosed with neonatal abstinence syndrome (NAS), requiring medical treatment to aid her withdrawal.

Both parents were engaged in a drug treatment programme, with known intermittent substance misuse episodes. There were reports of three domestic abuse incidents that were reported to Children’s Social Care by the Police. 

Substance misuse services reported concerns that Chloe continued the use of illicit methadone in addition to her prescribed prescription. Chloe was asked to come in to collect her prescriptions to ensure that she was seen by staff. 

Following the methadone ingestion, Daisy was transferred to the local emergency department, and died shortly after arrival. At the time of Daisy’s death her parents were separated.

All professionals had observed good bonding and relationships between parents and children. 

The family had contact with 21 different health services and there was consistent poor attendance at health appointments for all the children, some of whom had significant health needs. The parents had a history of delaying or not seeking medical attention for the children when required.

There were 16 referrals to Children’s Social Care, 7 initial assessments and 1 core assessment. There were also low level concerns for attendance at school and varying views of home conditions. There were further reports from professionals, at different times, about the home cleanliness, heating, lack of furniture and general concerns about the condition of the house. At other times all was well. 

The children were on enhanced health visiting support, and shortly before the incident, the health visitor made a failed home visit. She sent Chloe a text and offered a visit.

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Kieran was a well cared for six-year-old boy who suffered severe damage to his brain, had abdominal bleeding and bruises to his face and later died in hospital. 

Anna, his mother, was described as an attentive parent who responded to his needs and encouraged him to learn and develop. He was meeting his developmental milestones, apart from his speech, and was making good progress at school. 

He was always clean, well dressed and well groomed. Staff at the school, who knew him well, had no worries about him or his care.

Anna was granted a one-year student visa, but when this expired she remained in the UK as an ‘overstayer’. The terms of her visa stated that she had no recourse to public funds (NRPF). Kieran was assessed to be a ‘Child in Need’ under Section 17 of the Children Act 1989 so that support could be provided to Anna with her immigration status, and temporary accommodation was provided for her and Kieran. 

In the past, the Police had carried out a welfare check, following an anonymous telephone call reporting a domestic disturbance at the home. Kieran’s father explained he was only visiting as he had recently separated from Anna. A police merlin report was completed and advised that Kieran’s father was not to have direct contact with Anna, but there were no restrictions on having contact with Kieran. 

The health visitor had supervision and was advised to find out about the addresses where Anna and Kieran were residing. Anna informed the health visitor that she was due to spend a few days at Kieran’s father’s house. The health visitor made a record of this, but did not share the information. Anna was then transferred to the NRP team. On a following visit to the house where Anna and Kieran were staying, the social worker was informed that they were staying with a friend. 

Subsequently, Kieran started nursery, but they were unaware of Children’s Social Care involvement or that he was on a Child in Need (CIN) plan. His father regularly collected Kieran from nursery. 

Anna’s initial application to the home office was declined, however, with letters of support from the GP and social worker, she was granted leave to remain. She was supported to move into privately rented accommodation. 

A neighbour encouraged Anna to write to a friend called Ben, after Ben initiated contact with her in a handwritten letter from prison. They exchanged several letters, but his calls and letters were only monitored for the first month of his stay in prison. Anna said that her ‘boyfriend’ begged her to go and see him in prison and she visited him several times before his release. 

When Ben was released from prison, a probation officer saw him and there was a discussion about living in approved premises (AP). Ben was recalled to prison after being sentenced for common assault against his previous partner. He was described as being ‘high risk of harm to previous and future partners’. 

There were no restrictions on visits or letters in prison. The probation officer was unaware of Anna’s visits, so did not alert Children’s Social Care, who would have completed checks in relation to Kieran. 

When released from prison, Ben was on licence to the National Probation Service, followed by post-sentence supervision.

There were several conditions attached to his licence, including:

  • No unsupervised contact with under 16s without the prior approval of the supervising officer and social services;
  • Attendance at an offending behaviour programme, including a domestic abuse programme, as directed by the supervising officer;
  • Agreement to notify the supervising officer of any developing relationships with women.

The probation officer sought managerial advice to discuss:

  • Ben's failed appointments;
  • The fact he refused to give an address of where he was living;
  • That there was a high risk of domestic violence;
  • The suspicion that he was living with his partner and her child (Kieran).

At this point, he could not be recalled to prison as the licence period had ended and he was the subject of post-sentence supervision. It was agreed that he should be returned to court for failing to attend appointments. This was not proceeded with, as he later produced medical certificates for the absences. 

Ben continued to meet with the probation officer who stressed the need for him to attend these appointments, so that they could do some focused work on domestic violence. It was recorded that Ben had shown some insight, but that his motivation was not completely genuine. 

Ben failed to attend his appointment, but the probation officer decided not to send him a warning letter as he felt that they had developed a working relationship now, and a warning letter might damage this. 

Four days later, Ben assaulted Kieran who was taken to hospital and died two days later. He was later convicted of Kieran’s murder and sentenced to life imprisonment. Anna was unaware of his violent past.

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Alex was diagnosed with cystic fibrosis (CF) as a one-year-old, and was an active and lively child who enjoyed school. Although he had a common form of the disease, complications set in early, and he wanted to be involved in all aspects of the care provided.

Alex’s hospital admissions increased after the age of six-years-old and there were 14 admissions, three of which were emergencies in the last four years of his life.

Clinical care was led by the local children’s hospital and the professionals involved included: physiotherapists, psychologists, respiratory medicine clinicians, endocrinologists, dieticians, diabetic nurses, specialist play and youth services workers and CF nurses. There were also numerous contacts with the GP, social workers and the school.

A number of clinical specialists visited the home and school to work with school staff, and in the last year the school provided some elements of clinical care, including physiotherapy and diabetic care whilst Alex was in school.

Alex’s parents, Jessica and Martin, had separated early in Alex’s childhood and it was believed that domestic abuse and Martin’s alcohol problems were a factor in the break up. Alex continued to have contact with Martin, arranged through the court, and a restraining order was in place due to harassment. During this period Alex was made a Child in Need (CIN) and information was shared from Multi-Agency Risk Assessment Conference (MARAC).

Children's Social Care provided financial support and supported day care for Alex’s younger siblings, Bobbie and Stevie. It was assumed that Jessica was able to safeguard the children based on the fact that she reported all domestic violence incidents to the Police.

This meant that only his siblings were considered as children in need and Alex’s case was closed, without any contact having been made with clinical staff.

Aiden, his step father, became a key figure in Alex’s care and had considerable influence in decision making, engaging with staff in hospital and school, giving the impression that he had parental responsibility.

Clinical staff became concerned about Jessica and Aiden’s lack of engagement and alertness to Alex’s needs, and he was brought in very late for treatment on one occasion. On another occasion, Jessica had run out of steroids three days previously, and his medical regime had been disrupted due to prescriptions not being renewed.

The paediatrician was concerned about lack of weight gain and failure by Jessica and Aiden to prioritise his needs. The importance of sleep, structure for the day, getting Alex to appointments and paying attention to prescriptions and medication was explained to them.

The school initiated a Common Assessment Framework (CAF) meeting in an attempt to coordinate a family support plan and concerns were raised about whether physiotherapy was undertaken at home. This was essential for his care and later, physiotherapy was carried out at the school.

Martin had told police that Aiden had hit Alex and that he did not have physiotherapy at home. When the social worker made a home visit, Jessica and Aiden provided a plausible explanation and no further action was taken.

At the time Aiden was experiencing suicidal ideation and was finding the children’s demands very difficult. He was being treated by the GP and Psychiatrist, and he also spoke of an unhappy childhood.

Concerns continued to mount and the Cystic Fibrosis consultant made a formal child protection referral. The Police also informed Children’s Social Care of a call out for domestic abuse toward Jessica from Martin. He in turn, reported that Aiden had been arrested previously for assault towards a minor and that the children had told him that Aiden was ‘beating up mummy’.

The referral resulted in an initial assessment by Children’s Social Care and a Team Around the Family (TAF) meeting. Jessica fully cooperated with the plan and there were no observations in relation to problems of deficits in the care provided to Alex.

Further incidents were reported and the children’s behaviour at school deteriorated, there were repeated failures to bring Alex to appointments at the respiratory clinic and following a planned admission Jessica did not bring essential medications. The consultant explained that Alex's liver may be deteriorating and Jessica and Aiden responded that ‘they were tired of getting bad news’. Jessica complained about ‘treatment overload’ and that she found Alex’s care needs overwhelming and complex.

The pattern of non-compliance continued and the respiratory nurse instigated a CAF meeting with NHS colleagues due to worries about Alex and the family. Jessica and Aiden reported finding the treatment very difficult. They also said that Alex had behavioural issues, including low moods, scratching his arms, leaving marks and inducing vomiting when distressed. He was also not interacting with the family. Aiden asked if insulin could be stopped, as this was seen as a trigger for negative behaviour, it was explained that this was not possible.

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Archie arrived in the UK aged 11, initially living with his adult sister and three older siblings. He was enrolled into a local school but not the same school as his siblings as there were no places available in his year group.

Six months later, his sister died in a house fire which had a traumatic impact on Archie and his behaviour and attendance at school began to deteriorate. His mother became frustrated with agencies and began to reluctantly elect to ‘home educate’ her son while awaiting a choice of a new school.

Archie was detained, along with a male of a similar age, at a department store, and both boys admitted to the offence of shoplifting. Restorative justice was applied which included a condition to engage with the Community Youth Team. In the following months, there was a rapid and significant increase in the level of offending involving Archie. The offences were serious and involved use of violence and carrying knives, and he was frequently reported as missing and had become involved in gang culture.

An Initial Child Protection Conference (ICPC) was convened and Archie was made subject to a Child Protection Plan (CPP) under the category of physical abuse and he was subject to a Child Protection Plan at the time of his death. He was taken by ambulance to the Hospital Emergency Department with two stab wounds to his chest and sadly died as a result of his injuries.

His mother believed that it was inevitable that Archie began to hang around on the streets and go missing when he was removed from school, which also impacted on him playing for a local football team. She gave up work as she could not leave him at home all day when not in school, and she was also suffering poor physical and mental health. On several occasions she went out searching for her son and found him with older boys or young men, and he would usher her away to try and protect her.

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Darry had exhibited behavioural and language concerns at secondary school which led to a move to a school for children and young people with special educational needs at age 15.

The new school soon became concerned about Darry showing increased anxiety, low mood, lack of interaction with peers and self-harm, and referred Darry to CAMHS learning-disability team.

Two years later, when Darry was almost 18-years-old, her mother contacted CAMHS to report that her daughter had run away and expressed suicidal thoughts. She was advised to call the police who found Darry in a distressed state with self-harm cuts to her hand.

The police detained Darry under Section 136 of the Mental Health Act 1983 and took her to the hospital, where she was assessed under the Mental Health Act by a child and adult psychiatrist and a mental health social worker. Darry was assessed as lacking capacity and it was agreed that Darry would be reassessed the next day with her mother present to see if would help Darry feel more comfortable and able to talk.

The hospital social worker contacted the Children’s Social Care duty team, the children with disability team and the adult community learning disability team and all responded that they could not see what role they would have. An arrangement was made with the Intensive Support Team (IST) from the adult mental health services team to provide support despite this not being within their remit. Professionals from the IST made a home visit but found that Darry was unable to communicate, but she did agree to listen whilst her mother and her maternal aunt shared that Darry had been physically and emotionally abused by her father.

IST had no further involvement with Darry or the family and provided verbal feedback to CAMHS about their involvement. The family were seen at home by the CAMHS team but the support was not reviewed in response to the incident.

Darry’s school contacted CAMHS at the end of term as they remained significantly concerned about her. CAMHS confirmed that they continued their plan of support.

Darry ran away from home again and was found by the police in a distressed state unable to speak. They took her home and it was reported that she refused to take her medication.

Darry was taken for a CAMHS appointment the following day but ran away again and tried to take her own life. She survived but now has life changing physical injuries.

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Baby Adam was approximately six-weeks-old when bruising was first reported by his mother. Nothing abnormal was reported by the GP, so no further action was taken.
During a second visit to the GP, a small area of bruising on Adam’s right arm was confirmed by the GP. The haematology report indicated a possible abnormality and the results were filed without any further action being taken.

Adam was taken back to the surgery by his mother when he was just over two-months-old. An examination recorded bruising and swelling over the temple region of his head, and under his eye, and red marks on his left leg. The GP contacted the hospital immediately to arrange for a paediatric assessment and advised that a non-accidental injury (NAI) needed to be considered.

Adam was taken to the hospital by his parents on the same day. The paediatric registrar thoroughly examined the baby, taking a full history and recording all details, including a body map of the bruises. The nurse contacted the emergency duty team (EDT) and Children’s Social Care confirmed that the family was not known. The parents could not explain how the bruises might have occurred.

Adam was admitted to the paediatric ward for medical investigations and the nurse made a child protection referral to Children’s Social Care. The consultant paediatrician, employed in a safeguarding advisory role, confirmed that the bruising was most probably due to a bleeding disorder.

The blood tests and X-rays were returned with normal satisfactory results, which was interpreted as a positive sign. The skeletal survey was reviewed by another paediatric radiologist and a written report stated that there was ‘no conclusive evidence of NAI’. Adam was discharged home by the consultant paediatrician with an instruction to return to the clinic in one month for a review.

The mother contacted the GP and health visitor to report more bruises on Adam’s body and that he cried as if in pain when he moved. This information was not shared as Adam's mother had told the health visitor that social care was awaiting the outcome of the medical tests.

The report on the repeated chest and leg X-rays stated that healing fractures on the rib, a sign indicative of NAI, led to Adam being recalled to hospital. The paediatric examination on re-admission identified swelling over the left rib area. Adam was being depicted as a baby ‘who bruised easily’ and his parents were described as ‘appropriate, concerned, cooperative and compliant', at this point, medical causes were still being pursued.

Children’s Social Care advised the paediatrician that in the face of no other explanation, a child protection strategy meeting would need to be convened. The invitation was declined by the Police due to the lack of medical evidence to support a Child and Protection Investigation. The conversation was recorded as a ‘strategy discussion’, this resulted in a ‘professional meeting’ being held rather than a strategy meeting under section 47 of The Children Act 1989. The meeting was attended by health professionals, social care and Adam’s parents.

The outcome of the meeting was that the threshold of actual or likely significant harm had not been met. The decision was influenced by the view of professionals that the unexplained fractures and bruises could not be assigned to the care given by either of his parents. Adam was discharged home on the agreement that a Child in Need (CIN) assessment would be undertaken by Children’s Social Care.

A routine paediatric multi-disciplinary team (MDT) meeting identified that Adam might have been discharged home to an unsafe environment, risking further harm. Adam was re-admitted to hospital and a repeat skeletal survey was undertaken.

Children’s Social Care convened a strategy meeting which was attended by social care, police and health, including the consultant paediatrician with lead case responsibility for Adam. The outcome was to undertake a Section 47 Child Protection Investigation.

A plan was formulated that included a child protection medical for sibling Isaac and an agreement for Adam to remain in hospital whilst enquiries were in process. Instructions were also given to apply for an Emergency Protection Order (EPO) should the parents try and remove Adam. A legal planning meeting decided to initiate care proceedings and Adam was discharged from hospital into the care of his grandparents under an Interim Care Order (ICO).

Adam has made a full recovery. 

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 Rose and Saffron

Rose and Saffron

Rose and Saffron’s family have had a long history of Children’s Social Care involvement due to concerns about neglect. It involved long periods of the children being subject to a CPP and stepping down to Child in Need (CIN) plans, and then closure.

Concerns began to re-emerge shortly after the closure of the CIN plans and a second period of child protection planning followed. Legal proceedings commenced and following a multi-agency decision that the Child Protection Plan (CPP) did not achieve the changes that were required to safeguard the health and development of Rose and Saffron.

After the children were removed into care, they began to talk about being sexually abused in their previous home life.

The girls were aged between three to nine years at the time the child sexual abuse was first reported.

The children’s individual statutory care reviews initially focused on their care needs rather than giving attention to the disclosures. Professionals first decided that it would not be in the children’s best interest to be medically examined as it would be unlikely to produce credible forensic evidence or would not be seen as needed. Examinations eventually took place more than two years after the children made the allegations.

A complex and lengthy investigation followed due to protracted disclosures by the children, delays in the ability to interview the mother due to health issues, and delays in disclosure of material to the criminal investigation.

There were limitations to therapeutic work that could be started in case the children were required to give evidence in criminal proceedings, and the need for therapy to adhere to Crown Prosecution Service Guidance.

The children were also aware that their mother and her partner were subjects of protracted criminal law proceedings and this had an adverse effect on the children’s emotional wellbeing.

The children’s mother and her male partner were subsequently convicted of multiple offences of sexual abuse relating to both children. There was no evidence that the mother was manipulated or targeted by the perpetrator although it was recognised that she was a woman with significant vulnerabilities.

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Madison lived with her mother, stepfather and four half-siblings in an area with relatively low levels of deprivation. Madison’s birth father died when she was not yet two. Her stepfather is self-employed, worked long hours and was the primary source of income for the family.

Madison was only a few months old when concerns about risk of harm in relation to domestic abuse were reported to social care services. Section 47 enquiries was undertaken but the case did not progress to a child protection conference.

Paediatric services had contact with Madison for several years in regard to slow physical growth and speech development, falls and headaches.

When Madison started primary school there were referrals to support services which included psychology, education welfare and speech therapy.

The concerns raised involved hair pulling, Madison being frequently hungry, faltering growth, minor or unexplained injuries and frequent absences from school. Various referrals for specialist assessment or support were declined by mother on several different occasions.

When education welfare services gave notice that Madison’s school attendance needed to improve she was moved to a different school which involved a longer journey.

The new school contacted Children’s Social Care services to discuss a bruise to Madison’s face but the outcome was no further action. A multi-agency meeting was convened by the education psychology service to discuss a number of concerns and agreed that Children’s Social Care would be invited to attend a follow up review meeting.

The mother consulted the GP about her concerns about Madison’s scratching of arms and head banging in the hope that paediatric services were going to provide a diagnosis to explain the problems. Children’s Social Care accepted a referral about the mother’s concerns that Madison had ADHD and/or autism and was self-harming (pinching).

Madison was subsequently moved to a third school on the request of her parents. They contacted Children’s Social Care to report a bruise that Madison said was the result of colliding with a table at home and concerns were raised that she was not being fed.

The community paediatrician wrote to Children’s Social Care to confirm that a referral had been made to the CAMHS and expressed concerns that Madison was being emotionally abused. The perinatal mental health consultant psychiatrist also advised the GP about concerns regarding mother’s bonding with Madison and the apparent scapegoating of Madison.

Madison was subsequently admitted for an in-patient paediatric assessment to explore Madison’s emotional responses and reasons for her failure to thrive. Mother did not visit much and although Madison was needy of physical contact she looked to receive this from hospital staff rather than from her mother. Madison had a large appetite when at hospital.

Following a home visit by the paediatrician and Children’s Social Care the parents agreed to participate in work with the family centre but continued to deny that they treated Madison differently to their other children. The parents then attempted to change the paediatrician.

Children’s Social Care services completed a further assessment which described a positive picture of relationships within the family noting that the parents refuted the view of professionals that they were not meeting Madison’s emotional needs. The assessment identified several positive aspects in parenting and the family relationships and the GP reported that Madison had gained more than two kilograms of weight. The case was closed to Children’s Social Care.

Two years later, Madison was taken to the hospital emergency department complaining of suffering pain in her chest for a week. Tests confirmed that Madison was not suffering from a significant condition or illness; a differential diagnosis of abdominal migraine was noted in the hospital records although subsequent notification to the school nurse stated that a diagnosis was unspecified. Madison continued to complain of pain.

Madison subsequently spoke to the school pastoral team and was attending secondary school at this stage. A social worker visited the school and spoke to Madison who confirmed longstanding physical and emotional abuse from mother, stepfather and half-siblings.

A strategy discussion decided that a joint enquiry by Children’s Social Care services and the Police would be conducted. It was agreed that Madison would become looked after within ten days to allow arrangements for an appropriate carer to be identified.

Madison was aged 16 and therefore in law was regarded as having the legal and mental capacity for giving or withholding consent on important decisions regarding arrangements about where she should live as well as other matters such as health care.

Madison was moved to a foster care placement with her consent. Her mother and stepfather were informed of the section 47 enquiries being undertaken. The four half-siblings were spoken to separately at school by a social worker and a police officer; none of them reported any concerns or worries.


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