Good practice identified includes: early recognition of the family’s need for enhance support by the health visitor.Recommendations include: use a standardised, objective approach to the assessment of neglect; need for a shared understanding and common language of levels of needs/thresholds, particularly following a referral to Children’s Social care.Model: uses the Significant Incident Learning Process (SILP) methodology.Keywords: infant deaths, physical abuse, child neglect, voice of the child> Read the overview report, Serious and life-threatening injuries of a 5-week-old infant girl in August 2017 due to shaking.Learning: understanding parental history and vulnerability is important in assessing actual or potential risk to children; sharing information between health professionals should be seen as standard practice, especially during pregnancy and early childhood; the practical use of information, rather than just recording it, is critical to effective safeguarding arrangements; knowledge of controlling and coercive control in adult relationships can help practitioners make informed decisions about risk to children.Recommendations: for the LSCB to ensure that there is ongoing scrutiny to evaluate how effective improvement action has become embedded into routine practice; to seek reassurance that the decision making at the point of contact and referral are appropriate and based on appropriate information sharing.Model: used the Significant Incident Learning Process (SILP) methodology.Keywords: physical abuse, shaking, crying, infants, family violence> Read the overview report, Death of a 6-month-old infant due to a non-accidental head injury in June 2016.Learning: not all professionals have the same level of expertise in all areas of practice, so use of those with expert knowledge (e.g. Child Ab and siblings were removed from the care of their mother and stepfather.Learning includes: lack of curiosity about stepfather's past, or challenge to his dominance and control; need to question and challenge whether an adult who states that they are the parent of a child does indeed have parental responsibility; importance of professionals to challenge parental non-engagement with agencies and to be alert to disguised compliance; consideration of the national plans regarding home educated children and resources to enable elective home education to be effectively assessed and monitored.Recommendations include: reinforce the requirement for professionals to maintain vigilance and professional curiosity when engaging with families where there are safeguarding concerns and a step-parent is present; consider the issue of elective home education and hidden children, which is a national issue, with a view to undertaking a future thematic review.Keywords: child abuse, home education, professional curiosity, parental responsibility> Read the overview report, Death of a 13-year-old girl of unconfirmed causes in June 2015, two days after she had been reported missing from home. This is to ensure that the needs of children in SGO placements are met wherever they are placed.Keywords: kinship foster care, physical abuse, school attendance, home environment, family functioning, medical assessment.> Read the overview report, Neglect of four siblings over a period of several years.Learning includes: when professionals do not have an understanding of the family history, relationships and functioning it is difficult to have a clear picture about what daily life is like for the children; significant decisions should be informed through key assessments being completed, including pre-birth parenting assessment and risk assessments.Recommendations include: seek assurance that the model used in assessing risk within conferences is being used effectively; seek assurance in the practice of Independent Child Protection Chairs and their management of conferences; consider establishing a practice by which CP plans should not be removed at the first review unless there are evidenced circumstances; seek assurance that the professional resolution and escalation procedure is understood and effectively applied in all partner organisations.Keywords: child neglect; non-accidental head injury; heroin; neonatal abstinence syndrome; optimistic behaviour; teenage pregnancy.> Read the overview report, Institutional abuse of children at Medway Secure Training Centre (STC) in 2015.Learning includes: create safe working cultures within organisations, including safe recruitment, policies, training and supervision of staff; ensure statutory agencies’ arrangements for responding to allegations about adults who are in positions of trust are effective in protecting children from abuse; ensure appropriate, child focussed commissioning practice by national organisations responsible for contracts for service provision within the secure estate; consideration needs to be given to ensure the advocacy service is fully accessible and there are no barriers to children raising their concerns.Recommendations include: re-launch awareness programme and training on safer recruitment processes and audit to ensure these messages are embedded; consider STC staff undertaking training in Adverse Childhood Experiences (ACEs) to better understand children’s needs and behaviours; consider the implementation of regular formal supervision processes for staff.Keywords: institutional child abuse; whistleblowing; physical restraint; recruitment; secure accommodation; commissioning of services. Jersey registered charity number AJC179. 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. most high-profile case of recent years was Connor Sparrowhawk. Keywords: child neglect, disguised compliance, listening, optimistic behaviour > Read the overview report, Death of a 3-year-old child from an asthma attack.Learning: professionals need to take into account safeguarding concerns such as the impact of smoking and home environment; health professionals need to ensure they have a good understanding around the concept of good enough care for a child with a chronic illness; consider the father’s role in caring for a child; involving the housing provider in child protection meetings where there are rent arrears and neglect.Recommendations: lead health professionals to be identified for all children with a chronic health problem with clear communication systems in place for information sharing.Model: uses a systems approach based on the Manchester methodology.Keywords: child neglect, childhood illness, low income families, smoking> Read the overview report, Serious physical assault in September 2015 of a 16-year-old girl whilst she slept. The BBC is not responsible for the content of external sites. Keywords: parents with mental health problems, filicide> Read the overview report, Harmful sexual behaviour and death of 17-year-old boy in 2015 as the result of stab wounds.Background: Child F was assessed as a Child in Need in 2011. 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. Mother was vulnerable, her own mother had suffered serious mental illness and she had spent much of her childhood in the care of her grandmother. 'A's' mother had mental health problems and 'A' had been exposed to physical and emotional abuse and witnessed domestic violence from an early age.Learning: identifies learning under three headings: choice and initiation of placement; issues arising during placement, such as identifying the need for additional therapeutic support; and transition towards greater independence including help with coping with change and his move from therapeutic care.Recommendations: the need for training around the vulnerability of care leavers for Brighton and Hove Children's Social Care; all care and placement plans should include a contingency position; and the therapeutic unit should review organisational capacity to challenge care plans if they deem it necessary.Keywords: child mental health, children in violent families, family violence, harmful sexual behaviour, parents with a mental health problem, suicide> Read the overview report, Reported deaths of 2 brothers in Syria in 2014; it is understood they went with a friend to join their elder brother fighting for the Al-Nusra Front. The mother took her own life.Learning: the need to understand the impact of a parent’s mental health on the children and how professionals should understand the possible wider impact and risk within the family.Recommendations: the LSCB should implement a multi-agency ‘Think Family’ approach; to review arrangements in GP practices to ensure the welfare of children in assessing mental health of parents and carers.Model: uses a hybrid systemic model.Keywords: child deaths, maternal depression, post-natal depression, housing> Read the overview report, Death of a 16-and-a-half-year-old boy by suicide in May 2017.Learning: experience of violent relationships and emotional abuse can undermine a child’s self-worth and resiliency; lack of case records within children’s social care material renders work more difficult and time-consuming; differing levels of anonymisation and attribution of pseudonyms / abbreviations / roles by agencies submitting reports can complicate proceedings; involving extended family through a family group conference can identify relatives whose existence and interest may previously be unknown to agencies.Recommendations: consider whether existing arrangements across the borough for a multi-agency approach are sufficient when the circumstances of especially vulnerable young people are changing frequently; GPs should include details of any adult accompanying a child / young person to a consultation in the child’s record; GPs should escalate safeguarding concerns if they do not receive a timely and reassuring response to a referral / notification made to another agency.Keywords: suicide, family violence, foster parents, accident and emergency departments, anxiety, self-harm, emotionally disturbed children, information sharing, schools> Read the overview report, Death of an adolescent girl by suicide in January 2017.Learning: CAMHS to review its use of "texting" contact and develop guidance on use to ensure it meets required governance standards; consider the development of a multi-agency locally agreed policy/protocol for the management of high risk cases of self-harm and potential suicide; signpost and make accessible information and guidance for young people and their families/carers experiencing difficulties in managing social media and the internet; CAMHS service to review how they communicate with families about the outcomes of their psychiatric assessments and ongoing formulation of the young person's mental health; explore opportunities for practitioners to gain broader experience and knowledge to promote and deliver collaborative and multi-agency approaches to the prevention of suicide and self-harm.Recommendations: makes no recommendations except those included in the learning points.Keywords: suicide, self harm, social media, child mental health services, communication, schools> Read the overview report, Death of a 7-week-old infant from non-accidental head injuries in 2015.Learning: promoting participation of parents in multi-agency meetings; information management and sharing; the need for assessments to be a continuous process including at times of increased vulnerability and awareness; understanding and implementation of key policies and procedures.Recommendations: review key policies, procedures and protocols and update as needed; educate parents regarding the prevention of head injuries to babies; promote positive and safe parenting.Keywords: infant deaths, non-accidental head injuries, information sharing> Read the overview report, Death of an 11-week-4-day old boy after sharing a bed with his parents.Learning: it is important to explore and confirm the exact circumstances of previous children’s services involvement and use that and other information to inform care planning; transferring information when children move to another area, especially if there has been statutory involvement with a child identified as a child in need or a child in need of protection, should be required.Recommendations: review the guidance and information about ‘safe-sleeping’ arrangements provided to all prospective and new parents (including fathers or partners) and to the practitioners who may work with them, and consider promoting public awareness through a media campaign; share historic information about a child, young person or family with relevant practitioners and services (where appropriate) and include this in all assessments.Keywords: sleeping behaviour, maternal depression, parental involvement, alcohol, family violence, injuries.> Read the overview report, Life-threatening head injuries and other serious injury to 20-month-old boy in April 2016.Learning includes: the focus on processes in kinship care system to collect information rather than a full analysis of information gathered led to undue optimism about a potential kinship placement at the expense of critical thinking; the decision that Highland Council would retain management responsibilities when Child T moved to England was unrealistic.Recommendations include: ensuring that guidance supports staff to lead and contribute to risk assessment generally and specifically in relation to kinship care; discussion at national level with chairs of child protection committees (CPCs) and Social Work Scotland about disclosure/vetting systems between Scotland and England; the need to value foster carers contributions in the assessment and planning of children moving to kinship care.Model: uses the Social Care Institute of Excellence (SCIE) Learning Together model.Keywords: non-accidental head injuries, kinship foster care, information sharing, child protection services; adolescent mothers; physically abused children> Read the overview report, Death of a baby boy in December 2014 aged 6 weeks. 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