Themes and Lessons

Return to Serious Case Reviews
A review of the themes emerging from Serious Case Reviews (SCR) and Management Reviews (MR) in Cambridgeshire between 2005 and 2009.


1. Context
2. The purpose of this report is:
3. Introduction
4. Brief summary of each case
5. Characteristics of the children
6. Case Characteristic 
7. Themes arising from the reviews 
8. Conclusion
9. Recommendation

1. Context

When a child dies and abuse or Neglect is known or suspected to be a factor in the death, local organisations should always consider whether there are any lessons to be learnt about the ways in which they worked together to safeguard and promote the welfare of children. Consequently, when a child dies in such circumstance, the LSCB should always conduct a serious case review into the involvement with the child and family of organisations and professional. (HM Government WT 2013).

The purpose of serious case reviews carried out under the guidance set out in Working Together 2013 is to:

  • Establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote their welfare of children;
  • Identify clearly what lessons are, how they will be acted on, and what is expected to change as a result; and
  • As a consequence, improve interagency working and better safeguard and promote the welfare of children;
  • Serious case reviews are not inquiries into how a child died or who is culpable. That is a matter for the Coroner and criminal courts, respectively, to determine as appropriate.

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2. The purpose of this report is:

  • To see if there are some common lessons to be learnt from SCRs and MRs in Cambridgeshire from 2005-2009 and to see if common themes and trends can be drawn out which have implications for policy and practice;
  • To promote discussion between agencies;
  • To establish how local mechanisms can be developed to ensure key messages about identified risk factors in families can be disseminated to practitioners to enable them to improve their practice and more easily identify children most at risk from significant harm.

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3. Introduction

There have been 6 SCRs and 4 MRs in Cambridgeshire between 2005 and 2009. 9 children died and 1 child sustained serious injury. The characteristics of the children and information about their families and agency involvement is identified and compared to the data collected in the Biennial Analysis of Serious Case Review 2005-2007 in England. (Research Report DCSF-RR129).

It must be noted that the sample study is small (10 children) so the results, although interesting, may not be statistically significant.

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4. Brief summary of each case

4.1 TA

TA was the 3rd child of her mother (aged 24) who had learning difficulties. Her 2 older siblings had different fathers. All 3 children were of mixed heritage. TA was found lifeless and not breathing by mother's new partner. Emergency services were called. TA was pronounced died in hospital aged 81/2 months old. Initially there was confusion around TA's cause of death. Ultimately it was concluded that TA died of natural causes however a management report was completed because of concerns about the care the children were receiving.

4.2 PS

PS was the 1st child born to very young parents whose families were known to Social Care for 3 generations.  PS was found lifeless by her mother. Emergency services were called. PS was pronounced dead in hospital aged 6 weeks old. Post Mortems reported natural causes for the cause of death however because of social reasons, Cambridgeshire SCR panel elected to carry out a management review.

4.3 BW

BW was the 6th Child of his mother but the 5th child of his father. The oldest child in the family is in care because his mother had previously attempted to poison him. There were concerns about the care of the children. There had been a previous child death as a result of natural causes. BW became seriously ill, was admitted to PICU where his condition deteriorated and he died aged 7 days old. The cause of the illness was not known. The police questioned the parents in respect to the baby's death. The investigation did not lead to criminal proceedings. A serious case review was commissioned.

4.4 JB/DB

JB, aged 13 and DB, aged 16 were found dead at their mothers' house. The children had both died from multiple stab wounds to their chests. Their mother was arrested and charged with their murders. Their mother was later convicted of both children's murders. Cambridgeshire SCR commissioned a SCR into the children's deaths.

4.5 LA

Para medics were called to the home of LA. She was unconscious and unresponsive. Emergency treatment was given and LA was taken to hospital 1 where she received immediate treatment. Expert staff from hospital 2 transferred her to a paediatric Intensive Care Unit in hospital 3 where life support was withdrawn after 12 days, LA was 7 weeks old. LA had sustained around 30 fractures, plus bite injuries and brain damage. The father has been found guilty of her murder. The mother pleaded guilty to allowing the death. Cambridgeshire SCR panel commissioned a SCR.

4.6 CW

CW was admitted to hospital with serious non accidental injuries, aged 5 weeks. There was insufficient evidence to proceed to a criminal trial how ever the Cambridgeshire SCR panel recommended a management review be conducted.

4.7 LW

LW was found dead in his pram by his maternal aunt. His weight had dropped through 3 centiles and he was described as severely under weight. This may have been a contributing factor for his death. The Cambridgeshire SCR panel commissioned a management review to examine how agencies worked together.

4.8 FL

FL was the 2nd child of her parents who both had a history of Mental Health illness. The father brought FL into the local GP surgery, she was lifeless and unresponsive. Immediate resuscitation commenced. FL was pronounced dead in hospital. Her parents have been arrested and charged with the murder. They are currently patients in a secure mental health unit. The Cambridgeshire SCR panel commissioned a SCR.

4.9 JG

JG was the oldest child in the family. He had a troubled childhood and a difficult relationship with his mother. He exhibited behaviour problems and was know to the Youth offending Services. He committed suicide at a relative's house. He was 17 years old. Cambridgeshire SCR panel decided that the case reached the criteria set to commission a SCR.

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5. Characteristics of the children

5.1 Age of child at time of incident

Table 1 - Age at time of incident

Age Frequency in Cambridgeshire 2005-2009 Frequency in England 2005-2007
<1 year 70%  (7) 47% (39)
1- 5 years 0 24% (20)
6- 10 years 0 5%   (5)
11-15 years 20%  (2) 13% (11)
16-17 years 10% (1) 8% (8)

The high number of children under a 1 year matches the trend identified in the most recent study of SCRs [Brandon et al 2008] in England.  In Cambridgeshire 70% of children were under 1 year of age and 50% were under 3 months of age.

In the general population, only 6% of under 18's are less than one year old, but they have the highest percentage of reported injury. [Biennial Analysis of Serious Case Review 2005-2007 in England]  This highlights how vulnerable very young babies are and reinforces the importance of the safeguarding role of health professionals (especially midwives and health visitors) working with young babies and their families.

Lord Laming talked about building on 'Progressive Universalism' (Laming Report 2009) This means offering a more targeted health visiting service to families who have been assessed as having a higher level of need. This requires health visiting services to have in place sophisticated assessment and risk management systems to ensure the correct children are identified. It also requires the development of multi-disciplinary protocols and the roll out to Health Visiting and Midwifery services of the use of the Common Assessment Framework in Cambridgeshire.

5.2 Gender

In the Cambridgeshire sample there were more girls than boys.. 60% of cases reviewed involved girls compared to 40% boys. This is in contrast with national figures when there were more boy victims than girls especially children 1 year and below. Moreover, international comparisons note that boys are at greater risk of child death by injury or homicide than girls. [Unicef 2001]

Table 2 - gender and age
The source of England sample figures taken from the Biennial Analysis of Serious case Reviews 2005-2007

Age Group Cambridge sample
England sample
Female Male Female Male
< 1 year 40%  (4) 30%  (3) 41%  (34) 49%   (52)
1- 5 years 0 0 21%  (17) 26%    (27)
6- 10 years 0 0 13%  (11) 7%     (7)
11-15 years 20%  (2) 0 12%  (10) 9%    (10)
16 + 0 10%   (1) 13%  (11) 9%     (10)

The national figures tell us that the gender difference narrows for the older children so Cambridgeshire's statistic mirrors this trend.

5.3 Ethnicity

The ethnicity of children in the Cambridgeshire sample was recorded as 50% 'mixed heritage' and 50% White British. This is in contrast with the national sample where the majority of cases were recorded as White British (72%) and only 13% mixed heritage. This is a significant finding in that Cambridgeshire is a predominantly a White British population. 91% White British (2001 National Census).

This begs the question around what services are available to support mixed heritage families in Cambridgeshire. It also raises concerns that practitioners in Cambridgeshire are not supported and trained sufficiently adequately to work confidently and competently with mixed heritage families.

This requires the LSCB, working with the Children's Trust to review and develop appropriate ethnically sensitive services and to review the training, skills and practices of frontline staff in relation to ethnicity and mixed heritage children and families.

5.4 Birth Order

Birth Order (%)
Birth order (%) chart

The Cambridgeshire sample is similar to the findings in the National sample in that 44% of the children were the only or first child. The hypothesis that the youngest child might have a heightened level of vulnerability and risk is tentative, but the vulnerability of young babies is clear. Young babies are particularly vulnerable to physical injury and if this is coupled with adverse family and environmental characteristics risk of harm are greatly increased. In Cambridgeshire there is also a difference from the national sample in relation to the oldest child, although the sample size is too small to be able to draw conclusions about this.

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6. Case Characteristic

Table 3

Family Characteristics Frequency mentioned in the Cambridgeshire sample
Substance  misuse 100%   (10)
Families who miss medical appointment 100%   (10)
Hostile families/hard to engage 90%      (9)
Domestic violence 80%      (8)
Previously known to Social Care 80%      (8)
Mental health problems 70%    (7)
Missing from education 70%    (7)
Chaotic life styles 50%    (5)
Frequent family moves 50%    (5)
Young parents 50%    (5)
Absent/invisible fathers 40%    (4)
Child subject to a child protection Plan 10%    (1)

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7. Themes arising from the reviews

7.1 Environment and risk

Almost all of the Cambridgeshire sample had been living with past or current substance misuse, domestic violence and or parental mental illness which is a theme reflected in the Biennial Study [Biennial Analysis of Serious Case Review 2005-2007 in England].  As in other studies, the Cambridgeshire sample highlighted that many of the families were struggling with domestic violence, substance misuse and mental health issues, often in combination. The presence of these characteristics, even if they co-exist, does not predict serious injury or death of a child, However, it does increase the risks of harm to the child. [Ibid 2008a]

The environment in which a child lives is crucial to his or her health, safety and well being. Living with adversity compromises the life opportunities of the child [Brandon et al 2008a]. Nationally in the most recent study of SCRs where a child was being hurt or neglected, the relationships around that child were often abusive as well [Gardener and Brandon 2009:178].

Respectful Uncertainty' (Cm 5730 2003) needs to be part of a professionals mindset along side rigorous, systematic thinking and analysis. Professionals need to pool specialist expertise and be more alert to the way factors come together. (For example, domestic violence, missed appointments, mental health problems, substance misuse, young parents, out of education, frequent moves).

Howe notes that 'A deeper grasp of parents' state of mind and the way they understand and interpret the needs and behaviour of their children provide important clues about whether they can or cannot keep them safe'. (Howe 2005)

This highlights a significant issue in Cambridgeshire about the absence of a shared risk assessment tool to assist practitioners across all agencies to appropriately identify risk and address need in relation to that on both a single and a multi-agency basis. The LSCB needs to develop and introduce such a tool, linked to individual agency assessment tools as well as to the use of both the CAF and the Comprehensive Assessment of Children in Need material used by social care.

7.2 Thresholds and a focus on the child

In the Cambridgeshire sample one particular overarching theme emerged. This is the enduring problem of the child being 'lost' within the family 'chaos'. The child becomes 'invisible' to professionals.

The chaotic behaviour in many families was often mirrored in professionals' thinking and actions so that both families and professionals were overwhelmed and had low expectations of what could be achieved.

Many of these families also had frequent moves which is an emerging theme identified in the Biennial Analysis of Serious Case Reviews 2005-2007

This also relates to a theme relating to the application of thresholds for access to particular types of service, the nature of safeguarding within universal services, and of safeguarding practice in services designed to provide early intervention or family support services.

The majority of the children were living in 'overwhelmed' families which were acknowledged to be neglectful, but their circumstances were not judged to reach the thresholds for services from Children's Social Care. The families did not stand out. Comments were recorded by individual agencies, for example, the family 'were no worse than any other family in this locality'. Neither was consideration given by the agency in contact with the families to providing early intervention of prevention services to those families as part of a lower level of safeguarding interventions.

There is a need to think about developing training for staff that will guard against a culture of 'low expectations' both within the family themselves and the professionals providing.

There also is a need to continue to develop a better understanding of a graded approach to safeguarding, and to helping practitioners to see that they are part of the safeguarding continuum.

This will be enhanced by a broader use of the CAF process, as well as by further developing family support based safeguarding services that do not rely on the engagement and involvement of children's social care.

7.3 Missed appointments

Families' missing medical appointment is a common theme. This in isolation would not trigger particular concerns, however if it is linked with other environmental and family characteristics already identified, a more worrying picture emerges. In some services in Cambridgeshire missed appointments are currently seen as a reason to close cases, and there is no assertive follow up to establish the reasons for such missed appointments.

Anecdotally, In the Cambridgeshire sample, 3 out of the 5 babies under 3 months of age births were also not officially registered. This may reflect how the family valued the arrival of the new baby. More research into when parents register the birth of their babies would need to be undertaken to identify if this is a relevant feature to be considered when carrying out a risk assessment on a child. The LSCB may want to consider whether it needs to undertake that work currently.

Nationally good practice exists in some areas, where a pattern of missed health appointments is seen as a trigger for enhanced professional effort to engage and not a reason for a withdrawal of services. This more vigilant approach to missed appointments is a recommendation from the 2004 National Service Framework for Children.

The LSCB needs to work with partner agencies, particularly in the local Health Economy to establish whether they wish to introduce this recommended standard and what needs to happen in order to do so.

7.4 Family Context and the use of proper social histories to inform decision making

90% of the families were previously known to Children's Social Care but only 10% had an active child protection plan in place. It would therefore follow that awareness of both historical and current concerns should be taken into account when assessing the potential risk to a child whether the threshold for current social care involvement or for a child protection plan are met of not. The LSCB needs to look at the way in which referral  and assessment systems across all agencies use social histories to inform the outcome of those assessments, as part of its development of a risk assessment tool.

7.5 Working with hostile, falsely compliant or resistant families

In 90% of the Cambridge sample the families were described as difficult to engage or even hostile to professionals, and in at least 2 cases this includes disguised compliance. Working with such families is a tremendous challenge for professionals. Often they expressed that just 'getting over the threshold was seen as an achievement'. The child becomes increasingly isolated and unprotected. Being able to engage in these circumstances requires confident capable staff who are well supported and supervised.

Patterns of co-operation may be difficult to detect in day to day practice but professionals need to be alert to looking for patterns in parent's behaviour and to share this information with other agencies who maybe wrongly assume that the needs of the child are being met by another agency. Reluctant parental behaviour coupled with frequent moves can mean that children 'fall off the professionals' radar'.

Forrester noted that 'Hostility can be modified by positive engagement skills of staff and should not be considered an inherent or unchangeable attribute' [Forrester et al 2006, 2007].

There is scope for the LSCB to develop professionals' ability to work with hard to engage or hostile families by introducing specialised training courses.

7.6 The role of education, services to support young parents and the role of fathers

Another striking feature that emerged from the Cambridge sample was that in 70% of cases there were issues about either the child or the parents having problems with being missing from education.  50% of the mothers were also young mothers. Some of these mothers should have been assessed as Children in Need in their own right but this was not picked up by professionals working with the families. This may be because young parents did not stand out as unusual in the community so professionals believed that they would not merit a more intensive intervention.

As in the National picture, the Cambridgeshire sample also highlighted 'absent fathers'. In one of the SCR the father was described as 'very much in the background' with 'all the focus of attention on the mother'.

The importance of involving fathers as part of the assessment is highlighted in the DCSF 'Think Fathers' programme. (2007).

7.7 Hard to help young people

Whilst it has been identified that younger children are most vulnerable to death from abuse, nationally the next most vulnerable group is adolescence. This is reflected in the Cambridgeshire sample group. This 'hard to help' group of young people shared the same profile in Cambridgeshire as reported in the Biennial Analysis of SCR (2005-2009) in that many of the young people had a long history of agency involvement and years of high intensity services. The way that young people were able to slip from view was a powerful theme and this is mirrors in the findings of the Biennial Report (Research Report DCSF-RR129).

I of the cases (10%) of the Cambridgeshire sample group died from suicide. Most of the older adolescents in the Biennial Analysis of SCR 2005-07 (Research Report DCSF-RR129) died from suicide. Evidence from this study showed that their needs and distress was often missed or was too challenging, or expensive for services to meet. A high proportion of this vulnerable group had experienced a history of abuse and neglect coupled with environmental factors like domestic violence, mental health issues and poverty [Hindley et al 2006].

These young people might have been amenable to help if they had been offered the right approach [Finkelor D 2008].

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8. Conclusion

The major themes that emerged from the Cambridgeshire sample were the identification and management of risk; the importance of the family context (in particular substance abuse, domestic violence, and mental health problems); thresholds for involvement, (i.e. families that do not stand out); working with hostile or difficult to engage families; failure to attend medical appointments; working with hard to reach young people; the role of education; and work with young parents.'

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9. Recommendation

It is recommended that agencies acknowledge the content of this report. Note the proposed actions for the LSCB and through the LSCB integrate those actions into the overarching action plans currently in place as a result of the Serious Case Reviews.

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Biennial Analysis of Serious Case Review 2005-2007 in England

Brandon M, Belderson P, Warren C, Gardiner R, Dodsworth J, Black J (2008a) 'The preoccupation with thresholds in cases of child deaths or serious injury though abuse and neglect', Child Abuse Review, 17:313-330

Cm 5730 (2003) The Victoria Climbie Inquiry, London, The Stationary Office

Finkelhor D(2008) Childhood Victimisation; Violence, Crime and Abuse in the lives of young People, New York: Oxford University Press

Forrester D, McCambridge J, Waissbein C, Emlyn-Jones R and Rollinick (2007) Child Risk and parental resistance: impact of training social workers motivational interviewing,  British Journal of Social Work, Advance Access published Feb 7,2007 doi:10.1093/bjsw/bc1394

Gardener R, Brandon M (2008) Child Protection: Crisis management or learning curve, Public Policy Research Dec 08-Feb 09 177-189

Hindley N, Ramchandani P, Jones D (advanced publication 2006) Risk factors for recurrence of maltreatment: systematic review. Archive of Childhood Diseases, 91:744-752

Howe D (2005) Child Abuse and Neglect: attachment, development and intervention.  London, Palgrave

National Census (2001) ST101

The Lord Laming (2009) The Protection of Children in England: A Progress Report. HC 330, London: The Stationary office

Placement Stability: Research Handbook to Inform Practice - November 2009
Author: Amanda Harrison

Working with Children and Parents who are difficult to engage - November 2009
Author: Nancy Meister

Child Neglect: Research handbook to Inform Practice

Guidance for Professionals Working with Families Affected by Domestic Violence -January 2009

Information Sharing Guidance - reviewed March 2009

Protocol for Children who have a Mentally Ill Carer

Protocol to Safeguard the Welfare of Children at Risk where Parents or Carers have a Learning Difficulty

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