Inquiries and serious case reviews are undertaken when a child dies and abuse or neglect is suspected as being a contributing factor. The LSCB will also consider whether a serious case review should be conducted where a child has been seriously injured through abuse or neglect or been subjected to a serious sexual assault. The purpose of Serious Case Reviews carried out under this guidance 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 the welfare of children.
They identify clearly what those lessons are, how they will be acted on, and what is expected to change as a result; and as a consequence, improve inter-agency working and better safeguard and promote the welfare of children. For example, in the inquiry of Victoria Climbie’s case, the failure to follow proper procedure to protect her led to high-profile media attention because the people involved did not do their duty to keep her safe from the abuse she received from her guardians.The lack of communication between her social workers, doctors, nurses and the police was the reason why her guardians were allowed to continue abusing her and caused her death. Communication and co-operation between all the agencies involved in the protection of children and young people is important because this helps to ensure their welfare and to promote their well-being.
Another example that has gained media coverage is the death of Baby Peter. The serious case review which highlighted that all those involved with Peter were too willing to believe his mother’s accounts of how Peter’s injuries occurred.This informs practice because it shows that practitioners need to adopt a more vigilant and challenging approach in some situations to protect children at the earliest stage possible. The uncooperative, anti-social and even dangerous parent/carer is the most difficult challenge for safeguarding and child protection services. The parents/carers may not immediately present as such, and may be superficially compliant, evasive, deceitful, manipulative and untruthful.
Practitioners have the difficult job of identifying them among the majority of parents who they encounter, who are merely dysfunctional, anxious and hesitant.However, in this case the interventions were not sufficiently authoritative by any agency which is essential in this work setting. The authoritative intervention is urgent, thorough, challenging, with a low threshold of concern, keeping the focus on the child, and with high expectations of parents and of what services should expect of themselves. The review also found that injuries were not regarded as sufficiently serious by those involved, which stresses the importance of regular training in staff so they are aware of injuries that meet the threshold for care proceedings.
