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Learning from SCRs

Serious Case Reviews Learning

Haringey Safeguarding Children Board has reviewed key learning from local and national serious case reviews and has identified some key learning for agencies across the partnership

In 2017, we have developed some key themes for practice arising from all of the SCRs published in 2015-16, and themes arising from other case reviewing activity which we will be sharing with practitioners at the HSCB Learning Lunches during Jan-March 2018. Here is our latest Learning From Practice Bulletin Autumn 2017 (PDF, 195KB).

We've put the lessons in Poster Format so that settings can expose the messages to all staff. There are accompanying information sheets that can support managers and practitioners within settings to reflect on the issues raised.

Learning from SCRs: Mobile Families Learning from SCRs: Disabled Children

Learning from SCRs: Listening to Children Learning from SCRs: Mental Health Problems in Children & Young People

Learning from SCRs: Domestic Abuse Learning from SCRs: Professional Parents

Learning from SCRs: Information Sharing Learning from SCRs: Child Neglect

Learning from SCRs: Lost in Translation Learning from SCRs: Anti-Social Behaviour in Young People - They're Vulnerable Children Too

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Key Messages for Practice

Serious Case Reviews in Haringey have highlighted some common key messages for practice, that are also reflected in national research.

Authoritative practice assumes a level of 'healthy scepticism' in practice - that we Think the Unthinkable. This means that workers are respectful but challenging.

Other key learning for our practice:

Think the Unthinkable

As workers, we should always work with 'healthy scepticism' when dealing with families where children might be at risk.

Asking parents and families how they parent is not always the most reliable way of finding out what is happening in the home. Watching parenting in action (setting boundaries, play between parent and child) can be much more informative.

Research tells us:

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A Seen Child is Not a Safe Child

Almost every child who has been subject to a serious case review over the last 40 years was 'seen' by a professional within days (or hours) of their death.

Simply seeing a child is not protection against harm. Workers need to try to understand what the world looks and feels like for that child.

Getting a narrative of the child's day-to-day experience is a good place to start rather than getting them to answer yes/no questions.

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Assessment is a Process, Not a One-off Event

Assessment is about forecasting the future by reviewing past events. Review your thinking as new things happen - assessment should be ongoing; it doesn't end when a formal assessment has been completed.

We assess in order to make an appropriate plan, to implement that plan and to review how well its objectives have been met, and then to keep assessing.

Past experiences have a critical impact on present and future behaviour. Your understanding of a person's history must inform your assessment.

Assessments should not be carried out in isolation - we need to share information effectively and should always ensure we let others know what we know and what we are doing, as well as checking out what they know and what they are doing.

Questions to consider are are:

  • Who are the adults?
  • What is their story?

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Interaction is Not the Same as 'Attachment'

Parents may overcompensate or put on a display for strangers - but parents tend not to be able to 'fake it' for more than a few minutes. Why not ask them to play with their child and during the play demonstrate how they place boundaries.

Don't assume that a child has a secure attachment style because they are smiling. Determining the quality of attachment is a skilled and sometimes prolonged task.

Many children who are abused are compliant and eager to please. Often even very young children are torn between trying to protect their parents from detection by the authorities and protecting themselves.

Questions to consider are:

  • What is the quality of the parents' responsiveness to the child?
  • What evidence have you observed in the child's behaviour that suggests secure, ambivalent, avoidant, disordered?
  • What research supports your view?

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Neglect is a Relationship Issue

Neglect (nits, poor hygiene, weight loss, lack of supervision, etc) may signal a poor adult-child relationship. All neglect stems from parents prioritising something else over the child's basic needs.

Workers sometimes become too tolerant of high levels of neglect and fail to spot risk.

Questions to consider are:

  • What is going on in the relationship between the parent and child that has allowed this to happen?
  • Where do the parents' priorities lie?
  • Does the parent have a sense of the child's 'otherness'?
  • How aware is the parent of the child's needs, personality, strengths and struggles?
  • What is it like to be that child's age and living in that household?

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Consensus Isn't Always Safe

The fact that everyone agrees does not mean that they are right - and certainly does not keep a child safe.

There is no safety in numbers - risk does not decrease because more people agree.

Minority views are important and must be considered and noted within multi-agency work. Consider what it is about that worker's experience that differs from others'.

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Parental Participation is Not the Same as Cooperation

Don't confuse an apparent willingness to comply with an actual willingness to accept the need to change.

The Rule of Optimism, where professionals wrongly assume positive outcomes for children, is more likely to exist when staff feel under pressure and this can be very dangerous for children who are at risk.

The Rule of Optimism rationalises evidence that contradicts progress - so even where the facts show that risk is ongoing or increasing, professionals tell themselves that the opposite is true.

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Professional Involvement is Not the Same as Engagement

Just because another professional is involved with a child's case does not mean that they are proactively engaged with protecting the child.

The danger is that we assume that if a child has a social worker, they are being protected; or if a police officer visited the house after a domestic violence incident, the child is safe. The social worker may not know what you know; the police officer may not have had any cause for concern.

Never assume that someone else is doing something when you have a cause for concern.

Questions to consider:

  • Even once you communicate your concern to other workers, how sure are you that you are understood?
  • What actions are they taking?
  • How do you know?

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Domestic Violence is a Serious Risk Factor

  • Domestic Violence in a household puts a child at a high risk of harm: research tells us that children are at significantly higher risk to all forms of child abuse when Domestic Violence occurs in their home
  • A child does not have to be hit to be harmed: witnessing Domestic Violence can impair a child's development
  • In a family where there is a child under 12 months old (including an unborn child), even if the child was not present, any incident of Domestic Violence should trigger a Child Protection Investigation


Useful Contacts

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Report Abuse and Neglect

If you are worried about a child for any reason, contact MASH on 020 8489 4470.

If you are making a referral:

If you are calling between 5pm and 9am weekdays or anytime at the weekend, call the Emergency out-of-hours duty team on 020 8489 0000.

If you or a child is in immediate danger you should always phone 999.