Hertfordshire Safeguarding Children Board

SCR group and CDOP: 1st April 2011 - 30th August 2012

October 2012

SCR group

HSCB is required to carry out a SCR if:• a child dies and abuse or neglect is known or

suspected to have been a factor• to consider carrying out a SCR where a child has

been seriously harmed; abuse or neglect is known or suspected to have been a factor, and the case gives rise to concerns about the way local professionals and services worked together to safeguard the child

Referrals

• eleven referrals to the SCR sub-group

• no SCRs - three cases identified with issues in multi-agency working - PCRs initiated (two completed)

• two PCRs initiated in 2010/11 were completed in the 2011/12 period

• 2 PCRs initiated recently in the 2012/13 period

PCR approach

Facilitated workshops for practitioners and

managers identifying lessons learnt on:

• an individual basis

• a local basis

• a strategic basis

Recent PCRs: issues

• risks associated with ‘non-diagnosable’ mental health problems

• domestic violence and young teenage mothers, especially those leaving care

• vulnerabilities of all care leavers

• non-accidental injury to babies

Recent PCRs: issues (cont)

• vulnerabilities of children with disabilities - professionals focusing on a parent’s needs rather than those of the child

• lack of Ofsted regulation in semi-independent accommodation

Learning themes

• improved information sharing identified in all reviews with multi-agency chronologies and common shared IT platforms often suggested

• in all cases the need for specialist training was identified and in one, awareness-raising/publicity identified

Learning themes cont

• the need for improved escalation procedures and better understanding of them

• common use of assessment thresholds across agencies

Specific learning

• improve interface between adult mental health services and children’s services

• Improve the tracking of patients who move between GP practices

• improve the commissioning process for semi-independent accommodation

Specific learning cont

• better processes and procedures around CIN - training being rolled out

• improved assessment - the graded care profile to be adopted as a primary tool in the assessment of neglect

Other work

• a review of GP notes to ensure that no issues were missed in the case of a non-accidental injury to a baby in a domestic violence incident

• conference chairs to include safe-sleeping recommendations pre-birth conferences

• HPFT updated risk assessments for children in relation to adults who self-harm

CDOP

• reviews all deaths of children and young people up to the age of 18 who were normally resident in HSCB area

• identify any modifiable or avoidable factors or learning which could help to prevent similar deaths in the future

CDOP

• 2011 - 4th year of CDOP

• 66 deaths reported

• 62 reviewed

• 3 awaiting inquest

• 1 late notification

• 2010 – 58 deaths

Modifiable factors

• 12 deaths with modifiable factors (19%) - close to the national figure of 20% (6 SUDIs)

• down on 2010 where 32% of the deaths had modifiable factors (including 9 SUDIs)

• all deaths with modifiable factors found were in children under age five

• comparable with the 2010 figures with all but one in under fives group

• high proportion of cases with modifiable factors identified in both 2010 and 2011 were cot deaths with additional factors such as co-sleeping smoking, drug or alcohol use were identified

Category of death

Category of child death 2011

2- Suicide / deliberate self harm

3- Trauma - accidental including roadtraff ic

4-Malignancy

5- Acute medical / surgical condition

6-Chronic medical condition

7-Chromosomal / genetic /congenitalanomalies

8-Perinata / neonatal event

9 -Infection

10 -Sudden unexpected unexplaineddeath

Safer sleeping campaign

• recommended safer sleeping campaign - launched April 2012.

• based on findings in 2010 and 2011 that co-sleeping was a common finding in sudden unexpected death in infancy (cot death), often together with smoking and/or drug or alcohol use.

Looped blind cords

• publicity about dangers of looped blind cords in causing strangulation.

• prompted by two similar deaths, one occurring 2011 and one early in 2012

• Backed by parents

Water safety

campaign on water safety prior to 2012 summer holidays,

following the deaths of three Hertfordshire children in private swimming pools, since the start of the CDOP process (one during 2011).

publicity backed by parents of the child who died in 2011

Other work

• bereavement support continues to be monitored

• rapid response continues to provide comprehensive service

• contributing to national learning by responding to and reporting to ‘virtual’ national CDOP group

• attendance at regional groups and FSID conference