East Sussex Local Safeguarding Children Board Serious Case

East Sussex Local Safeguarding Children Board Serious Case Reviews, and local reviews: learning for schools and education settings

Introduction What are serious case reviews (SCRs) What are local learning reviews Learning, improving practice, shaping policy Looking at relevant East Sussex reviews and learning • Confidentiality and sensitive subject matter • Hindsight bias • •

Purpose of SCRs • Learning from cases where a child has died or been significantly harmed. Focus on how agencies worked individually and together • Improve practice, inter-agency communication, systems, policy and procedures • Produces action plans to ensure changes made • SCRs are not about blame, it is not conducted to hold individuals, organisations or agencies to account

Process for deciding a SCR LSCB Case Review Group • CRG discuss case and agree if requires a ‘rapid response’ • A ‘rapid response’ is collated within 15 days • Provide recommendation to initiate SCR LSCB Chair National Review Panel • Agrees if meets SCR threshold (based on recommendation) • Rapid response and decision is shared with National Review Panel • The panel provide response to decision to SCR • The Panel provide advice if local or national review LSCB Case Review Group • Agree model for SCR • Commission Independent Author • Agree To. R and timetable

If not a SCR…. . ? CRG Local Review CDOP LSCB Learning • The case will continue to be monitored and reviewed by LSCB Case Review Group • A local review could be agreed; this is usually because there will be some specific learning • Child Death Overview Panel reviews all child deaths to identify if could have been prevented • The LSCB may conduct a learning event or a themed audit

East Sussex SCRs • Four SCRs published since 2015: Family S (2018), Child M (2016), Child P (2016), and Child K (2015) • One further SCR recently published – Child T (25 th June 2019) • One local review completed – school related • Two SCRs currently running

Family S • Family S concerned two children who experienced significant neglect. The children were living with their mother in a privately rented flat where the home conditions were so poor it was deemed unfit for human habitation. • The older child (7 years old) was found to have a significant disability which had not been addressed and led to significant medical treatment. • Significant feature of this serious case review was the low level of contact that professionals had with the mother and children. • Older child was in an East Sussex School. Important learning from this review was the link between school attendance and safeguarding issues, leading to updated guidance for schools. • East Sussex LSCB SCR – Child S – Overview Report • East Sussex LSCB Family S SCR – Learning Briefing – 2018

Child T • Child T died in hospital when he was 18 years old • He lived with his Mother and was an only child • Child T had type 1 diabetes • History of lack of engagement with diabetes treatment • History of missed appointments • Neglect and self neglect were identified • His death was sudden and unexpected

Child T – thematic analysis Child’s lived experience Transition Persistent DNA/WNB and neglect Self neglect and mental capacity Plans and working together

Child T – education related • The SCR covered January 2014 (child T 15 yrs) to May 2017 (when Child T died). However there had been previous involvement: concerns that Child T was morbidly obese when in primary school; school attendance was poor when he was in secondary school. • Child T’s school attendance was around 67% early in 2014; he was noted to have lost a lot of weight. Education attendance officers were involved; school attendance increased for a short period; Mother avoided prosecution. During his time in Year 11 (2014 -15) Child T often reported to the school first aid room with headaches and stating that he felt unwell. This information was not shared. • Child T started a college course in September 2015. He was noted to be unmotivated and often complained of feet and back pain. By December 2015 Child T was no longer attending college, and Mother later informed them that due to his health issues he would be leaving. This was not challenged or questioned further. • In 2016/17 the post-16 education team were also trying to contact Child T over these months. They had no response despite trying phone calls, letters, and social media contact.

Child T - learning • Limited consideration of the child T’s lived experience when professionals were in contact with the family. • Trust placed on what Mother was saying without considering the impact on Child T, without speaking to him directly about his life, without checking with other professionals. • DNA/WNB policy not used – lack of professional curiosity and ownership.

Child T - learning • All 16 -17 year olds should be subject of children’s safeguarding procedures. • Schools and colleges have a role in child’s health and wellbeing – not just a ‘health’ issue. • Need for greater understanding of impact of diabetes (and other serious health conditions) by non-health professionals.

Learning for schools and colleges • Take a proactive role in partnership with health services to ensure individual planning and support when children have medical needs – especially when this impacts upon their attendance • Attendance issues must be assessed and reviewed alongside wellbeing and safeguarding concerns • Schools must robustly challenge parents about poor attendance throughout a child’s time in education and make referrals to services in line with ES Attendance Guidance • Children’s safeguarding files must be transferred between institutions in line with ES Record Keeping Guidance

Continued…. • School /college to undertake home visits where there is a lack of response from parents to non-attendance • Complete more detailed recording on visits to medical rooms • Regularly review where parents have refused school nurse / health care service and question this • Request evidence of medical appointments (and if possible of subsequent attendance at these) • Ensure there is shared decision-making about complex safeguarding cases and regular review of progress

Child T • The full report can be found on the LSCB website: LSCB Serious Case Reviews • Learning briefing to be disseminated

East Sussex School • During 2018 a local review was undertaken following three separate incidents of peer on peer child sexual abuse at a primary school in 2017. • The Case Review Group requested two Individual Management Reviews (IMRs): Social Care, and Education. The Education IMR was completed by an independent reviewer.

Learning • The IMR for the school identified the intense and extraordinary pressure that the school was under as a result of these incidents • Schools may wish to consider how quickly they escalate issues with other agencies via formal processes. • Schools which encounter negative media attention should have ongoing support in managing sensitive situations and where necessary and appropriate, escalate this to engage legal services. • Schools need to continue to work with children’s services and the police to make sure there is a clear understanding of information which support them to reduce the risk of peer on peer abuse. • In January 2019 the ES Protocol for Managing Peer on Peer Harmful Sexual Behaviour in Schools was published. This was the result of joint work between SLES, SPOA and SWIFT specialist services, and in part, as a response to these cases. • Protocol for managing peer on peer harmful sexual behaviour in schools

Q&A • Any further comments and questions for the LSCB?