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Serious Case Reviews and Domestic Homicide reviews
� Key themes arising from reviews; some of these are reoccurring themes, how do we break the cycle locally? What needs to happen � Public perception between children and adult reviews: Are there differences? What are they? What factors influence this? � How can local safeguarding boards improve support for staff, professionals and families involved in Children or Adult Reviews? � How to best engage local staff / professionals in dissemination of learning from reviews: What methods should be used?
� Determine what lessons can be learnt about how professionals/ agencies (individually and together )work to safeguard children or adults at risk. � To review the effectiveness of local safeguarding procedures (multi-agency and single agency) � Inform and improve local inter-agency practice
� Regulation 5 of the Local Safeguarding Children Boards Regulations 2006: the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. � Care Act 2014 – enacted April 2015, requires Local Adult Safeguarding Boards to arrange a Safeguarding Adults review
Hamzah’s decomposed body was found by police in the home, almost two years after he starved to death. The Serious Case Review in Bradford, identified some of the key events prior to the death: � Mother was late notifying her pregnancies, history of alcohol misuse � Mother victim of repeated Domestic Violence incidents, but refused to formally complain to police about her partner. � GP & Health Visitor: children’s access to immunisations health appointments was a problem. Hamzah was described in the report as an “invisible child” to agencies. � Older sibling distressed following DV incident, reported this to the police in 2006. Child returned home after initial assessment by Children Social Care. � Missing from home incident reported to police with older sibling.
� School attendance problems with children. � Communication across agencies not always effective sharing information. � Home conditions very poor. Lessons learnt: � Importance of listening to children � Good assessment practice needs to be based on good theoretical understanding of concepts such as vulnerability and neglect. Long process of multi-layered issues � Importance of “think family” and providing early help to family and children in need � Importance of good information sharing across agencies
Daniel was starved and beaten for months before he died in March 2012 at his Coventry Home. The SCR report says that the boy appeared ‘invisible’ to the authorities, who “demonstrated a failure of the most basic aspect of child protection work”. A midwife with serious concerns was persuaded by a social worker not to refer the case to the children’s services at Coventry City Council, for example. Teachers saw Daniel scavenge for food from bins, and police received 26 reports of domestic abuse at his home, but no-one got to the bottom of what was going on in time to save his life
� Dangers of Silo Practice – children not always taken into account within adult assessments for services. Importance of “think family or whole family approaches” flagged. � Importance of taking forward early help / CAF to support families, when required. � Importance of listening to the voice of the child; supporting them with communication when English not main language. Child observed repeatedly scavenging food, underweight. � Importance of information sharing and collating information across agencies � Importance of escalation and challenge
� Domestic Violence, parental substance misuse, mental ill-healthhigh risk factors. Collectively referred to as “toxic trio” represented in many SCR’s. � Domestic Violence- separation does not always mean safety, risks may increase, i. e. stalking behaviours. � Importance of escalation; if a child or adult is in need of safeguarding and there are concerns about an agency response.
� Collation of information and the importance of understanding the “history”- use of chronologies. � Importance of pre-birth assessments. � Communication and information sharing between local children and adult services- often a gap � Hostile or avoidant behaviours, can divert professional attention to the adults, away from children or vulnerable adults in the home.
� Dangers of “hidden” adults gaining access to children who pose a risk – Baby Peter died 2007. � Dangers of professional “rule of optimism” and not being child focused. � Immobile babies and unexplained bruising – importance of demonstrating “respectful uncertainty”. Safeguarding referral procedures not followed. Child Z Leicester City LSCB (2013)
� Impact of accumulative community anti-social behaviour on vulnerable adults – importance of reviewing all information and risk assessment of these on the individual Pilkington Leicestershire (2008). � Importance of collating and reviewing safeguarding concerns when they arise in a single provider setting. Summervale, Leicester (2012). � Importance of sharing relevant information about vulnerable adults, at points of transfer of care. Applying the Mental Capacity Act 2005 working with vulnerable adults in residential settings. Leicester, JG SILP (2012). � Sourcing appropriate care arrangements when agencies remove main carer, MS Review (2010).
Winterbourne View Hospital was a Private hospital providing long term care for adults with Learning Disabilities and autism. An undercover BBC reporter secured employment as a support worker at Winterbourne View Hospital. Who filmed colleagues tormenting, bullying and assaulting patients. Findings were exposed on Panorama 11 care workers who admitted a total of 38 charges of neglect or abuse of patients at a private hospital have been jailed. SCR taken forward by Gloucestershire SAB, Independent Author Margaret Flynn
� NHS commissioners -there was no overall leadership. Even though the hospital was not meeting its contractual requirements in terms of the levels of supervision provided to individual patients, commissioners continued to place people there. � Families felt dis-empowered: influencing placing decision making. � Mental Capacity Act 2005 principles not followed, particularly for adults not detained under the provisions of the Mental Health Act 1983. � Whistle-blowing: concerns were not addressed by Winterbourne View Hospital nor Castlebeck Ltd
� Clinical leadership and professional responsibility, Low threshold for detaining patients under section 3 Of the Mental Health Act and the safeguards of a second, Independent doctor supporting the application and the independent decision by an Approved Mental Health Professional were overridden. � Volume and characteristics of safeguarding referrals Which were known to South Gloucestershire Council Adult Safeguarding were not treated as a body of significant concerns. Recognition and response to other alerts: notifications to the Health and Safety Executive; the hospital’s inattention to the complaints of patients or relatives; restraint incidents excessive; high level of police presence responding to incidents and repeated absconding.
� Joint LLR Agency Winterbourne action plan across local agencies: Commissioning of placements for adults with long term disabilities being more community focused. Active review of quality of local learning disabilities services. Whistleblowing procedures – reinforced embedded Large Scale Safeguarding Investigations – procedures in place Empowerment and advocacy for service users.
Stephen Hoskin: died 2006 Cornwall A 39 year old man with learning disabilities – his “friends” beat him, imprisoned him, drugged and tortured him. His body was found at the base of railway viaduct. Over 40 missed opportunities across agencies to protect him. Gemma Hayter: died 2010 Warwickshire Had a significant learning disability, was found dead on a disused railway embankment. Gemma considered the 5 convicted of her murder as “friends”. They had forced her to drink urine from a beer can, beaten with a mop and stripped before being left for dead.
DHR’s were established on a statutory basic under section 9(3) of the Domestic violence, Crime and Victims Act (2004). Came in force April 2011, a DHR should be taken forward when: q Death of a person aged 16 years or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom s/he was related or with who s/he had been having an intimate personal relationship or A member of the same household as himself, held with a view to identifying the lessons to be learnt from the death.
Between 13 April 2011 and 31 March 2013, 54 completed reports were received by the Home Office. The emerging themes: � The importance of a consistent approach to risk identification, assessment and management for all professionals was identified in a number of reports. DASH risk assessment needs to be applied consistently across agencies. � Agencies need to make informed decisions – preferably with victim consent - to share information and only share when it is safe to do so, to ensure that the victim is not placed at higher risk. Importance of staff understanding good information sharing practice.
� Domestic Violence and abuse were not always identified agencies were focusing on addressing, for example, the mental health or substance misuse of the adult, identifies the importance of asking questions about DV during assessment. � Inadequate information sharing between agencies -where a perpetrator is released on bail or from prison. Some reviews highlighted the importance of compliance with existing processes and procedures specifically in relation to bail management ( including breach of bail ) as this is critical in protecting victims and managing suspects. � In a smaller number of reports there were cases where opportunities were missed to refer cases to Children’s Services. This included those cases where children were in households where domestic violence and abuse occurred between adults but the impact on the children was not necessarily considered.
� � � � Community Safety Partnerships have reviewed the report and local position and are strategically leading the DV agenda. Ensure that staff in your agency or service have the appropriate training in Domestic Violence to include risk assessment and management. http: //www. caada. org. uk/marac/RIC_for_MARAC. html Royal College of General Practitioners have developed a DV e-learning training course for GPs. http: //elearning. rcgp. org. uk/course The National Institute for Health and Care Excellence (NICE) guidance on preventing domestic violence, 2014 Vulnerable groups | Guidance and guideline topic | NICE Training tools are being developed for health visitors on domestic violence and are expected to be launched in 2015. The NOMS Multi-Agency Public Protection Arrangements (MAPPA) team plan to observe level 2 and 3 meetings on Category 2 violent offenders to look for best practice of risk assessment risk management planning and sharing of information and this will include management of offenders with complex needs. Midwives should undertake routine enquiry by asking all pregnant women whether they are at risk of, or are suffering/suffered from domestic violence.
� What are the legal powers? � What does my agency AND inter-agency policies and safeguarding procedures tell me? � What are my civil duties? � What do information sharing protocols or agreements allow me to do? � Am I carefully balancing the rights of adults and children? � What are the best interests of child or adult? � Do I need legal advice?
� Good assessment, information sharing and review of information � Accessing good supervision � Early intervention and support � Following local multi-agency procedures � Effective partnership working � Good risk management and review � Working within Legal Frameworks � Good Record Keeping Standards.
� Hull Safeguarding Adults Partnership Board. A decade of serious case reviews: our vision for adults safeguarding: 2014 www. safeguardingadultshull. com � Manthorpe J & Martineau S, First Annual Report: national panel of independent experts on serious case reviews adult safeguarding 2014 Kings College London � OFSTED, Ages if concern: learning lessons from serious case reviews: a thematic report of Ofsted’s evaluation of serious case reviews (april 2007 to March 2011). 2011 www. ofsted. gov. uk � Home Office, Multi-agency Statutory Guidance for the Conduct of Domestic Homicide reviews: revised, august 2013 home office � For SCR or DHR reports referenced log onto relevant LSCB or SAB website.