Serious Case Review

Jacinta, FRG Adviser
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Joined: Mon Feb 13, 2017 11:01 am

Serious Case Review

Postby Jacinta, FRG Adviser » Wed Aug 30, 2017 11:00 am

You might be interested in this article in Community Care which discusses a Serious Case Review (SCR) by Luton Safeguarding Children Board into the death of a 13 month old boy.

Luton SCR

You can access the report Luton SCR Child J here.

Some of the issues addressed in the SCR include:

• Risks of possible physical harm to child not properly considered although he was living with domestic violence.
• The review categorises domestic violence into 4 typologies: coercive controlling violence, situational couple violence, separation instigated violence and violent resistance.
• It highlights the lack of guidance /research where adult is violent to another adult (outside the family/home environment) and what risk this may post to a child.
• The lack of formal procedures for transferring child in need cases to other boroughs.
Last edited by Jacinta, FRG Adviser on Wed Nov 01, 2017 11:41 am, edited 1 time in total.
Reason: Replacing a broken link
Jacinta, FRG Adviser

Jacinta, FRG Adviser
Posts: 44
Joined: Mon Feb 13, 2017 11:01 am

Derbyshire SCR Polly

Postby Jacinta, FRG Adviser » Wed Nov 01, 2017 12:25 pm

This serious case review into the death of a 21 month old girl was published in September 2017. Polly, as she is known in the review, was on a supervision order and a child in need plan at the time of her death. Her mother has been convicted of murder and child cruelty and mother’s partner (who was not the child’s father) of causing or allowing her death.

You can find the report here: Derbyshire serious case review Polly .

Domestic violence was one of the features of this case. The review highlights problems with the common social work practice of using written agreements and notes that where a woman is in a situation where there is a risk of domestic abuse it will be very hard for her to keep to a written agreement.

SafeLives’ press release following the publication of the report makes some interesting points in relation to language used and some conclusions in the report and how this was represented in some media accounts of the case. The statement challenges media reporting of the relationship between the child’s mother and her partner as ‘volatile’ when in fact it was identified as violent and abusive and suggest that a whole family response is needed.

You can read the full press release SafeLives respond to serious case review published on 6th September 2017 here.
Jacinta, FRG Adviser

Jacinta, FRG Adviser
Posts: 44
Joined: Mon Feb 13, 2017 11:01 am

Cafcass Learning from SCR submissions

Postby Jacinta, FRG Adviser » Wed Nov 15, 2017 2:49 pm

Cafcass Learning from SCR submissions

Cafcass recently published new research based on learning from 97 SCRS undertaken between 2009 –2016 to which they had contributed.

You can read the full report Cafcass Learning from SCR Submissions 2017 here.

Domestic abuse was the most common risk factor and was a feature in 71 per cent of the cases.
Jacinta, FRG Adviser

Jacinta, FRG Adviser
Posts: 44
Joined: Mon Feb 13, 2017 11:01 am

Wolverhampton SCR Child G

Postby Jacinta, FRG Adviser » Tue Jan 16, 2018 4:38 pm

Wolverhampton Safeguarding Children Board has recently published the review into the death of Child G, who was 2 years and 9 months old when he died. His mother’s partner has been convicted of his murder and his mother of allowing the death of a child.

Some of the learning from the review relates to domestic violence as well as working with families who have no recourse to public funds, with vulnerable families who are transferred from one area to another part of the country and assessing the impact of faith and religious beliefs.

You can find the report here: Wolverhampton Safeguarding Children Board SCR Child G.
Jacinta, FRG Adviser

Jacinta, FRG Adviser
Posts: 44
Joined: Mon Feb 13, 2017 11:01 am

Portsmouth SCB Child E

Postby Jacinta, FRG Adviser » Wed Mar 14, 2018 11:51 am

This is a very tragic case involving the death of an 18 day old baby boy, Child E, in 2014. The cause of the baby’s death was found to be “head injury”. His mother was convicted of murder and grevious bodily harm and his father tried and acquitted of causing or allowing the death of a child.

You can find the report here: Portsmouth SCB Overview Report Child E.

The family’s circumstances included:

Domestic violence:

• In parents’ relationship and in both parents' relationships with previous partners.
• Each parent viewed as perpetrator and victim in different incidents.
• Reliance on parents’ self-reports of incidents.
• Lack of emphasis on the experience of the child/ren.
• Concerning incident when baby was one day old. His mother was seen to have blood around her mouth following an altercation between parents. The baby and his sibling were present throughout and mother was holding the sibling for some of the time. The parents had a protracted argument in a public ward despite being asked to stop and had to be moved to a side room to minimise distress and risk to other patients.


Concealed pregnancy (Child E) – no antenatal care, cessation of engagement with health professionals and of maternal health treatment during pregnancy, high risk pregnancy and birth (although mother and baby were well following the birth).

Father’s alcohol use.

Mother’s mental health difficulties.

Family isolation.

Little known or explored about father’s history and role within the family.

The midwifery service’s demonstrated good practice by proactively escalating their concerns via their Safeguarding Team. This ensured that the Safeguarding Team made a comprehensive referral to Children’s Social Care resulting in the case being allocated to a social worker for a child in need assessment rather than a midwife doing a common assessment framework (CAF), as previously decided.
Jacinta, FRG Adviser

Jacinta, FRG Adviser
Posts: 44
Joined: Mon Feb 13, 2017 11:01 am

Kent SCR Jamie Child D

Postby Jacinta, FRG Adviser » Wed Jun 20, 2018 3:40 pm

Jamie, who was the youngest of 8 siblings (7 under the age of 11), suffered a fatal injury when he was four months old; 2 weeks later his life support ceased and he died. The post mortem found that Jamie had a brain injury and 28 fractures in 19 different bones, of differing ages but sustained in at last 5 different events over a 10 week period. He was also found to have been exposed to controlled drugs.

Jamie’s mother and her partner were convicted of causing or allowing the death of a child and causing or allowing the serious physical injury of a child. Jamie’s mother was sentenced to 8 years in prison and her partner to 13 years.

You can read the full report here Kent SCR Child D Jamie.

Jamie and 5 of his siblings had child in need plans at the time of his death (having previously had child protection plans) whilst his 2 year old sibling remained the subject of a child protection plan as he had suffered a number of bruises and injuries.

There were many issues in this family and concerns around:

• Physical neglect
• Emotional neglect
• Lack of supervision
• Unexplained bruises and injuries
• Drug and alcohol use and alleged dealing
• Overcrowding
• Chaotic and inconsistent parenting
• Inappropriate sexual behaviour between children
• Domestic violence

The review focuses on chronic neglect and chaotic parenting versus risk of serious physical injury. Domestic violence was a consistent feature though and often co-exists with other forms of abuse so below there is a specific focus on the issue of domestic violence.

Summary of events:

Jamie’s mother had witnessed domestic violence in childhood and is described as both a victim and a perpetrator in her adult life.

Jamie’s father’s history is incomplete – he absented himself from assessments, parenting work and meetings with professionals and was excluded on one occasion that he did seek to attend, because of his aggressive behaviour. He was violent in the family home to Jamie’s mother.

There were 14 reported incidents of domestic violence from 2007 – 2014 when father lived in the family home; some of which were witnessed by the children and some of which involved alcohol use. The family home sustained damage during some of the incidents. Mother did not support a police prosecution of father in one case.

Both parents denied the domestic violence and played down any impact on the children who professionals thought were coached not to talk about their home situation.

Mother’s partner was known to police in relation to a historic assault in an affray and for being drunk and disorderly whilst living with Jamie and his family. Jamie’s father said he was concerned about mother’s partner having contact with the children but the reasons for his concerns were not explored. Whilst mother initially agreed that her partner would not be left alone with the children this was not kept to and does not seem to have been challenged subsequently.

The female lodger who lived with the family before and after Jamie’s birth and moved with them when they were allocated a larger property was a perpetrator of domestic violence. Initially this was misrepresented and she was portrayed as a victim of domestic violence. However, Housing clarified that she had been excluded from the property where she lived with her partner for her domestic violence against them. She was the subject of a civil order preventing her from returning to the property and it seems used this to remain in Jamie’s family home.

There were recurring concerns about anti-social behaviour including whilst mother’s partner and the lodger lived with the family – the issues were to do with the home conditions, 4 dogs in the property, visitors to the property and the lodger’s abusive behaviour.

Jamie’s mother did attend some Freedom Programme sessions which she found helpful but cancelled others.

During Jamie’s short life, there were a number of incidents of domestic violence which at least some of the children directly witnessed.

On once occasion, Jamie’s mother attended a neighbours’ house with four of her children in the early hours of the morning. She has been drinking and kicked her partner on her return.

A few days later policed were called to the family home where mother’s partner was said to be drunk and disorderly, there were arguments/fighting going on between the couple and in the presence of the children who police described as unkempt and crying. Mother’s partner was asked to leave but returned to live in the family home a few days later having denied that he drank in front of the children. The lodger (who was drunk) agreed to move out. There was also evidence of cannabis use.

Later at school one of the children said that the lodger had tried to strangle mother which mother denied.

The last situation was where Jamie sustained the fatal injury which resulted in his death and which lead to his siblings being taken into care.

Summary of analysis in relation to domestic violence

• The work done with Jamie’s mother on understanding domestic violence was seen as positive, including by mother, although it was incomplete as she cancelled some sessions.
• It was noted that the lodger was recognised to be a strong and intimidating woman but her influence or control over Jamie’s mother was not considered.
• Drug and alcohol use were factors during some of the domestic violence incidents. The impact of this was not addressed robustly.
• Police did not assess the severity of the incidents as high so the case was never referred to a MARAC. Police procedures have since been updated and now police send a Domestic Abuse Notification (DAN) to the Central Referral Unit where they will be reviewed and when there are children in the household, appropriate child safeguarding procedures will be followed.
Jacinta, FRG Adviser


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