Serious Case Review

Jacinta, FRG Adviser
Posts: 39
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: 39
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: 39
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: 39
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: 39
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


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