A summary of the professional summaries or complete overview reports of very severe case reviews, significant instance reviews or multi-agency kid training reviews posted in 2020. The national repository to find all published case reviews search.
Loss of Aya, a 6-month-old infant whom died after putting up with non-accidental head injuries whilst when you look at the proper care of her daddy on 25 December 2016. AyaвЂ™s dad pleaded accountable to her murder and received a life phrase.Learning: there is certainly presently no certain universal programme of utilize dads either in the antenatal or postnatal duration; the necessity to routinely concern all moms about domestic physical violence.Recommendations: make certain that routine questioning about domestic punishment is embedded within all agencies working together with females and kids; that updated guidance should include within it that most people in the main medical care group whom make use of moms and dads and kids receive notification of every youth damage; the necessity to implement areas of the Healthy Child Programme that relate genuinely to fathersвЂ™ engagement.Model: the methodology used was according to a broad systems approach.Keywords: infant fatalities, abusive dads, solitary moms, non-accidental mind accidents, partner physical physical violence> Read the overview report
2018 вЂ“ Bristol вЂ“ Becky
Loss of a girl that is 16-year-old 2015. Her step-brother and his partner had been convicted of her murder and manslaughter correspondingly. A Domestic Homicide Review is handling the circumstances by which Becky died.Learning: the lack of an evidence-based knowledge of the requirements and circumstances of adolescents can result in adolescents being viewed as troublesome instead of troubled; the propensity of professionals to take parent/carer views at face value without triangulating information off their sources can cause a finite comprehension of a new personвЂ™s needs; professionals are less challenging of the not enough engagement of fathers in child welfare practice.Recommendations: Makes no tips but sets lots of concerns when it comes to neighborhood Safeguarding Board to consider.Keywords: youngster death, murder, adolescents, expert fascination, fathers> Read the report that is overview
2018 вЂ“ Bristol вЂ“ Child D
Loss of a 17-year-old child in February 2016.Learning: the important significance of building relationships whenever using families where you can find both requirements and challenges; the necessity to create a constructive training model with teenage boys and males whom may well not build relationships services; the necessity for improved reactions to domestic abuse in families in circumstances if it is perhaps perhaps not intimate partner punishment.Recommendations: ChildrenвЂ™s personal Care and Youth Offending Team to attract regarding the learning using this review to boost joint working; to consider working with adolescent boys as a thematic concern with its strategy.Model: it is a joint Domestic Homicide Review (DCR) and Serious Case Review (SCR).Keywords: adolescent boys, murder, sibling relations, substance misuse> Read the overview report
2018 вЂ“ Bromley – Elizabeth
Loss of a 16-year-old woman in January 2014. Elizabeth had been killed with a 16-year-old friend x at their home in Surrey. In October 2014 he was discovered bad of murder and sentenced to life imprisonment with the very least term of 25 years.Learning: a written report by Elizabeth concerning an event in the family members, set into the context of other problems, justified it being considered a safeguarding issue and really should have now been responded to accordingly; counselling services might have categorised her reports of sexual intercourse as exploitative and initiated a referral to childrenвЂ™s social care; no formal means existed in BSCB for unanticipated son or daughter fatalities become reported into the LSCB on an incident by case basis.Recommendations: the known as GP should move to techniques this new susceptible Adolescents Strategy and associated protocols; training to incorporate expert curiosity and safeguarding danger assessment whenever young people current with anxiety; to accomplish an review regarding the quality of information sharing within and between partner agencies.Keywords: murder, mother-child relationships, self harm, counselling, medication and liquor solutions, Gillick competency> Read the overview report
2018 вЂ“ Bury – Mario
Death of a 16-year-old child by obvious suicide in February 2018.Learning: professionals seen Mario in isolation from concerns about his wider family members; advice provided to college because of the multi-agency safeguarding hub (MASH) wasn’t in line with safeguarding policy and training; Mario had not been associated with domestic punishment incidents at his motherвЂ™s house; plus the counselling serviceвЂ™s safeguarding policy and training requires development.Recommendations: increase knowing of the antecedents of committing suicide amongst young ones and young adults; share learning with schools within the neighborhood authority; and ensure assessments look at the requirements of siblings perhaps maybe not staying in the household.Keywords: anxiety, divorce proceedings, inter-agency cooperation, self harm, siblings, suicide> Read the overview report
2018 – Cambridgeshire and Peterborough – instance P
Intimate assault of the child that is 14-year-old. The young person reported the attack in November 2015, in the chronilogical age of 18.Learning: understanding of danger and exactly how that can be handled has to be better; agencies have to identify individuals whom present a danger to young ones and flag those individuals of their agencies in order to be handled in a multi-agency fashion; parents and carers should be prepared to spot grooming, especially when a danger is well known or observed.Recommendations: make sure that organisations can efficiently flag and monitor people defined as presenting a risk to kids; make sure staff feel confident in distinguishing and referring people whom provide a risk to children; review exactly how effective disclosures is possible from young ones and young people where there was a not enough spoken disclosure.Keywords: son or daughter intimate punishment, disclosure, siblings, professional fascination, information sharing> Read the overview report
2018 вЂ“ Camden вЂ“ Baby C
Death of a 7-week-old baby from non-accidental accidents brought on by shaking in February 2016. Father had been convicted of manslaughter in March 2018.Learning: there is absolutely no particular universal programme of make use of dads into the antenatal or postnatal period.Recommendations: connection with dads should always be routinely recorded in midwifery and wellness visitor documents; details about the web link between crying infants and non-accidental mind injury must be within the core wellness advertising package provided to brand new moms and dads.Keywords: dads, baby deaths, non-accidental mind injuries, shaking> Read the overview report
2018 – Cardiff and Vale of Glamorgan – CPR 03/2016
Neglect and feasible intimate abuse of a 6-year-old child.Learning:little evidence that the childвЂ™s views had been collected and supported; son or daughter security seminars became dedicated to helping mother as opposed to the kid; and delayed choices can indicate that kiddies experience lengthy exposure to punishment and neglect. Suggestions: upgrade protocol on dealing with families who aren’t cooperating; make sure that training on information sharing for safeguarding kids can be obtained to staff in partner agencies; and guarantee that there surely is engagement that is meaningful schools over the area. Keywords: addicted moms and dads, son or daughter abuse that is sexual disguised conformity, interagency cooperation, schools, sound of this son or daughter.