The actual number of cases is probably much higher because many people fail to report known or suspected abuse. On one occasion FC2 told police he hadn’t seen PB, but PB was found hiding undressed at FC2’s home. Father had convictions for domestic violence, assault, drug dealing and breeding dogs for fighting. Child W died soon after his 18th birthday (but travelled when he was under 18) and Child X died aged 17.Background: the children had several siblings and grew up in Brighton but spent considerable periods in their parents’ North African/Middle Eastern country of origin. For at least 6 months before her death, she was exposed to and ingested heroin, methadone, ketamine and various benzodiazepines. Telling someone what’s going on means you don’t have to deal with it on your own. Good practice identified includes: early recognition of the family’s need for enhance support by the health visitor.Recommendations include: use a standardised, objective approach to the assessment of neglect; need for a shared understanding and common language of levels of needs/thresholds, particularly following a referral to Children’s Social care.Model: uses the Significant Incident Learning Process (SILP) methodology.Keywords: infant deaths, physical abuse, child neglect, voice of the child> Read the overview report, Serious and life-threatening injuries of a 5-week-old infant girl in August 2017 due to shaking.Learning: understanding parental history and vulnerability is important in assessing actual or potential risk to children; sharing information between health professionals should be seen as standard practice, especially during pregnancy and early childhood; the practical use of information, rather than just recording it, is critical to effective safeguarding arrangements; knowledge of controlling and coercive control in adult relationships can help practitioners make informed decisions about risk to children.Recommendations: for the LSCB to ensure that there is ongoing scrutiny to evaluate how effective improvement action has become embedded into routine practice; to seek reassurance that the decision making at the point of contact and referral are appropriate and based on appropriate information sharing.Model: used the Significant Incident Learning Process (SILP) methodology.Keywords: physical abuse, shaking, crying, infants, family violence> Read the overview report, Death of a 6-month-old infant due to a non-accidental head injury in June 2016.Learning: not all professionals have the same level of expertise in all areas of practice, so use of those with expert knowledge (e.g. The case transferred between local authorities but the family were reported as missing. Harry had experienced significant neglect, trauma, emotional and mental health difficulties.Learning: the need for a greater appreciation of the impact of early childhood adversity and trauma and the importance of using this information to inform decision making and safety planning; importance of information sharing across borders and agency boundaries; the need for prompt action to secure the appropriate type of support and intervention when young people experience an acute and serious mental health episode. The Panorama findings come eight years after abuse was uncovered at another hospital for people with learning disabilities, Winterbourne View, near Bristol. .css-orcmk8-HeadlineContainer{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}Boeing to pay $2.5bn over 737 Max conspiracy.css-1dedj2h-Rank{-webkit-align-self:center;-ms-flex-item-align:center;align-self:center;color:#B80000;margin-left:3.125rem;}1, Ashli Babbitt: US Army veteran who lost her life in riots2, Capitol riot: Calls grow for Trump to be removed from office3, Stella Tennant: Family confirms model's death was suicide4, Elon Musk becomes world's richest person as wealth tops $185bn5, Capitol riot: Five startling images from the siege6, Capitol riots: Boris Johnson condemns Donald Trump for sparking events7, Capitol riots: Questions mount over security failure8, Capitol riots: Who broke into the building?9, Capitol riots: A visual guide to the storming of Congress10. All children were taken into care.Learning: five priority findings emerged including: loss of clarity about the appointment of a Lead Professional resulted in lack of coordinated overview of children's needs; assumption that giving and receiving information equates to communicating which can lead to misunderstandings about the current assessment of children's situations; tendency to restrict evidence of children's experience to what they say, which results in missed cues and the privileging of the voices and views of adults; some services for adults take insufficient account of children connected to their clients and thereby fail to identify risks to their wellbeing and safety.Recommendations: There are no recommendations but the review raises a number of questions for the Child Protection Committee relating to each learning point.Methodology used: SCIE's Learning Together model.Keywords: voice of the child, child protection, assessment, child neglect> Read the overview report, Sexual abuse of a 12-year-old girl in 2015 by her mother’s partner.Learning: intra-familial abuse is still likely to be the most common form of sexual abuse that professionals will encounter; the verbal disclosure of a child is one aspect of the investigation of sexual abuse and lack of further disclosures or supporting forensic evidence should not negate the belief that the child may have been abused; practitioners should be aware of disguised compliance; describing the results of medical examinations as ‘inconclusive’ or ‘neutral’ in the context of sexual abuse may bring a risk that the absence of a definite finding could be taken as ‘evidence’ that alleged abuse did not occur.Recommendations: face-to-face, multi-agency strategy meetings should be held in cases of suspected child sexual abuse; all agencies must ensure that listening to, and hearing what children say is important.Keywords: child sexual abuse, disguised compliance, listening> Read the overview report, Disclosure of abuse and asking to be taken into care by 16-year-old female child, who had been living with her mother, step-father and half siblings in March 2016.Learning: the need to distinguish between behaviour that might indicate cruel rather than neglectful care; children more readily disclose information to adults such as teachers or health practitioners whom they can trust; professionals must be aware and sceptical about how parents may seek to influence how information is processed; recognition and response to self-harm.Recommendations: to ensure the voice of the child is sought by professionals to appropriately inform judgements and decision making during enquiries and assessments; to ensure that chronologies are appropriately collated and analysed to inform judgements and decision making when concerns are raised in regard to child abuse.Model: investigatory model for collating information with analysis using elements of a learning review model.Keywords: assessment [social work], bereavement, bruises, emotional abuse, failure to thrive> Read the overview report, Death of a 16-year-old boy by suicide in June 2017.Learning: professionals should make notes of disclosures made by children as soon as possible after the conversation, which must not include leading questions; notes must be suitable for disclosure to any future enquiry or investigation.Recommendations: ensure that staff understand, in line with the school’s updated policy, that it is not the role of staff to investigate disclosures by interviewing the child or others involved, unless asked to do so by police, CSC or NSPCC; review the interagency CSE procedures to ensure that when there are sufficient concerns to support a section 47 enquiry that the appropriate multi-agency response is triggered; undertake an audit of CSE meetings; promote the increased use of the Early Help Assessment Framework by agencies and explore the barriers which prevent professionals from completing them.Keywords: suicide, body image, child sexual exploitation, disclosure, deception, anxiety, self-harm, eating disorders, sexuality, schools> Read the overview report, Injury of an 11-week-old boy in September 2015 as a result of shaking.Learning: improved understanding by neonatal staff about the triggers which can lead to abusive head trauma in young babies; help with the support and guidance that neonatal staff offer to all parents, particularly those whose babies are considered vulnerable; more professional awareness of pre-birth assessment procedures would be beneficial in mitigating potential future safeguarding risks.Recommendations: criteria and procedures for starting pre-discharge meetings should be robust and understood by all professionals involved; consideration should be made to cooperating with other LSCBs to explore how learning can be shared to develop policy and practice.Keywords: non-accidental head injuries, shaking, antenatal care, nurses and nursing, midwives, information sharing> Read the overview report, Inflicted abdominal trauma to a 6-year-old child in June 2014 while in the care of mother’s partner.Learning: professionals engaged in multi-agency working must be attuned to non-verbal methods of communication and advocate for a child that is not being heard.Recommendations: LCSBs must ensure GPs are part of multi-agency safeguarding arrangements; working directly with men in families must be embedded in professional thinking.Keywords: voice of the child, unknown men, risk assessment, injuries, health care, abused women> Read the overview report, Death of Child E aged 18-days-old, cause of death recorded as ‘head injury’. Mother and partner were arrested and prosecuted.Learning: risk and harm from control and coercion represents a different threat to other forms of domestic violence and abuse; intimidated adults and children are unlikely to disclose information; prior history of domestic violence and abuse is a significant indicator of higher risk in subsequent relationships.Recommendations: issues for national policy considerations include: guidance on coercion and control as a safeguarding issue and the implications for practice; guidance and arrangements for training for magistrates in regard to domestic violence and abuse.Keywords: physical abuse, family violence, disclosure, voice of the child.> Read the overview report, Death by suicide of a teenage girl in January 2019.Learning: early help for young people suffering self-harm and/or suicidal tendencies needs development to promote multi-agency working; responses to a young person disclosing sexual abuse may be more effective if they feel included in discussions regarding decisions and potential outcomes; training required to assist social workers exercise their right to disclose information confidentially.Recommendations: to enhance the use of the self-harm referral pathway and refer young people when support is needed; to ensure similar enquiries are managed by the police in a sensitive manner when a young person feels unable to proceed with a prosecution and victims are better informed if there is no intention to speak to the alleged perpetrator.Keywords: child sexual abuse, self harm, threshold criteria, voice of the child, suicide.> Read the overview report, Death of a 14-year-old young person from an aggressive malignant tumour.Learning: Child F’s voice was heard but was not understood and acted on; evidence of poor inter-agency communication and information sharing; the need to manage conflict and work with challenging carers whilst not losing focus on the child; quality of care issues raised by Child F received an inadequate response by Children’s Social Care.Recommendations include: children cared for by the Local Authority should be provided with advice either from an independent legal advisor or advocate when they are in disagreement with professionals or carers; raise awareness regarding prevalence and symptoms of brain tumours in children and young adolescents; foster carer recruitment, training and supervision should encompass lessons from this review. A child protection plan had been in place for all children 1 year before the death due to concerns of neglect. Child E's step-father pleaded guilty to manslaughter and no inquest was carried out.Learning: a focus on the physical care of the children and home conditions diverted attention from other serious issues, including risk of being in contact with people who presented risks to the children; professional challenge and escalation is important in effective intra and inter-agency work; agencies that saw signs of concern dealt with them appropriately most of the time but some intra and inter-agency communication and information sharing could have been better.Recommendations: more training on neglect and its impact on children; more understanding of legal processes and what local authorities must evidence to secure statutory orders; raise awareness of the Escalation Procedure and the importance of robust, respectful professional challenge between and within agencies; consider the introduction of a panel, chaired by a different professional to take a “fresh look” at cases that are making insufficient progress.Keywords: assessment, child neglect, child deaths, home environment, optimistic behaviour, step-parents.> Read the overview report, Neglect of a 5-year-old girl in September 2015.Learning: the number of children in the family and the number and range of professionals involved posed a challenge to effective communication; professionals were not curious enough about Child Q’s experiences and too quick to accept parents’ explanations without considering the whole context of her life.Recommendations: develop a multi-agency policy for the management of non-attended appointments across multiple services; review of information sharing systems between hospitals, GP practices and child health professionals, focusing on communication; ensure that requirements for all children’s voices to be heard at child protection conferences are met and that those who cannot speak for themselves are adequately represented.Keywords: pre-school children, school attendance, malnutrition, child neglect, home environment, child protection registers.> Read the overview report, Death of a 1-year-old boy in November 2017 from unascertained causes.Learning: the child’s experience must run through all work undertaken with families and thresholds should be focused on the impact of parenting on the child; professionals need to use the neglect framework and practice guidance to help them identify neglect; if a parent voices concern about being a parent due to their childhood experiences of sexual abuse, specialist support should be made available; when assessing if an injury is consistent with the story provided by the parent, consideration should be given to the child’s developmental stage.Recommendations: to question how professionals in partner agencies make referrals that provide the evidence and information required when they have safeguarding concerns; to request assurance from partner agencies that professionals understand the risks of interfamilial sexual abuse and a parent’s adverse childhood experiences (ACEs).Keywords: adverse childhood experiences, father-child interaction, neglect identification, mother-child relationships, nutrition, sudden infant death.> Read the overview report, Bruising first reported on a 6-week-old boy in March 2016, with further bruising and fractures documented over the next month and six days.Learning: a hierarchical approach in the working environment leads to professional deference and makes challenging medical professionals and decisions difficult; child protection practice requires collaborative work and professional respect; needs of fathers must be properly assessed and engaged; change to modern service delivery models cannot guarantee continuity of care; service thresholds were applied that did not correspond to the needs described.Recommendations: all agencies must undertake a review of internal and inter-agency information sharing systems including use of electronic recording, flagging and coding systems; community health visiting and children’s social care services must incorporate a ‘think family approach’ as standard; the LSCB must develop and agree a protocol for responding to bruising in pre-mobile babies and disabled children who are dependent and unable to communicate.Keywords: adults with physical disabilities, father-child interaction, fractures, health visitors, medical assessment, optimistic behaviour.> Read the overview report, Death of a 14-week-old boy from serious non-accidental injuries in July 2016.Learning: failure of the systems and processes designed to safeguard children with inaccurate recording; the interface between Child in Need and Team Around the Child did not work well; system around midwifery care was disjointed with lack of communication between midwifery teams and midwives and GPs; insufficient focus of emotional impact of Elias and Child A’s diagnoses on their parents.Recommendations: health services should review documentation and assessment tools and include household composition and functioning of the household; to seek assurance from health and partner agencies of emotional impact of having a child born with any abnormality/disability features within consultations with recognition of any risks to the child; all GPs to be notified of the pregnancy of all women registered in their care; to seek assurance that the application of thresholds is now consistent.Keywords: bruises, burns, children with physical disabilities, congenital disorders, housing, murder.> Read the overview report, Death of an infant in November 2017 from injuries linked to being shaken three months earlier. Right before the judge read his sentence, he said to Kevin that this case was odd to him. risk and harm from control and coercion represents a different threat to other forms of domestic violence and abuse; intimidated adults and children are unlikely to disclose information; prior history of domestic violence and abuse is a significant indicator of higher risk in subsequent relationships, issues for national policy considerations include: guidance on coercion and control as a safeguarding issue and the implications for practice; guidance and arrangements for training for magistrates in regard to domestic violence and abuse. Child V’s father was convicted of manslaughter in December 2017.Learning: victims of domestic abuse often withdraw police statements, which complicates the prosecution process; professionals must question and challenge decisions and concerns directly with colleagues, irrespective of their professional background or status; the matter of language difficulties and consistent use of interpreters is an area for improvement.Recommendations: Norfolk LSCB and partner agencies need to develop a system to support non-engaging parents in domestic abuse offences and rape criminal cases; to have robust and easily accessible systems in place to support team functioning and staff wellbeing; ensure that the children’s services workforce understands the limitations of solution focused interventions for relationship counselling where domestic abuse is suspected; neonatal and maternity services should implement systems to routinely gather and share safeguarding / domestic abuse information.Model: uses the NSCB Thematic Learning Framework model.Keywords: abusive fathers, emotional neglect, premature infants, fractures, family violence, language> Read the overview report, Sexual assault of a 14-year-old male by a 20-year-old male care leaver in June 2016. © 2021 BBC. The family moved to a London borough soon before Child S’s death.Learning: escalation of concerns; core and follow up assessments; continuity in social work practice; healthy scepticism about long term drug use; reporting and sharing information in drug services; experience of the child; transferring information between areas; hidden men; safeguarding children with disabilities; police sharing information.Recommendations: pre-birth planning and assessment appropriate with drug using parents; Children in Need meetings properly recorded and CSC assessments up to date; compliance with 2009 guidance on safeguarding children with disabilities; review compliance on transferring cases; embedding healthy scepticism about long term drug using parents.Keywords: cerebral palsy, addicted parents, non-attendance> Read the overview report, Child 1 witnessed mother’s death in the family home in 2014 from multiple stab wounds caused by father. He was not known to any services. Keywords: child neglect, disguised compliance, listening, optimistic behaviour > Read the overview report, Death of a 3-year-old child from an asthma attack.Learning: professionals need to take into account safeguarding concerns such as the impact of smoking and home environment; health professionals need to ensure they have a good understanding around the concept of good enough care for a child with a chronic illness; consider the father’s role in caring for a child; involving the housing provider in child protection meetings where there are rent arrears and neglect.Recommendations: lead health professionals to be identified for all children with a chronic health problem with clear communication systems in place for information sharing.Model: uses a systems approach based on the Manchester methodology.Keywords: child neglect, childhood illness, low income families, smoking> Read the overview report, Serious physical assault in September 2015 of a 16-year-old girl whilst she slept. Both the woman and perpetrator had been in care with parental histories of violence and substance abuse; the perpetrator’s behaviour as a child was challenging and disruptive and he had convictions for assault. Physical abuse. and DadPad (prevention of abusive head trauma tools) and evaluate these programmes; medical professionals should provide documented analysis of any symptoms of non-accidental head injury.Keywords: Infants, crying, physical abuse, shaking, fathers> Read the overview report, Significant neglect of two siblings, including neglect of their physical, emotional, social developmental, health and medical needs.Learning: at times the focus was on the adults rather than the lived experiences of the children; over-optimism about the likelihood of the adult carers improving their care of the children; a lack of challenge to adult family members which led to gaps in information. Boise Police arrest woman accused of physical abuse of 6 children By Ruth Brown. .css-14iz86j-BoldText{font-weight:bold;}The abuse and mistreatment of vulnerable adults at a specialist hospital has been uncovered by the BBC's Panorama programme. > Read the overview report, Death of a 17-year-old girl by suicide in August 2017.Learning: assessing competence, resilience and emotional attachment disorder in adolescents and considering the impact of adverse childhood experiences (ACEs) and impact of cannabis use; using a holistic family approach to assessing children and young people where their parents have difficulties; recognising when young people are carers; the importance of reflective supervision.Recommendations: to work with the Safeguarding Adults Board to develop a ‘Think Family’ approach; review how practitioners are supported and trained in assessing adolescents who have complex and unresolved emotional issues, possibly coupled with drug use and impulsivity; promote awareness of and response to contextual safeguarding.Keywords: adolescents, suicide, adverse childhood experiences, drug misuse.> Read the overview report, Death of a 9-month-old child in February 2014 as the result of a hypoxic brain injury. 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