WELCOME Improving health services…
Learning Lessons from Serious Case Reviews Improving health services…
‘CCGs should ensure that Robust processes are in place to learn lessons from cases where children die or are seriously harmed And abuse or neglect is Suspected’ (NCB 2013:11) ‘There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the Welfare of children’ (Working Together 2013:66) Improving health services…
5 Serious Case Reviews: • The child’s view and the child’s experience were not central to the practice or consideration of the case; • Rules of optimism and tendency to start again with each incident or new engagement with the family; • Key information not shared across the professional network; • Social work assessments; • Multi-agency assessments such as pre-birth; • No one had a full picture of all the circumstances of the child and family; • Domestic violence, drugs or alcohol misuse or psychological problems were features; • In nearly all cases there was evidence of resource and organisational, capacity and capability problems in key agencies Improving health services…
Daniel Pelka SCR Published September 2013 (Coventry LSCB) Improving health services…
When Daniel had a broken arm in January 2011 the medical assessment was inconclusive but there were concerning features to the injury and its presentation. The recommendation was for a core assessment. This was undertaken but did not focus on the injury and its background and the long history of domestic violence. The assessment did not lead to any intervention with the family; Improving health services…
Daniel’s presentation in school, which Daniel started in September 2011, as always hungry. Daniel was observed scavenging for food and was stealing other children’s food. His mother said he had health problems and the school sought help from the family GP and the school nurse referred Daniel to the community paediatrician. In addition school staff noticed a number of injuries to Daniel on his head and neck which were not explained. These were not linked to the eating problems and did not lead to any onward referral or other intervention; Improving health services…
An appointment with a community paediatrician in February 2012. This examination linked his low weight and eating problems to a likely medical condition and did not consider emotional abuse and neglect as a possible cause of Daniel’s weight loss. Improving health services…
Additional key features of this case: Daniel’s mother and step father set out to deliberately harm • him and to mislead and deceive professionals . Patterns of domestic abuse and violence alongside • excessive alcohol - Police were called to 26 separate incidents at the family home. • Lack of consistency in officers dealing with separate DV incidents • Excuses made by Daniel's "controlling" mother were accepted by agencies Professionals needed to "think the unthinkable" and act • upon what they saw, rather than accept "parental versions" ** Daniel's "voice was not heard" because English was not his • first language and he lacked confidence • No record of "any conversation" held with Daniel about his home life, his experiences outside school, or of his relationships with his siblings, mother and her partners Improving health services…
Current position Action required 1 • Monitoring of the implementation of the Pre-birth to 5 years pathway review and No action required development of health visiting and the service redesign in progress (Integrated implementation of the healthy child programme Commissioning Unit) 2 • Ensuring that the notifications in respect of In place domestic abuse are processed appropriately in GP Practices. CYP notification has been rewritten in view of the process now being managed by the Joint The CCG should gain an understanding of how Action Team (JAT). CYPs are screened by a CYP notifications about domestic abuse are senior practitioner in social care then given to No action required managed and processed by Solent NHS Trust the JAT health visitor who forwards them and gain assurance that the system is effective HV/SN teams. The admin teams forward to in sharing and the recording of information. the relevant HV and upload onto the child’s electronic record (Solent NHS Trust). 3 CCG to ensure GP Practices use the In place No action required recommended READ codes for child safeguarding to alert other health professionals of their concerns 4 • All GP Practices should have a named health In place No action required visitor who liaises with GP Practices about All GP practice populations have a dedicated vulnerable children HV team who liaise closely with their surgery. All HVs are based together ‘hot desking’ at Wimbourne St James (Solent NHS Trust). Improving health services…
Current position Action required 5 Use of interpreters In place and no evidence known that the No action required current systems are not effective 6 The CCG to seek assurance that the WIC In place for GP Practices Executive Lead and Named includes a requirement for routinely notifying GP to review a sample of attendance of children to GPs and to notify The HV/SN only receives notifications from notifications. health visitors or school nurses of any ED QAH, not the Walk- in centre at St concerns and record the name and Mary’s (which is managed by Care UK in Designated Nurse to visit relationship of the person attending with the Portsmouth) unless there is a concern. safeguarding leads in WIC child. The notification from ED does have who (Care UK). brought child and relationship (Solent NHS Trust). 7a • • Medical staff considering child abuse as a TARGET ½ day held April 13 Ensure lessons from • differential diagnosis where there are Dec 12 LSCB study day – Neglect SCRs disseminated unclear concerns (including domestic abuse) through training and • All health professionals working monthly newsletter to 7b Training in identifying neglect and emotional across Portsmouth area have access GP Practices • neglect to multi-agency training (LSCB) Ensure NICE Guidance 89 is available on CCG website Improving health services…
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