WELCOME Improving health services Learning Lessons from Serious - - PowerPoint PPT Presentation

Improving health services…

WELCOME

Improving health services…

Learning Lessons from Serious Case Reviews

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‘There should be a culture of continuous learning and improvement across the

• rganisations that work together to safeguard

and promote the Welfare of children’ (Working Together 2013:66) ‘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)

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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
• rganisational, capacity and capability problems in key

agencies

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Daniel Pelka

SCR Published September 2013 (Coventry LSCB)

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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;

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Daniel’s presentation in school, which Daniel started in September 2011, as always hungry. Daniel was

• bserved 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;

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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.

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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

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Current position Action required 1 Monitoring of the implementation of the development of health visiting and the implementation of the healthy child programme

• Pre-birth to 5 years pathway review and

service redesign in progress (Integrated Commissioning Unit) No action required 2 Ensuring that the notifications in respect of domestic abuse are processed appropriately in GP Practices. The CCG should gain an understanding of how CYP notifications about domestic abuse are managed and processed by Solent NHS Trust and gain assurance that the system is effective in sharing and the recording of information.

• In place

CYP notification has been rewritten in view of the process now being managed by the Joint Action Team (JAT). CYPs are screened by a senior practitioner in social care then given to the JAT health visitor who forwards them HV/SN teams. The admin teams forward to the relevant HV and upload onto the child’s electronic record (Solent NHS Trust). No action required 3 CCG to ensure GP Practices use the recommended READ codes for child safeguarding to alert other health professionals

• f their concerns

In place No action required 4 All GP Practices should have a named health visitor who liaises with GP Practices about vulnerable children

• In place

All GP practice populations have a dedicated HV team who liaise closely with their surgery. All HVs are based together ‘hot desking’ at Wimbourne St James (Solent NHS Trust). No action required

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Current position Action required 5 Use of interpreters In place and no evidence known that the current systems are not effective No action required 6 The CCG to seek assurance that the WIC includes a requirement for routinely notifying attendance of children to GPs and to notify health visitors or school nurses of any concerns and record the name and relationship of the person attending with the child. In place for GP Practices The HV/SN only receives notifications from ED QAH, not the Walk- in centre at St Mary’s (which is managed by Care UK in Portsmouth) unless there is a concern. The notification from ED does have who brought child and relationship (Solent NHS Trust). Executive Lead and Named GP to review a sample of notifications. Designated Nurse to visit safeguarding leads in WIC (Care UK). 7a 7b Medical staff considering child abuse as a differential diagnosis where there are unclear concerns Training in identifying neglect and emotional neglect

• TARGET ½ day held April 13
• Dec 12 LSCB study day – Neglect

(including domestic abuse)

• All health professionals working

across Portsmouth area have access to multi-agency training (LSCB)

• Ensure lessons from

SCRs disseminated through training and monthly newsletter to GP Practices

• Ensure NICE Guidance

89 is available on CCG website