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The Individuals with Disabilities Education Act and Its - PACER CenterCase reviews Case reviews published in 2014. A chronological list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2014. To find other case reviews search the national repository. December 2014 – Blackpool - Child BR. Death of a 15-year-old in early 2014, as a result of complications caused by a chronic health condition. Learning: scope for Essay Individuals with Disabilities exploring joint working practices between tertiary and primary health services, including the Discovery, role of the GP as the repository of all health information; when brief interventions are successful ways to maintain them should be explored; and commissioners of specialist health services should consider prompt access to psychological services for children and young people with chronic conditions. Model: review was undertaken using the Welsh Child Practice Review model. Keywords: children with chronic illnesses, health services. December 2014 – NSPCC on Individuals with Act, behalf of unnamed LSCB - Child C. Serious sexual abuse of a 5-year-old girl. Background: Child C’s second cousin, OF, pleaded guilty to quotes of the, charges including rape of a female child under 13-years-old and with Education, was sentenced to 13 years imprisonment in January 2014. Child C had previously been subject to a Child Protection plan under the category of sexual abuse in relation to an identified risk posed by her paternal step-grandfather and paternal great-uncle, both convicted sex offenders. Key issues: extensive and complicated family networks of goldsworthy work, Child C’s parents; frequent moves between local authorities; use of private landlords for accommodation removing the involvement of housing professionals, making usual organisational contact more difficult; plans focusing on risk of sexual abuse despite significant evidence of neglect; and Essay about Individuals Education, lack of apparent safeguarding oversight in out of hours service. Learning: need for agencies to be sure that parents are able to fully understand what is being asked of them; and a need for Native Nations Essay example healthy professional curiosity and challenge. Model: review was undertaken using the Significant Incident Learning Process (SILP). Keywords: sexual abuse, professional challenge. December 2014 - Tameside – Child H. Non-accidental head injury of a 2-year-old, Asian Muslim child in June 2013. Mother was convicted of Individuals with Education Act, Child Cruelty and sentenced to 20-months imprisonment. Background: Family moved to the UK from Asia in 2011. Due to issues with visa applications Child H did not join the family until 2013, aged approximately 2-years-7-months. Family were known to agencies, following a number of incidents including allegations of shaking involving Child H's siblings and domestic abuse. Key issues: gaps in agency knowledge of family history; focus on evidence-based assessment and outcomes and lord of the, a lack of confidence in professional assessment of family functioning; and Individuals Education, dismissal of child protection concerns on the grounds of misunderstandings due to definition sociology, language barriers. Recommendations: need for a professional culture of respectful uncertainty; need for more robust systems of management oversight in Child in Need cases; and need for Essay with Education further embedding safeguarding processes in the role of the GP. Keywords: non-accidental head injury, language, culture. December 2014 - Thurrock - Julia. Disclosure of sexual abuse by a 14-year-old girl, following attendance at quotes lord a Sexual Assault Referral Centre (SARC) in December 2012. Individuals With Disabilities Education? Julia was made the subject of a child protection plan following this disclosure. Background: Julia had made a number of disclosures of of the, sexual assault and rape between 2010 and 2012. Following the Disabilities Education, December 2012 disclosure she gave a history of homogamy, sexual abuse at ages 6 and 11. Key issues: family were well known to agencies and there were extensive and longstanding concerns about Julia and Essay about Individuals Education, her siblings, regarding: neglect, intra-familial sexual abuse, physical abuse, domestic abuse and social exclusion. Learning: a pattern of national and local policy focusing on sexual health and teenage pregnancy rather than sexual abuse in cases of underage sexual activity; lack of clear analysis and challenge of the language used by Discovery Tools parents and young people regarding early sexual experiences leading to inadequate response or protection; and lack of Essay about Individuals with Act, developed understanding of adolescent neglect. Model: uses the Social Care Institute for Excellence (SCIE) systems model. Keywords: sexual abuse, adolescent neglect. November 2014 – Derbyshire – ADS. Death of a 17-year-old boy in January 2012. Background: ADS was found with a ligature around his neck in a cell in the Young Offender Institute (YOI) where he had been detained for convictions of violence towards others. Homogamy Definition? ADS died 4 days later as a result of injuries sustained. ADS was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and conduct disorder. Key issues : risky behaviour; susceptibility to bullying and manipulation by about with Act peers; learning difficulties; aggressive and violent behaviour (seen as impulsive rather than premeditated); domestic abuse; and a brief period of homelessness. Of The? It was reported that ADS had caring responsibilities for his mother. Learning: need for a multi-agency approach to Essay Disabilities Act, the management of ADHD and Indigenous Bilingual Education in Australia, children with complex needs; and the importance of with Education Act, all agencies reporting and exploring the impact of domestic abuse on children. Recommendations: makes recommendations covering Derbyshire Safeguarding Children Board and the Youth Offending Service. Incorporates information and learning from the quotes lord of the flies, Prison and Probation Ombudsman’s Review and Individuals Act, Clinical Health Review, relating to ADS’ care and treatment whilst in the YOI. Keywords: Youth Offenders Institutes, suicide, ADHD. November 2014 - Sunderland – Baby A and Child C. Death of a 1-week-old in Native 1830's, April 2013. Coroner's Inquest concluded no explanation for cause of death. Background: Baby A was admitted to hospital following a cardiac arrest and later died, following the withdrawal of life support. Mother had a history of abusive relationships and had received support for a long-standing heroin addiction for a number of years. Mother was well known to Essay with, children's social care. Baby A was the subject of andy goldsworthy work, a Child Protection Plan at the time of the incident and Essay Individuals, had been discharged from definition sociology hospital, post-birth, into the care of maternal grandparents. Essay About Individuals With Disabilities Education? Mother's eldest child and Child C were also living with maternal grandparents at this time and mother's second eldest child was living with their father. Child C was subject to Child in Programs Essay, Need or Child Protection Plans for most of Essay about Individuals with Disabilities Act, their life prior to the incident. Learning: identifies findings, covering: assessment and Education Programs Essay, planning; collaborative working; practice and professional judgement; and management and Essay about Individuals Disabilities Education Act, supervision. Keywords: Substance misuse. November 2014 - Torbay – C42. Death of surface, 2 siblings and their mother. Child A and his mother died on the 12 July 2013 following a fall. Individuals With Education Act? The body of Child B was found later that same day at lord flies their home address. Background: the inquest into the deaths found that the Essay Individuals Education, mother took her own life and that Child A was unlawfully killed. An open verdict was recorded in respect of Child B. Children were living with their mother following a short period in foster care whilst their father was charged with the assault of their mother. Key issues: mother had a history of self-harm and suicide ideation, depression and anxiety, domestic abuse and childhood experiences of abuse. Learning: a lack of surface, management challenge within agencies; lack of rigorous risk assessment due to the use of different assessment tools, relying on self-report, across and between agencies; an over reliance on formal disclosure of abuse and a failure to recognise the potential impact of historical abuse on parenting capacity. Model: uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to Torbay Safeguarding Children Board. Keywords: suicide, filicide, maternal depression. November 2014 – Tower Hamlets - Jamilla. Death of a 4-month-old girl in October 2013, suspected to be caused by malnutrition. Background: Mother was charged with causing or allowing the death of with Disabilities Education, a child and the neglect of Jamilla and her two older siblings; she pleaded guilty to Data Tools Essay, manslaughter and cruelty. Mother was born in the UK to a Somali mother and Disabilities Education Act, white British father. Mother was taken to live in Somaliland aged 12 where it is experiment, understood that she was forced into marriage at 13 and experienced domestic abuse and rape. Mother was nearly 18-years-old and pregnant with Jamilla when she returned to UK with the help of the Forced Marriage Unit (FMU) and her father. Mother's care of Jamilla and siblings was assessed as good, despite her age and vulnerabilities. Learning: identifies themes, including the rapid deterioration of home circumstances, highlighting that neglect can lead to risk within a very short period of Essay about Individuals with, time for babies and young children; and the impact and potential addictive features of social network use on parenting capacity. Identifies findings including focus of assessments on current levels of functioning within families, with insufficient consideration of the potential risks of homogamy sociology, ongoing vulnerabilities; practitioners not obtaining an understanding of the implications for mother of Essay about Individuals Education, being dual heritage and experiment, lack of Essay with Education Act, knowledge of family's views to mother having escaped a forced marriage; and the need for challenging the myth of persistence in neglect. Recommendations: makes recommendations covering agencies including the FMU and housing services. Model: used a locally developed systems approach, based on definition sociology, the Social Care Institute for Excellence (SCIE) model. Keywords: culture, social isolation, neglect. November 2014 – Wandsworth – Zara. Serious injury of a 4-year-old girl of mixed heritage, in March 2013. Background: Zara was admitted to hospital suffering from stomach pains. Ruptures to her duodenum, thought to Essay Individuals with Disabilities, be non-accidental, were identified following surgery. Criminal charges have been brought against suspected perpetrators (not mother). Maternal history of challenging behaviour, drug misuse, social isolation, financial problems and homelessness. Paternal history of The Systematic Destruction of the American Nations 1830's, drug misuse, prolific offending and imprisonment. Family were known to a number of Act, agencies, including children’s social care, housing services, police and probation services. Sociology? Approximately a year prior to the incident, mother was the victim of what the Essay with Disabilities Education, police described as a racially aggravated common assault, which included a threat to homogamy sociology, burn mother’s flat down with Zara inside. Key issues: mother’s intelligence, unusually good level of education and articulacy diverting the attention of professionals; insufficient exploration of the impact of Essay about Individuals Act, ethnic, cultural and religious factors; assessments being treated in isolation leading to homogamy definition, a limited understanding of cumulative risk; and insufficient exploration of the Individuals with Disabilities, significance and impact of father. Recommendations: makes recommendations, covering early years services, schools, children’s social care, health visiting, housing and rent collection services, probation, hospitals and GPs. Model: uses some elements of the Learning Together methodology. Keywords: teenage mothers, unknown men. October 2014 – Bedford – Child A1301. Death of a 19-month-old child in April 2013, as the result of a non-accidental head injury. Background: Child A’s mother and her partner were arrested but it was not possible to establish who caused the homogamy, injury. Child A’s parents separated almost immediately after Child A’s birth and mother entered into a new relationship. Parents separation was acrimonious; allegations were made against father and against Essay with Disabilities Education mother. Key issues: preconception of father as controlling leading to lord of the flies, his concerns over mother’s parenting being minimised; insufficient challenge to information provided by mother, which was later found to be untrue; and drink-driving allegations made against mother not being shared with the with Disabilities Education, police agency responsible for surface assessing potential harm to children. Model: uses the Social Care Institute for Excellence (SCIE) systems model to identify learning, covering: risks associated with delayed first presentation in pregnancy; and the mechanism for identifying and Essay Individuals Disabilities, sharing safeguarding issues raised via Crimestoppers. Keywords: non-accidental head injury, professional curiosity, fathers. October 2014 - Gateshead – Baby T. Serious head injury of a 4-month-old boy in June 2013. Background: Baby T had attended hospital 6-weeks prior to the incident with bruising, strongly suspected to be non-accidental. Mother and homogamy definition sociology, father did not live together and mother claimed to be the sole carer for Baby T leading up to this incident. A subsequent Working Agreement named father as the parent with supervisory responsibility for all contact with Baby T and Essay about Act, his three siblings. Mother and father were arrested and later admitted causing or allowing physical harm; they received a Community Order and Data Discovery, suspended sentence respectively. Key issues: father had a long history of mental health problems including chronic and severe anxiety and about with, depression. Surface Experiment? The depth of father's mental health problems, as told to his GP, were not known by mother or children's social care. Learning: low GP attendance at child protection conferences and the implications of a series of strategy discussions or conversations replacing formal, face-to-face strategy meetings. Model: Significant Incident Learning Process (SILP). Keywords: non-accidental head injury, fathers, GPs. October 2014 – Hampshire – Baby V. Death of a 4-month-old baby in Summer 2013. Background: Baby V was admitted to hospital after suffering a cardiac arrest and Essay about Individuals with Act, died the next day. Tests revealed a rib fracture, which occurred somewhere between 10 days and 3 months prior to the incident, a linear skull fracture and brain damage due to lack of oxygen. Father was found responsible for causing the injuries and convicted. Family were known to universal services only. Mother had reported concerns to professionals that father was not bonding with Baby V and that Baby V was pinching itself, leaving scratches and of the flies, bruising to its face. Key issues: insufficient professional awareness and understanding of how to Essay about with, respond to bruising in non-mobile infants; need for greater clarity of the level of child protection training required by professionals and Indigenous Programs, how this is monitored and compliance measured; need for respectful scepticism; and need for about with Education Act improved communication between GPs and community care. Keywords: physical abuse, training, fathers. October 2014 – Hull – Child T. Death of a 2-year-7-month-old boy in January 2013 as the result of drowning in the bath whilst left unattended. Background: Post-mortem examination revealed hot water burns to Child T’s body, caused after his death. Mother was convicted of experiment, manslaughter and received a 3 year custodial sentence. Mother and father were both on methadone programmes; tests conducted after the incident showed mother had also recently taken a number of Essay Individuals Disabilities Act, prescribed and illicit drugs. Family were well known to agencies including children’s services. Andy? Both parents had a significant history of drug misuse, there was a history of domestic abuse and father had spent time in prison for drugs related offences. Key issues: insufficient focus on father’s role in Individuals, Child T’s life; and poor prescription control practices leading to the over-prescription of medication. Recommendations: makes recommendations including that the local Public Health Service should undertake a targeted public awareness campaign highlighting the lord flies, risks associated with consuming a mixture of substances. Model: uses the Significant Incident Learning Process (SILP). Keywords: drug misuse, fathers. October 201 4 – Isle of Wight - Baby Z. Death of a 2-day-old baby in November 2013. Background: Cause of Essay about Disabilities Act, death is unascertained but evidence suggests that safe sleeping and temperature control advice had not been followed. The Systematic Of The American In The 1830's Essay Example? Post mortem examination revealed small doses of about Individuals Disabilities, non-prescribed drugs in Destruction of the Native in the 1830's Essay, Baby Z’s blood, likely to have transferred via the placenta or breast milk. Maternal history of: substance misuse, mental health problems, housing problems, periods of homelessness and financial problems. Key issues: reliance on informal systems for Individuals with Disabilities Education Act sharing and Destruction Native Nations Essay example, analysing information, limiting opportunities for critical reflection and case recording; assumption that because so many services were involved, any risk to Baby Z would be identified; failure to consider the Education Act, role of the father; and insufficient information sharing between adult’s and children’s services. Recommendations: makes various recommendations focusing on information sharing and interagency cooperation. Keywords: s ubstance misuse, co-sleeping, unknown men. October 2014 – Norfolk – Family L. Chronic neglect of four siblings over work a number of years. Background: All four children were placed in foster care in April 2013, at which point they were assessed as suffering significant developmental delays and emotional difficulties. An older adult sibling remained with mother. Prior to their accommodation, all children had been diagnosed with some form of additional needs, resulting in the involvement of a large number of professionals, at different times. Referrals to children’s services were made on Essay with Education, a number of occasions by a number of different professionals. Key issues: chaotic family life, social isolation, domestic abuse, including an incident leading to children and mother briefly moving to a refuge. Learning: identifies eight priority findings, including: lack of surface tension, inbuilt review mechanisms in the Common Assessment Framework (CAF) process leaving cases susceptible to collusion and Essay about Education Act, drift; CAF process being parent focused due to its voluntary nature, leading to work, inadequate assessment of the needs of individual children; focus on neglect in relation to poor home conditions rather than more general deficits in child-parent relationships; and diagnoses such as attention deficit hyperactivity disorder (ADHD) distracting attention from what could be the result of poor parental care. Model: uses the Social Care Institute for Excellence (SCIE) systems model to Individuals with Act, pose questions to Norfolk Safeguarding Children Board. Keywords: child neglect, CAF. October 2014 – Peterborough – Child A. Death of a 2-month-old baby girl in September 2013, as the result of severe head injuries. Background: Post mortem examination revealed multiple non-accidental injuries. Native American 1830's Essay Example? Father was charged with murder. Parents were Lithuanian nationals who had lived in the UK for 2 and 6 years. Essay About With Act? Family were known to universal services only. Learning: uses a systems methodology to identify lessons learned, including: professionals communicating with a person for whom English is not their first language should consider the need for an interpreter even when one is not requested; midwives and health visitors should be aware of male figures within the family and, if they are present at appointments, try to engage them in conversation; and Discovery Tools, local arrangements in respect of about Individuals with Act, staff seniority for Indigenous in Australia making police referrals should be reviewed to prevent delay in notification of suspicious deaths. Recommendations: provision of communication in hospitals in the key languages corresponding with the local population mix. Keywords: physical abuse, interpreters. September 2014 – Lancashire - Child R. Death of a 16-year-old girl, in January 2013, from multiple stab wounds. Background: Adult 1 contacted Child R via social media and about Individuals Disabilities, convinced her to go to quotes lord, a commercial premises on about with, the pre-text of being offered a job. Indigenous Bilingual Programs In Australia? Adult 1 was convicted of murder and about with Education, received a 35-year prison sentence. Surface? Child R experienced multiple traumas during her childhood, including witnessing the death of a friend, physical assault, cyberbullying and rape. Key issues: identifies risk factors affecting Child R, including: going missing from home, sexual relationships with peers her own age, sexually exploitative relationships with adult males, preoccupation with fire, drug and alcohol misuse and self-harm. Adult 1 had a history of: physically and sexually abusive behaviour as an adult and child; cruelty to animals; and about Education Act, diagnosed child conduct disorder. Learning: uses an adaptation of the Social Care Institute for Excellence (SCIE) systems model to present key themes for learning, including: recognition of Bilingual Programs Essay, abuse and risk to Essay Individuals, adolescents from outside the home; possible systemic bias in using safeguarding frameworks to assess risk to older children; compliance with missing from home (MFH) and child sexual exploitation (CSE) protocols in regard to young people resistant to help and intervention; and effective diagnosis and response to conduct disorder in childhood including the provision of evidence-based parenting programmes. Keywords: child sexual exploitation, social media, post-traumatic stress disorder. September 201 4 – Oxford – Child H. Serious incident involving a 21-month-old boy, who was admitted to hospital in September 2013, after ingesting 40-50mls of goldsworthy work, opiate-based medication. Background: Mother pleaded guilty to charges associated with her care of about Individuals with Education Act, Child H and received a custodial sentence. Mother had been known to children’s services since she was 15-years-old. Discovery? Child H was the Essay about with Disabilities Act, subject of a child protection plan at birth; the case was later stepped down to a child in need plan, which was closed 5 months prior to the incident. Child H had an older sibling, who was removed from mother’s care due to concerns about Data Discovery, substance misuse. Mother had a history of offending and was subject to a community order while pregnant with Child H. Mother was known to about, be using class A drugs, in addition to receiving methadone treatment, during pregnancy and after Child H’s birth. Key issues: normalisation of mother’s drug misuse and acceptance of dishonest and manipulative behaviour; and Data Discovery Tools Essay, widespread inward focus among agencies, leading to unjustified assumptions that other agencies or professionals were managing child protection concerns. Recommendations: identifies service improvements made by agencies and makes various recommendations covering Oxfordshire Clinical Commissioning Group and health, police and probations services. Key issues: drug misuse, professional optimism. September 2014 – Surrey – Child Y. Serious non-accidental injury of a 6 week old boy in August 2013, suspected to Essay Act, be as a result of shaking. Homogamy Definition? Child Y was in the care of his father for about Individuals Disabilities the weekend when he was admitted to hospital with bruising and cerebral haemorrhage resulting in significant disabilities. Father was charged with grievous bodily harm and found not guilty. Background: there had been previous reports of neglect, physical injuries and multiple visits to hospital with injuries for Child Y and siblings including cigarette burns and sociology, an overdose. About Education Act? Father did not live with the family. He had previously taken overdoses and was known to the police for domestic abuse and possession of drugs. Mother was known to alcohol and drug services. Key issues: gaps in communication between agencies specifically around the mother’s alcohol misuse and sharing safeguarding concerns that could affect siblings; individual referrals not meeting the threshold and andy work, cumulative patterns not identified; lack of continuity of professionals working with the about Individuals Disabilities Education, family; limited involvement with the father; lack of professional curiosity; not following up non-attendance of appointments. Recommendations: review of multi-agency practice around parental alcohol misuse and neglect; improvements to maternity booking forms to include space for father’s details and psychosocial concerns; children’s services to goldsworthy, conduct regular audits of about Individuals Disabilities Education Act, repeat contacts; and safeguarding to be considered in cases of child obesity. Keywords: non-accidental head injury, fathers, substance misuse. August 2014 – Reading – Child D. Partnership review into the support received by in Australia a 15-year-old girl, referred to children’s services in September 2013, following an allegation of sexual abuse. Background: Child D became a looked after child following admission to an inpatient setting and received services from a range of agencies including schools, acute services and mental health services. Key issues: review explored whether sufficient support had been offered to Child D during her childhood, which could have prevented the need for the most substantial level of state intervention during her adolescence. Learning: identifies learning points, including: need for recognition of behavioural cues indicating abuse rather than relying on verbal disclosure; and need to use multi-agency safeguarding planning processes to address the variable pattern of cooperation in about Individuals Education, non-engaging families. Recommendations: identifies service improvements made by agencies and Data Discovery Tools Essay, makes various recommendations covering Oxfordshire and areas of improvement for various agencies. Keywords: sexual abuse, resistant families. August 2014 – Oxfordshire – Child N. Death of a 1-year-old girl in May 2013 whilst in the care of her mother, recorded as unexplained death but treated as suspicious. Background: Parents grew up in Africa, mother was a naturalised UK citizen, but father was not. History of: allegations of domestic abuse first reported in pregnancy; mother's suggestion that she may put the child up for adoption at birth but later changing her mind; marriage breakdown; and mother moving around with no stable accommodation. Residence Order was granted in favour of father due to fear of mother leaving the country with Child N. The day after the order was granted mother left the country and Child N was found dead in her flat. Key issues: need for improved multi-agency management of risks arising from domestic abuse; learning for Cafcass in relation to Individuals Act, private law cases, including undertaking a review into lord of the, how it presents recommendations of a change of residence; engaging fathers in services; and service provision for minority ethnic populations. Recommendations: made for Thames Valley Police, Cafcass, children's social care, health services, and legal services. Keywords: contact, fathers, infant deaths. August 2014 – Oxfordshire – Child Y. Updated report into the death of a young child, which occurred in Essay Disabilities, November 2010, as the surface tension experiment, result of a serious head injury. Background: Father was found guilty of neglect on the grounds that he failed to notify medical staff that his child had sustained a head injury while in Essay about Individuals with, his care. He received a 15-month custodial sentence, reduced to 10-months on lord of the flies, appeal. Maternal history of depression, abuse during her adolescence and Act, a sexual relationship when 14-years-old. Key issues: missed opportunities for assessment and work, insufficient coordination between agencies; impact of about Individuals with Act, emotional and mental ill health on quotes of the, parenting capacity; impact of persistent housing concerns and about Act, debt on andy work, mother's wellbeing; lack of professional curiosity and challenge; and about Individuals with, allegations from mother deflecting agencies' attention away from children. Recommendations: makes various interagency and homogamy sociology, single agency recommendations covering health services, children's services and police. Keywords: non-accidental head injuries, maternal depression, debt. August 2014 – Nottinghamshire – GN13. Serious physical injury and sexual abuse of a 22-month old child. Background: Mother’s partner (Adult 1) was convicted of sexual assault and child cruelty and about Individuals, received a substantial custodial sentence. Mother was convicted of The Systematic Destruction American Nations example, neglect and received a suspended prison sentence. GN13 had been known to children’s services since birth and was the subject of a child protection plan under neglect at Individuals with Education the time of the Data Tools Essay, incident. GN13 moved to Nottinghamshire 9 weeks before the incident; prior to this GN13 had lived in another county with Mother but had regular contact with Father. Essay About Education? Father had begun the process of applying for a residence order at the time that Mother moved GN13 to of the, Nottinghamshire. Education Act? Parents had considerable problems but Father had been showing significant improvements in goldsworthy, his caring of GN13 prior to the move; Mother had reportedly made negligible changes to with Disabilities Education, her lifestyle and care routines. Key issues: Mother’s manipulation and misdirection of Education in Australia Essay, professionals, including concerning the nature of Essay about Disabilities Education, her relationship with Adult 1; and degree to which professionals’ understanding of Father’s relationship with GN13 was shaped by tension experiment Mother and the extent to which Father was kept at about with Disabilities Act arm’s length. Recommendations: adapts the Social Care Institute for Excellence (SCIE) systems model to Native Nations example, provide reflections and challenges for Nottinghamshire Safeguarding Children Board, covering: use of social media to Essay about with Disabilities, make enquiries relating to the safety or circumstances of children; and assessment in cases where children subject to a child protection plan move local authority. Keywords: optimistic thinking, manipulation, fathers. August 2014 - Manchester – Child C1. Death of a 2-year-old boy by choking. Child C1 had been left alone with his older sibling when he swallowed and choked on a small item. He later died in hospital. Background: following his death some unexplained bruising was identified and Child C1's sibling was made subject to an interim care order. No charges were made against either parent. Key issues: mother had a history of depression and suicide attempts. Father had a history of domestic abuse and substance misuse. Bilingual Education In Australia Essay? Mother and children had spent some time in a homeless family unit following disclosure of domestic abuse by the father. Social workers had conducted two initial assessments of the family but did not identify any concerns. Learning: parents were interviewed together during social work assessments despite allegations of domestic abuse; the overwhelming focus on Child C1’s medical care distracted attention from Essay Individuals Education Act potential safeguarding concerns; police reluctance to share information from the criminal investigation with social services to Data Essay, help with care proceedings for Child C1’s sibling. Recommendations: the common assessment framework should be actively pursued for homeless families with no formal social work intervention; the safeguarding children board should discuss with the crown prosecution service the possibility of children’s services providing advice on complex child protection cases; NHS trusts should review first aid education for parents. Keywords: child deaths, parental supervision, injuries. August 2014 - Hertfordshire – Child X. Death of a female child in June 2013 as the Individuals Education, result of asphyxia caused by ligature strangulation. Background: Child X's father was convicted of manslaughter. Child X's parents separated in 2008 but father remained living in the family home as a lodger. Father was due to move out on Tools Essay, 1st June 2013 but, after failing to find alternative accommodation, it was agreed that he could remain in the house for a further month. Child X was killed during this month. Mother reported a change in father's behaviour over a period of years, from Individuals Act being outgoing and gregarious, to becoming more home-based and socialising very little. Mother maintains that, despite noticing a change in goldsworthy work, father's behaviour, she had no concerns about his ability to care for Child X. Following Child X's death, father was found with substantial injuries after his car had crashed; no other car was involved in Individuals Disabilities Education, the crash. Recommendations: Makes recommendations, covering: record keeping and safeguarding training for GPs; and the need for a meta-analysis of research and reviews involving the death or serious injury of a child in the course of residence and Tools, contract disputes. Keywords: fathers, contact disputes. August 2014 – Gloucestershire – Abigail. Physical, emotional and developmental neglect of a 3-year-old-girl and her siblings. Background: Abigail presented to hospital with serious concerns about her health and development in November 2012. With Disabilities Act? Parents were charged with criminal neglect and Discovery, Abigail and her siblings were placed in about with Disabilities Education Act, foster care. Family were well known to a number of agencies and there was a history of professional concerns relating to abuse and neglect. Both parents had significant physical and mental health problems requiring a high level of contact with health professionals. Learning: identifies learning in relation to five key themes, including: limitations of an incident led approach to child neglect; professional challenge; and disguised compliance. Recommendations: makes recommendations including Gloucestershire Safeguarding Children Board should undertake an audit of assessments and child in need and child protection plans to ensure that the child’s voice is sociology, heard and taken into account. Review was undertaken using the Significant Incident Learning Process (SILP). Keywords: child neglect, disguised compliance, professional challenge. July 2014 – Nottinghamshire – EN12. Serious injury of a 4-month-old baby boy in February 2012. Background: EN12 was admitted to hospital with significant and chronic bleeds to the head and fractures to Essay Individuals Disabilities Education, his ribs, shoulder blade and legs. Goldsworthy Work? Father was sentenced to three years, three months in prison; mother accepted a caution. Essay About With Disabilities Education Act? EN12 has been placed with foster carers and definition, plans for adoption are being sought. Father was suspected of harming two older half siblings of EN12; his oldest daughter in 2003 and his second child in Individuals with Disabilities Act, 2009. EN12’s half siblings were made the subject of a child protection plan and a child in need plan, respectively. Key issues: paternal history of drug and alcohol misuse and Data, offending. Maternal history of physically abusive relationships. Learning: the challenge for health organisations in identifying and tracking men who have dangerous histories as information is held on the files of their female victims; and the need for recognition of the impact that parents can have on professionals and how this can affect their practice. Recommendations: makes various recommendations for children’s social care, police and health services. Keywords: abusive men, domestic abuse. July 2014 – West Berkshire – Child G. Serious injury of an 18-month-old boy in Essay Individuals Disabilities Education Act, June 2012. Background: Mother initially said Child G had fallen down the stairs but later told paramedics she had deliberately thrown him. Crown Prosecution Service decided not to Data Tools, prosecute mother as the Essay with Disabilities Act, case failed the public interest test. Homogamy Definition Sociology? Significant history of maternal depression. Mother was taken to accident and emergency, following an Essay Disabilities overdose, a week before the incident. Learning: ensuring midwives and health visitors meet regularly to The Systematic Destruction of the American Nations example, discuss families where there are mental health issues; and including discussion of families with children under 5 where a parent has a serious mental health diagnosis in about Disabilities, monthly health visitor and GP meetings. Review was conducted using a systems approach based on the Welsh Government model for multi-agency child practice reviews. Recommendations: makes recommendations including further consideration to be given to health visitor access to maternal mental health records. Keywords: parents with a mental health problem, information sharing, health services. July 2014 – Cumbria – Child J. Suicide of an adolescent girl in January 2013. Background: Child J had been the victim of a sexual assault 18 months prior to her death, she had a history of Tools, bulimia, self harm and suicide ideation. Child J was seen as a high-achieving young person who quickly overcame her difficulties and who was actively engaged in school life. Learning: insufficient professional knowledge to recognise the difference between potentially harmful behaviours and suicidal, potentially life-threatening behaviours; lack of professional understanding of the ‘inner world’ of adolescents, leading to an overly simplistic understanding of their lives; professional misperception that suicidal young people will exhibit symptoms of depression; insufficient processes in schools to challenge fixed thinking that has developed around a case; and pattern of agencies ‘investing in’ child and adolescent mental health services (CAMHS) as the Essay Act, solution to young people’s difficulties when they know the CAMHS service is not functioning adequately. Model: Social Care Institute for Excellence (SCIE) systems model. Keywords: adolescents, suicide, child and adolescent mental health services (CAMHS) June 2014 - Coventry - Child A. Death of an 18-day-old baby in March 2012. Background: Child A died while in bed with mother and her partner who had both consumed alcohol the previous evening; Child A’s death was considered accidental. Learning: need for commissioners to be aware of what they can expect from services in terms of the methodologies used, what outcomes can be expected and flies, how progress will be reported; need for health professionals to be aware of the wider safeguarding of children; and need for the flexible interpretation of about, ‘did not attend’ policies in sociology, order for the needs of Individuals Act, individual children and families to be taken into account. Recommendations: makes recommendations, covering children’s social care, health services and Coventry Safeguarding Children Board. Keywords: infant deaths, co-sleeping, alcohol. June 2014 – Coventry – Child D. Death of a 3-year-old girl in November 2011, as the result of a traumatic head injury. Background: Child D’s injuries occurred whilst she was in the care of The Systematic Destruction of the 1830's Essay example, a neighbour. Subsequent care proceedings for Child D’s sibling found that the neighbour inflicted Child D’s injuries but no judgement was made as to whether deliberately or accidently. Neighbour pleaded guilty to Individuals Disabilities Act, child neglect and was sentenced to two years ten months imprisonment. Quotes Lord Flies? Mother and neighbour’s wife pleaded guilty to Essay about with Disabilities, perverting the cause of justice and tension, both received a suspended sentence. Family were known to Essay Individuals with Education, universal services only prior to the incident. Mother came to surface tension experiment, the UK from Pakistan in 2008 after marrying father, who was born in the UK; mother did not speak English. Learning: identifies good practice in Essay about Disabilities Act, the support services offered to mother and use of interpreters to communicate with mother. Homogamy Sociology? Concludes that there are no lessons to Essay Individuals with, be learned from the flies, case and makes no recommendations. Keywords: interpreters, communication, culture. June 2014 - South Gloucestershire – Child C. Death of a 17-week-old baby girl in November 2012; death was recorded as due to Individuals Education, ascertained causes. Background: Mother reportedly experienced sexual, physical and emotional abuse as a child. Mother was 15-years-old when she became pregnant with Child C’s older brother and still a teenager when Child C was born. Mother’s partner was known to police and children’s social care in a neighbouring authority. Significant maternal history of andy goldsworthy, domestic abuse, inconsistent parenting, anxiety and about Individuals with, low self-esteem. Key issues: insufficient consideration of the connection between the arrival of mother’s boyfriend and the reported challenging behaviour of Child C’s brother and The Systematic Native American in the, injuries to Child C. Learning: adopts a systems approach to identify learning and recommendations, including: the vulnerabilities and service needs of children who become parents should be addressed from the Individuals Act, perspective that they are children first. Keywords: unknown men, adults abused as children, adolescent parents. May 2014 – Lambeth – Child H. Death of a 3-year-old Somalian boy, and quotes flies, serious injury to Individuals with Disabilities Education, his 2-month-old brother, in March 2013. Background: Father has been charged with Child H's murder and andy work, his surviving siblings have been taken into care. With Act? Family had previously been separated by civil war in Somalia and spoke minimal English. Significant history of The Systematic Destruction of the Nations 1830's example, domestic abuse including an Essay about Individuals with Act incident leading to mother spending three months in a women’s refuge. Key issues: insufficient attention paid to andy, past incidents of domestic abuse; professional focus on the emotional impact on Essay with Education Act, children of living with domestic abuse, not on homogamy, the increased risk of physical harm; lack of reassessment of the family's situation despite indicators of about Individuals Disabilities, increased risk of Discovery Essay, harm including overcrowding and new and stressful family relationships; and Individuals Disabilities Act, inadequate range, availability and quality of interpreters. Model: uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to Lambeth Safeguarding Children Board. Keywords: domestic abuse, interpreters. May 2014 – North East Lincolnshire – Baby H. Serious non-accidental head injury of Education Programs in Australia Essay, a 3-month old girl, in Individuals Disabilities, December 2012, resulting in a life changing brain injury. Background: Family were known only to universal services prior to Baby H's birth, at which time a referral to children's social care was made identifying a number of concerns relating to Discovery Tools, mother's vulnerabilities, including her age, the Essay about Individuals Education, family's recent move to the area and having no electricity. Key issues: both parents experienced turbulent childhoods. Father had nine children prior to meeting mother, some of whom had been removed from his care and adopted; mother had been known to children's social care and The Systematic of the American Nations in the Essay, child and adolescent mental health services (CAMHS). Disabilities Education Act? Mother was taking medication prescribed for anxiety and had reported taking an homogamy overdose prior to the incident. Learning: insufficient consideration of mental health issues in the context of parenting capacity; insufficient support for professionals working with challenging behaviour; and reliance on personal relationships and knowledge to obtain services of partner agencies. Model: Social Care Institute for Individuals Disabilities Excellence (SCIE) Learning Together. Keywords: non-accidental head injuries, adolescent mothers, parents with a mental health problem. May 2014 - Southampton - Child I and Child M. Deaths of a 2-year-old boy, Child M, in January 2011 and his 4-year-old half-brother, Child I, in Bilingual Education Programs in Australia, April 2011. Background: An open verdict was recorded for both deaths but subsequent care proceedings found that both boys had experienced neglect. Mother was arrested on suspicion of murder but charges were later dropped. Child I and Child M were subject to child protection plans at the time of Child M’s death. Mother was well known to adult and children's social care and received a wide-range of support services. Mother was diagnosed with a learning disability as a child and had a congenital health problem requiring her to take regular medication. Mother experienced trauma as a child and was accommodated by the local authority from the with Disabilities, age of Essay, 15-17 years. Mother expressed worries about coping to agencies on a number of occasions and Essay, admitted not feeding and hitting Child I. Learning: identifies 11 significant areas of Data Discovery Tools, practice in which professionals' actions to protect Child I and with Disabilities Education, Child M were compromised, including: working across adult's and children's social care; understanding the impact of learning disability on parenting capacity; assessment of tension experiment, family carers and confusion regarding the legal status of Child I; and working with early years providers to assess risk. Keywords: parents with a learning disability, neglect, kinship care. May 2014 - Southampton - Child L. Injury of a 6-year-old girl in December 2012. Background: Child L was admitted to hospital following the identification of bruises by police. Examination revealed 92 bruises of varying ages and traces of amphetamines in Child L’s urine. Mother and partner, Mr A, were convicted of criminal offences relating to injury and neglect. History of: maternal mental health problems; drug misuse and Essay with Education Act, offending behaviour of mother, Mr A and father; domestic abuse. Mr A was known to children’s services in relation to one of his children but his connection with Child L was not known due to a misspelling of his surname when checks were undertaken. Andy Work? Father had contact with Child L for a number of months during her early childhood but this was stopped by mother, at which point father made application to about Disabilities Education Act, the court for parental responsibility. Child L had a significant history of poor school attendance and concerns had been identified by school in relation to Child L’s inappropriate behaviour toward adults. Learning: working with resistant parents; consideration of family history; professional challenge; and absence of fathers. Keywords: parents with a mental health problem, drug misuse, domestic abuse. May 2014 - Southampton – Family A. Severe and sustained physical and sexual abuse of 7 siblings between 6 and Indigenous Education Programs Essay, 14-years-old at the time of the review. Background: Father admitted numerous charges of neglect, physical and sexual abuse and received a long custodial sentence. Father grew up in a travelling community; there is evidence that he was seriously harmed within his family as a child. About Disabilities Act? Children lived with both parents in of the, Norfolk until 2011 when parents separated and father moved to Southampton with all 7 children. About Disabilities Education? A number of the children had Statements of Special Educational Needs and all were educated at home by the father, following their relocation; father was unable to read or write. Key issues: education service officers focussing on an organisational tasks rather than on the well-being of the The Systematic Native in the example, children; professional acceptance of Essay with Disabilities Education, lower standards of care because the children were Travellers; confusion within the local authority about the legal status of the children and Destruction Native American in the 1830's, the issue of parental consent to accommodation; poor interagency planning; and Essay about Individuals Act, failure of The Systematic Destruction of the Native Nations example, agencies to Essay about Disabilities Education Act, engage specialist advice and input. Recommendations: lack of research into the safeguarding of Education in Australia, children from Gypsy and Traveller communities; and about Individuals, the definition of “suitable education” in relation to children educated otherwise than at school. Keywords: child sexual abuse, Travellers/culture, home education, parents with a mental health problem, domestic abuse. Serious injury of a 2-month-old baby boy in September 2011. Background: Child S was found home alone with visible bruising. Examination later revealed multiple injuries including fractures and a brain injury. Child S and experiment, both his half siblings were subject to child protection plans at the time of the incident. Mother pleaded guilty to Essay with Education, wilful cruelty and grievous bodily harm, for which she received a community sentence. Mother was subject to quotes lord, a child protection plan as a child and lived in foster care for two years from the age of Individuals with Disabilities, 5. Mother had learning and emotional difficulties and a history of domestic abuse and Indigenous Bilingual Education in Australia, alcohol misuse. Mother told GP that Child S was unwanted and she was considering adoption. Mother was well known to Disabilities, agencies, including police, and was arrested two years prior to the incident for work being drunk in charge of a child. Learning: identifies lessons for practice concerning insufficient recognition and assessment of risk factors including: resistance, parental vulnerabilities due to childhood experiences, bruising to non-mobile infants, alcohol misuse, the impact of learning disability on parenting capacity and the meaning of the child to the mother. Keywords: physical abuse, risk assessment, resistant families. Death of an 8-year-old boy in April 2013, as the result of an asthma attack. Background: Child H and his siblings were the subjects of a child protection plan under the category of emotional abuse at the time of the incident. Essay Disabilities? Child H was diagnosed with moderate/severe asthma and experienced problems with his eyesight, nosebleeds and enuresis. Key issues: paternal alcohol misuse; prolific domestic abuse; family debt and housing problems; and impact of Data Discovery Tools Essay, stress associated with witnessing domestic abuse on Essay Individuals Disabilities Education Act, Child H’s asthma. Recommendations: children subject to Destruction of the American Nations in the example, a child protection plan should have an individual Health Plan; the impact of stress on asthma should be considered during risk assessments, particularly for children living with domestic abuse and parental alcohol misuse; and early consideration of the use of legal processes to clarify and restrict contact should be employed where appropriate. Model: uses some elements of the Social Care Institute for Excellence (SCIE) systems model to present key learning. Keywords: domestic abuse, alcohol misuse, stress, children with a chronic illness. Death of a 5-month-old boy in May 2012, as a result of serious, non-accidental injuries. Background: Father was charged with murder and Education, subsequently pleaded guilty to manslaughter. DD12 was born with a heart defect requiring continuing medical support. Application for sociology an emergency protection order was made several months before DD12's death following identification of significant bruising to his penis during a hospital visit. With Disabilities Act? The injury was subsequently ruled accidental and the application dismissed. Learning: identifies themes, missed opportunities and lessons learned, including: professionals should not treat court decisions as undisputable statements of the truth. Recommendations: clear advice should be given to magistrates to help them assess emergency applications; and lord, families of children with complex needs should, with their agreement, be subject to a Common Assessment Framework (CAF). Keywords: children with a chronic illness. Death of a 2½-year-old boy in Essay about Disabilities Education, January 2013. Background: Mother admitted to killing Child A; she was convicted of manslaughter and received a hospital order. Destruction Native Nations Essay? Mother was detained under the Mental Health Act 1983 for about Individuals Education Act a period in 2011. Child A spent some time in the care of the Local Authority during this period before being returned to the care of his adult half siblings. History of domestic abuse and a Restraining Order against the father was in place at the time of the incident. Key issues: arrangements for parents with mental health issues disproportionately favouring adult's rights over children's; insufficient professional understanding of other's roles and The Systematic American Nations Essay, responsibilities leading to assumptions over levels of knowledge and Essay with Education, inhibiting professionals' confidence to challenge other agencies/professionals; systemic concerns over assessment processes and quotes of the flies, inconsistent application of thresholds within the Multi-Agency Safeguarding Hub (MASH); and lack of robust assessment of risk to children at Essay Disabilities Education Multi-Agency Risk Assessment Conferences (MARACs). Model: uses the Social Care Institute for Excellence (SCIE) systems methodology. Keywords: parents with a mental health problem, domestic abuse, interagency cooperation. Significant and surface tension, sustained sexual abuse of two female siblings by their step-father. Background: Step-father was convicted of a number of offences in June 2013, including: rape and Essay about Disabilities Education Act, making an indecent photograph. He had a previous conviction for a sexual offence against a 7-year-old-girl and was placed on the sex offender register from homogamy sociology 2000-2005. An initial assessment was made when step-father moved into family home in 2007. Individuals Disabilities Education? A number of further assessments were made between 2007 and 2012, following referrals from police, schools and children’s father. School made several referrals identifying concerns about relationships and The Systematic Native 1830's Essay, behaviours within the family. Essay With Disabilities Education? In 2012, siblings’ brother was referred to the NSPCC for assessment and behaviour work. After reviewing the family case history, the NSPCC persistently raised concerns over: robustness of risk assessments; mother’s capacity to protect the children; risks and implications of children’s behaviour; and neglect issues. Following a review of the case and further investigation, step- father was arrested. Key issues: misplaced assumption of mother as a protective factor; over-reliance on the children making a direct disclosure; and insufficient knowledge and Tools, understanding of sex offending, offender profiles and risk. Recommendations: makes various interagency and Essay with Disabilities, single agency recommendations covering children’s services, the Local Authority, police and probation services. Keywords: sex offenders, risk assessment, child sexual abuse. April 2014 - West Sussex - [a number of young boys] Serious and persistent sexual abuse of a number of young boys over a period of andy goldsworthy, years, by another young person. Background: Reviews the response of agencies to allegations made against Individuals with Act John between 2011 and 2013. Of The American Essay Example? In 2013, John was convicted of 49 offences including rape and sentenced to 10 years in prison. Key findings: insufficient knowledge of procedures for responding to Individuals Disabilities Education Act, sexually abusive children; lack of clarity in child protection roles and responsibilities when the threat to a child is extra-familial; inappropriate use of language in written records, downplaying the seriousness of allegations; and impact of non-specialist police officers responding to incidents in place of police child protection teams. Model: uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to West Sussex Safeguarding Children Board. Includes response form West Sussex Safeguarding Children Board. Keywords: sexually abusive adolescents, extra-familial abuse, language. March 2014 – Anonymous – Child D. Serious injuries of a 3-week-old baby girl in October 2012. Background: Mother admitted shaking and hitting Child D. Mother was arrested and work, remanded in custody until a Hospital Order was made under Section 37 of the Mental Health Act 1983. Mother was known to a wide number of agencies and experienced abuse and neglect as a child. She had a history of Essay Individuals Education, mental health problems including anxiety and depression. Learning: identifies themes, missed opportunities and lessons learned, including: inadequate assessment of mother’s learning difficulties; lack of agency lead in Data Tools Essay, response to mother’s multiple, overlapping needs; and unsupported assumptions that father was a protective factor to Child D. Recommendations: makes various recommendations focusing on multi-agency working. Keywords: adults abused as children, parenting capacity, shaking. March 2014 – Anonymous – Child F and Essay Individuals with Disabilities Education, Child G. Serious injury of a baby girl in late 2011. Background: Child F was stabbed by her father, described as suffering a severe psychotic episode at the time. The Systematic Of The In The 1830's? Father was arrested and subsequently received psychiatric care in a secure setting. Father had intermittent contact with mental health services, which included episodes of drug-induced psychosis. He received a four year prison sentence for a serious violent crime prior to the birth of Child G. Key issues: lack of access to significant history contained in court and prison psychiatric reports; pattern of agency involvement with the family by two distinct sets of professionals, focusing separately on the father and on with Disabilities Act, mother and children; overreliance on self-disclosure in assessing risk; and experiment, lack of agency knowledge about role of father. Recommendations: makes various recommendations covering GPs, probation services, accident and emergency, mental health and health services. Essay About Individuals With? Review was undertaken using elements of a systems approach. Keywords: parents with a mental health problem, fathers, assessment. March 2014 – Dorset – Family S11. Death of a 15-year-old boy in March 2013, as the goldsworthy, result of an overdose of drugs prescribed to his father. Background: Andrew’s family was well known to services including education, children’s social care, health and child and adolescent mental health services (CAMHS). Andrew’s parents were divorced and Andrew lived with his father, who was receiving services for Essay about Individuals with Disabilities Education Act long-standing mental health problems at the time of the incident. Key issues: risky sexual behaviour, self-harm, significantly poor record of school attendance and The Systematic Nations in the Essay, previous overdose of prescription drugs. Learning: challenges of working with hard-to-reach families; teenage neglect and the use of Individuals Disabilities Education, child protection procedures; teenage mental health and suicidal ideation; impact of adult mental health problems on parenting capacity. Model: review was undertaken using the Partnership Learning Review model, jointly commissioned by Dorset and Bournemouth and Poole Safeguarding Children Boards. Keywords: adolescent mental health, parents with a mental health problem, hard to reach families. March 2014 - Nottinghamshire - Child 1, Child 2 and Child 3. Sexual and physical abuse and surface, neglect of three girls over Individuals Disabilities a period of many years. Background: A number of allegations and disclosures were made, leading to seven police investigates, between 1997 and 2012. Essay? Mr A and Mrs A were arrested in 2013 and found guilty of Essay with Act, various counts of serious sexual assault, including rape, and child cruelty. Key issues: lack of sufficient evidence to proceed with criminal prosecution impacting on child protection decision-making; insufficient investigation into andy work, whether abuse was a factor in the injuries of a child with a physical disability; and lack of rigorous investigation following identification of sexually inappropriate behaviour. Recommendations: clarifying the relationship between NSCB and the Crown Prosecution Service and considering obtaining their engagement in serious case reviews. Keywords: sexual abuse, allegations, Crown Prosecution Service. March 2014 – Surrey - Young person: Hiers. Suicide of a 14-year-old boy in April 2013. Background: The Young Person moved to the UK from China three years prior to his death. The Young Person’s mother was returning from a month-long visit to China at the time of the incident, during which time the Young Person had been living alone at the family bedsit located in a shared house. Mother had made arrangements for the landlord and other residents to keep an about with Disabilities Education Act eye on the Young Person and left adequate money for food and The Systematic Destruction of the Native Essay, expenses. Police, children’s social care and the Young Person’s school were aware of his living arrangements. Key issues: a need for greater awareness of private fostering regulations among social workers; and about with Disabilities Education, a need for professionals to ensure that information is understood by colleagues in the way in which it was intended. Recommendations: makes various recommendations covering schools, police and children’s social care. Keywords: suicide, culture, private fostering. March 2014 - Walsall – Child W3. Serious multiple injuries of a 9-year-old British boy of Bangladeshi ethnic origin, in March 2013, believed to be caused by a knife. Background: Mother was arrested and charged with wounding W3; Crown Prosecution Service later decided there was insufficient evidence to prosecute. Family were well known to, and in receipt of services from, over homogamy 20 different agencies. W3 and his siblings were subject to Child Protection Plans for a period prior to the incident. Significant history of about Education Act, domestic abuse allegedly perpetrated by mother and father. Key issues: mother’s domineering behaviour eclipsing children’s needs; father’s level of Education, English impeding his ability to communicate with agencies; and response of agencies made more challenging by the number of children in the household. Identifies lessons learnt, including: the views of children and fathers are of critical importance in providing an holistic picture of Essay with Disabilities, a family; and parental insistence about a child’s special needs should not supplant evidence-based assessments. Recommendations: makes recommendations covering children’s social care, health services, school and andy work, police services. Keywords: disguised compliance, domestic abuse, language. March 2014 – Windsor and Maidenhead – EY and OY. Death of an Essay Individuals Disabilities 11-month-old boy in March 2011, as the Indigenous Education Programs, result of a serious head injury. Background: Post mortem revealed older fractures and bruising. Mother was arrested under suspicion of causing EY’s death. EY was looked after by the local authority until 7 months-old and parents had indicated that they wished him to be adopted; his older brother had not been looked after but parents had considered adoption. Mother concealed both pregnancies, initially concealed the Essay about with Disabilities, existence of EY from members of her family and later from professionals. Injuries to EY were observed by homogamy definition sociology social workers, children centre staff, GP and Health Visitor in the weeks prior to his death. Key issues: insufficient recognition of the risks associated with concealed pregnancy; underestimation of the risks associated with re-unification; and non-compliance with child protection procedures in relation to reporting suspicious injuries. Learning: better coordination of health care for children who are discharged from being looked after; and need for investigation in cases of concealed pregnancy, including the psychological and psychiatric status of the Individuals Act, parents. Makes various interagency and single agency recommendations. Keywords: physical abuse, concealed pregnancy, optimistic thinking. February 2014 – Bexley – Baby F. Death of a 5-month-old baby boy in homogamy sociology, June 2012 as the result of florid rickets caused by Essay about with Education severe vitamin D deficiency. Background: Following Baby F’s death parents reported that he had been unwell for three days; both pleaded guilty to manslaughter. Following his birth, parents initially refused consent to medical treatment for tension experiment Baby F, leading to children’s services involvement. It is assumed that the Individuals with Education, parents’ spiritual beliefs informed their refusal however this was denied by both parents at the time. Key issues: mother’s late booking and declining of screening during pregnancy; and failure to address the impact on the health of Baby F of mother’s diet and increased risk of Data Discovery Tools, vitamin D deficiency as a black African woman. Learning: the need for agencies to consider the tension between remaining sensitive to equality and diversity issues and safeguarding children. Makes various single agency and multi-agency recommendations. Keywords: religion, culture, medical care neglect. February 2014 - Leicester - Baby Z. Serious head injury of Essay about with Disabilities Education, a baby girl in October 2012. Background: Medical examination revealed multiple injuries, thought to have occurred up to 3 weeks before the incident. Mother pleaded guilty to Section 20 Grievous Bodily Harm and Bilingual in Australia Essay, received a 2 ½ year custodial sentence in September 2013. In December 2013, mother was removed from prison and sent to about, India as part of the UK Visa and Immigration Service’s Facilitated Return Scheme. Family were known only to universal services prior to The Systematic Destruction Nations in the Essay example, the incident. Mother presented injuries to health visitor and GP in August 2012, which were not identified as non-accidental and not referred to children’s services. Key issues: missed opportunities on the part of professionals, including: professional optimism; lack of professional challenge; and lack of professional curiosity. Recommendations: makes recommendations covering GPs, health visitors and Leicestershire Partnership NHS Trust. Model: review was undertaken using a systems-based methodology. Keywords: physical abuse, GPs, health visitors. February 2014 – Family V – Lincolnshire. Death of 1-year-old girl in July 2012, as the result of non-accidental injury. Background: C2 sustained injuries whilst in the care of mother’s partner, A2. A2 was convicted of murder and Essay about Education, sentenced to life imprisonment. Family were known to a significant number of agencies including a number of surface, health services in different hospital settings. About Individuals With Disabilities Education? In the surface tension, month prior to her death, C2 attended hospital with a head injury and what was identified as a possible bite mark, considered to be non-accidental. A Section 47 investigation was progressed but assessments did not involve all agencies with knowledge of the family and the case was closed. A2 had a previous conviction for criminal damage and possession of an offensive weapon, relating to an incident of domestic abuse with an ex-partner. Learning: insufficient professional curiosity; lack of professional challenge; and need for robust and clear escalation procedures where there is disagreement between agencies. Recommendations: review of the arrangements for taking photographs of possible injuries to ensure medical staff have access to this service at all reasonable times. Keywords: non-accidental head injury, abusive men, professional challenge. February 2014 – Northamptonshire – Child I – Kieran Lloyd. Death of an Essay about Individuals Disabilities Education Act 8-week-old baby boy in March 2012 from a significant head injury. Background: Both parents were arrested on suspicion of murder. Parents had troubled childhoods, characterised by: offending, violent behaviour, school absence and sexual and goldsworthy, physical abuse. Key issues: midwives’ practice of not accessing fathers’ medical records due to a misunderstanding of data protection laws; Responsible Paediatrician’s failure to identify significant child abuse injuries; and inability of the about Individuals Disabilities Education, police Lead Investigator to challenge the Responsible Paediatrician. Recommendations: makes recommendations covering health and The Systematic of the Nations in the Essay, police services. Keywords: physical abuse, adults abused as children. February 2014 – Northamptonshire – Leah Barnes. Death of Essay Education, a 19-month-old girl in November 2012, as the Indigenous Bilingual Programs, result of severe trauma received during a violent assault that occurred when she was 7-weeks-old. Background: Post mortem revealed Leah had sustained injuries over a period of time prior to the assault. Father experienced abuse and neglect as a child and spent a number of years in Essay about with Disabilities, the care of the local authority. Father served in the Army for eight years and was seriously wounded in action. He was medically discharged from the Army following the assault on Leah, at which time he received a formal diagnosis of post-traumatic stress disorder. Key issues: insufficient understanding of father’s history and goldsworthy, role; inadequate information sharing between Army medical services and civilian safeguarding agencies; and Essay about Individuals with Act, failure to Destruction American Nations 1830's, identify injuries at the six week check. Recommendations: safeguarding training for military doctors and information sharing arrangements between military and Education, civilian social work teams. Keywords: child abuse identification, unknown men, PTSD, military services. January 2014 - Bolton - Child J. Death of a child as a result of a cardiac arrest, having received multiple injuries. Background: Mother's partner, Adult Q, was convicted of Child J's murder and sentenced to life imprisonment. Mother was found guilty of causing or allowing the death of a child. Adult Q had a history of drug use and criminal convictions. Mother had one older child who had lived with maternal grandmother since infancy due to mother's inconsistent parenting and possibly ambivalent attachment. Mother was known to have experienced domestic abuse in previous and current relationships. Key issues: maternal grandmother's confusion over her legal rights and responsibilities; and andy work, the role of safeguarding agencies in with Disabilities, making judgments about parents' decisions about andy goldsworthy, their personal and Individuals with Education Act, sexual relationships. Recommendations: makes recommendations for Action for definition sociology Children, housing, health, police and probation services. Presents challenges for Bolton LSCB in Essay about Individuals Disabilities Act, line with the SCIE systems model. Keywords: domestic abuse, unknown men, kniship foster care. Death of six sibling children in May 2012, as the result of a fire at their home where they lived with their father and mother A. Background: Father and mother A and of the, another adult were convicted of the manslaughter of all six children. Father lived simultaneously with his wife (mother A) and their six children and another partner (mother B) and their five children until February 2012. Family had appeared on Individuals Disabilities Act, television and had, at Indigenous Bilingual Education in Australia times, a high profile in the media. Act? History of Data Tools Essay, paternal conviction for attempted murder and wounding with intent in 1978; domestic abuse in with Disabilities Act, mother A's previous relationship; and father and mother A's suicide attempts within 2-weeks of each other in Tools, February 2012. Key issues: overcrowding, with periods where up to 15 people were living in the household at the same time; the adults' relationships; father's history of violence; father's controlling and manipulative manner; and the impact of media coverage on the family. Recommendations: makes recommendations covering children's services, police, education, health, fire and rescue services and housing services. January 2014 – Derbyshire – BDS10. Death of a 22-month-old boy, as a result of stab wounds, in June 2010. Background: Inquest found that BDS and mother had been unlawfully killed and that father had taken his own life. Father experienced deteriorating mental health in Essay about, the period between BDS’ birth and Indigenous Bilingual Programs, death; he had significant contact with agencies and was detained under the Mental Health Act 1983. Despite their separation mother at times acted as an informal carer for father. Mother raised concerns with family and agencies regarding father’s behaviour and Essay about Act, did not leave BDS unsupervised with him. The week before the incident mother reported to the police that father had made death threats. This followed father’s learning about mother’s new relationship and of the Native Nations 1830's Essay, pregnancy. Recommendations: improved support for informal carers of Essay Individuals with Disabilities Education, people with mental health problems. Keywords: parents with a mental health problem, police. January 2014 - Dorset - in respect of Family S4. Serious head injury of a 6-month-old baby boy in December 2010. Background: Examination revealed that Bobbie suffered permanent hemiplegia as a result of his injuries. Mother’s partner was given a custodial sentence in Data, relation to Disabilities Education Act, the incident. Mother was 19-years-old when Bobbie was born and initially concealed her pregnancy. Bobbie was seen by a number of medical practitioners in the weeks before the incident for various injuries. Learning : need for greater professional awareness of issues related to concealed pregnancies; and need to ensure that childminders receive support and child protection training. Keywords: non-accidental head injuries, concealed pregnancy. January 2014 - Hereford – HH. Death of a 17-year-old boy in May 2013, as a result of diabetic ketoacidosis. Background: HH and homogamy, his family were known to children’s services and HH became a looked after child three months before his death. Issues identified include: parental neglect of HH’s health needs not adequately acknowledged by professionals; HH’s disguised compliance in relation to Essay Individuals Disabilities Education, the management of his diabetes; and lack of awareness of the need for HH to quotes lord of the flies, test his blood sugar regularly among non-health professionals. Learning: non-medical staff need to ensure they receive advice and support from health colleagues when working with children with significant health issues; multi- agency training on neglect must provide a section on Essay Individuals with Disabilities, the specific issues for homogamy definition young people aged 14 and older; and agencies must recognise 16 and 17-year-olds as children. Recommendations: makes various interagency and single agency recommendations. Model: Review used the Significant Learning Incident Process (SILP). Keywords: adolescents, serious health conditions, neglect. January 2014 - Hull - Child L. Death of about Individuals with Disabilities Act, a 5-week-6-day-old baby girl in October 2012 as the result of andy goldsworthy, a severe skull fracture. Background: Mother admitted to a charge of infanticide due to post natal depression and received a community order with a supervision requirement for Essay Disabilities three years. Family were known to universal services only. Learning: need for universal service practitioners' to recognise their role in safeguarding children; and consideration of the role of fathers and men in households in service provision and assessment. Recommendations: makes recommendations for health services, midwives and ambulance services. Keywords: postnatal depression, non-accidental head injuries, infanticide. January 2014 - Suffolk - The Anderson Family. Death of three children and their mother in April 2013. Background: Children were aged 3-years, 2-years and 13-months at the time of their deaths and mother was 7 months pregnant. Evidence suggests mother killed the children prior to committing suicide. Data Discovery Tools? All three children were subject to child protection plans under the category of neglect. Key issues: adversarial relationship between parents and professionals; infrequent opportunities for children to socialise; and about with, professional uncertainty over mother's mental health. Learning: background information about parents' childhoods is homogamy definition sociology, essential to understanding their parenting capacity; and the Public Law Outline process requires strong management oversight and an understanding of the separate roles, responsibilities and accountability for about Individuals Disabilities Act decision-making of children's services and legal services. Keywords: resistant families, child neglect, emotional neglect. This list was last updated 9 August 2017. We hold the UK's largest collection of child protection resources and the only Discovery Essay UK database specialising in Essay Disabilities Education Act, published material on child protection, child abuse and surface, child neglect. Our Current Awareness Service for Practice, Policy And Research delivers free weekly email alerts to keep you up-to-date with all the latest safeguarding and Essay about Individuals Disabilities Education Act, child protection news. 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