Serious Case Reviews
Learning from National Serious Case Reviews
For a list of all National Serious Case Review Publications, please visit the NSPCC National repository of case reviews. The NSPCC thematic briefings highlight the learning from case reviews that are conducted when a child dies or is seriously injured and abuse or neglect are suspected. Each briefing focuses on a different topic, pulling together key risk factors and practice recommendations to help
Serious Case Review Claire/Anne – published 6th January 2020
Today North Tyneside Safeguarding Children Board (NTSCB) is publishing a Serious Case Review (SCR) that was commissioned by the Board in October 2017. The SCR is about Claire and Anne, siblings, who suffered emotional harm and neglect over a number of years and sexual abuse.
The purpose of a SCR is to undertake a rigorous analysis of the contact the children and their family had with services, to try and understand what happened and why. It brings together senior representatives from all agencies who had been involved with the family. The agencies responsible for services can then identify any lessons to be learnt which could be used to improve services and reduce any future risk of harm to children and young people. The NTSCB oversees the review to ensure that its findings are objective and fair, in order to support agencies in acting on the learning.
The report was completed by an independent reviewer and is supplemented by a Summary Report that seeks to focus the learning locally so that it ensures that local arrangements can be better in the future as a result.
Over three years, the family received early help involvement in the form of parenting support. This intervention continued for some time, and despite new information and events coming to light the needs, vulnerabilities and risks each child faced were not felt to meet the threshold for a more formal multi-agency approach. As a result, the harm the children suffered was not recognised.
The schools that the children attended are commended for their tenacity in raising their concerns. The learning from the review identifies that multi-agency working arrangements fell short of the expected standards in responding to these concerns. With hindsight the review identified that the direct disclosures the children made to a number of agencies and professionals over the period should have resulted in a more effective multi-agency response. As a result, each child continued to suffer different forms of harm. The review is clear about the significant learning in relation to listening to what children and young people are telling us and keeping their views central at all times.
Richard Burrows, Independent Chair of NTSCB commented, “The work of safeguarding is complex. We rely upon practitioners at all levels to be able to recognise and raise concerns they have about children and young people they are in contact with and that they receive an appropriate response to their concerns. The systems and arrangements in place are intended to support what are often difficult decisions and have been strengthened as a result of this review. The aim is to ensure that when any child, or practitioner working with a child, has concerns for their safety and wellbeing, that this is looked at on a multi agency basis. It will be important that in working together the agencies continue to improve their understanding of the harm children can suffer in their families, and that they work to improve how they ensure that their focus is on the children, and that they fully take into account the different forms abuse and harm can take.
He continued, “The Board and its partners are resolved to act on the learning from this review. They have commissioned a detailed action plan which identifies achievable and measurable actions to ensure that wherever possible in the future children will be protected from harm. Several agencies have already delivered or commenced work on their actions. We want to be confident that anyone who raises a concern, especially when this is a child, can be assured that agencies will work together to act in the best interests of children.”
The difference the learning makes will be reviewed by the new Multi – Agency Safeguarding Arrangements, which came into operation from 29 September 2019 and are known as the North Tyneside Safeguarding Children Partnership. These new arrangements replace the role of the Local Safeguarding Children Board.
North Tyneside Safeguarding Children Board (NTSCB)
Serious Case Review Harry – published 29th November 2019
Today North Tyneside Safeguarding Children Board (NTSCB) is publishing a Serious Case Review (SCR) that was commissioned by the Board in October 2018. The SCR is about Harry, a 14 year old who sadly took his own life in the summer of 2018. Harry moved to the UK from Hungary in 2016 with his mother and younger brother. He was described as a quiet, polite and thoughtful young person. He attended school regularly, where he settled well and made friends. His death came as a shock to all who knew him and a tragedy for his family and friends.
The purpose of a SCR is to undertake a rigorous analysis of the contact Harry and his family had with services to try and understand what happened and why. The organisations responsible for services can then identify any lessons to be learnt which could be used to improve services and reduce any future risk of harm to children and young people.
The report, carried out by an independent reviewer, does not identify any single factor that could have prevented Harry taking his own life. It demonstrates that the schools he and his brother attended and other services who became involved did their best to support them and their mother.
The review identifies that statutory and voluntary agencies will need to continue to improve how they recognise and share some of the key indicators of when children and their families are struggling and take into account the impact of moving to a new country. Also, to strengthen our understanding of how parental mental ill health can place significant pressures on their children.
The Board and its partners are resolved to act on the learning and have commissioned a detailed action plan which identifies achievable and measurable actions to act on the learning identified in the Review.
This work will be reviewed by the new Multi – Agency Safeguarding Arrangements, which came into operation from 29 September 2019. These new arrangements replace the role of Local Safeguarding Children Boards, and are known as the North Tyneside Safeguarding Children Partnership.
Richard Burrows Chair of the NTSCB said “Harry’s death was a tragedy for his family, and I would like to offer my sincere condolences to them. We know that nationally the numbers of young people who take their own lives is higher than it should be. The review offers partner organisations a real opportunity to strengthen the local response to children in need and who may need help. It can be difficult to identify when a person is thinking about suicide, and the learning from this review will help strengthen the local response”.
If you are worried about someone you know, the following services can offer support:
In North Tyneside young people aged 11-18 can access Kooth.com for support on any issues or concerns they may have. Kooth provides an anonymous and confidential service using a mix of counselling, support and advice on a drop in, out of hours and structured sessions.
You can access a copy of the SCR report here
North Tyneside Safeguarding Children Board
Serious Case Review – Child T
North Tyneside Safeguarding Children Board (NTSCB) commissioned a Serious Case Review into the case of Child T to identify any significant learning, so as to be assured that all partner agencies can continue to learn from joint working practice and that this supports continuous improvement. A copy of the case briefing note which gives the background information to the case can be found here and a copy of the executive summary of the case can be found here.