Serious Case Reviews and Domestic Homicide reviews.

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LEARNING LESSONS Serious Case Reviews and Domestic Homicide reviews

Transcript of Serious Case Reviews and Domestic Homicide reviews.

Page 1: Serious Case Reviews and Domestic Homicide reviews.

LEARNING LESSONS

Serious Case Reviews and Domestic Homicide

reviews

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WORKSHOP OBJECTIVES: PARTICIPANTS TO IDENTIFY

Key themes arising from reviews; some of these are reoccurring themes, how do we break the cycle locally? What needs to happen

  Public perception between children and adult

reviews: Are there differences? What are they? What factors influence this?

  How can local safeguarding boards improve support

for staff, professionals and families involved in Children or Adult Reviews?

  How to best engage local staff / professionals in

dissemination of learning from reviews: What methods should be used?

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PURPOSE OF SERIOUS CASE REVIEWS Determine what lessons can be learnt

about how professionals/ agencies (individually and together )work to safeguard children or adults at risk.

To review the effectiveness of local safeguarding procedures (multi-agency and single agency)

Inform and improve local inter-agency practice

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STATUTORY FRAMEWORKS

Regulation 5 of the Local Safeguarding Children Boards Regulations 2006: the requirement for LSCBs to undertake reviews of serious cases in specified circumstances.

Care Act 2014 – enacted April 2015, requires Local Adult Safeguarding Boards to arrange a Safeguarding Adults review

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HAMZAH KHANBRADFORD LSCB – PUBLISHED 2013

Hamzah’s decomposed body was found by police in the home, almost two years after he starved to death. The Serious Case Review in Bradford, identified some of the key events prior to the death:

Mother was late notifying her pregnancies, history of alcohol misuse

Mother victim of repeated Domestic Violence incidents, but refused to formally complain to police about her partner.

GP & Health Visitor: children’s access to immunisations health appointments was a problem. Hamzah was described in the report as an “invisible child” to agencies.

Older sibling distressed following DV incident, reported this to the police in 2006. Child returned home after initial assessment by Children Social Care.

Missing from home incident reported to police with older sibling.

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HAMZAH KHAN School attendance problems with children. Communication across agencies not always

effective sharing information. Home conditions very poor.

Lessons learnt: Importance of listening to children Good assessment practice needs to be based on

good theoretical understanding of concepts such as vulnerability and neglect. Long process of multi-layered issues

Importance of “think family” and providing early help to family and children in need

Importance of good information sharing across agencies

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DANIEL PELKADaniel was starved and beaten for months before he died in March 2012at his Coventry Home.

The SCR report says that the boy appeared ‘invisible’ to the authorities, who “demonstrated a failure of the most basic aspect of child protection work”.

A midwife with serious concerns was persuaded by a social worker not to refer the case to the children’s services at Coventry City Council, for example.

Teachers saw Daniel scavenge for food from bins, and police received 26 reports of domestic abuse at his home, but no-one got to the bottom of what was going on in time to save his life

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LEARNING FROM SERIOUS CASE REVIEW – COVENTRY 2014 Dangers of Silo Practice – children not always taken into account

within adult assessments for services. Importance of “think family or whole family approaches” flagged.

Importance of taking forward early help / CAF to support families, when required.

Importance of listening to the voice of the child; supporting them with communication when English not main language. Child observed repeatedly scavenging food, underweight.

Importance of information sharing and collating information across agencies

Importance of escalation and challenge

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THEMES ARISING FROM NATIONAL AND LOCAL SERIOUS CASE REVIEWS CHILDREN

Domestic Violence, parental substance misuse, mental ill-health- high risk factors. Collectively referred to as “toxic trio” represented in many SCR’s.

Domestic Violence- separation does not always mean safety, risks may increase, i.e. stalking behaviours.

Importance of escalation; if a child or adult is in need of safeguarding and there are concerns about an agency response.

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THEMES ARISING FROM NATIONAL AND LOCAL SERIOUS CASE REVIEWS

Collation of information and the importance of understanding the

“history”- use of chronologies.

Importance of pre-birth assessments.

Communication and information sharing between local children and adult services- often a gap

Hostile or avoidant behaviours, can divert professional attention

to the adults, away from children or vulnerable adults in the

home.

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Dangers of “hidden” adults gaining access

to children who pose a risk – Baby Peter died 2007.

Dangers of professional “rule of optimism” and not being child focused.

Immobile babies and unexplained bruising –importance of demonstrating “respectful uncertainty”. Safeguarding referral procedures not followed. Child Z Leicester City LSCB (2013)

THEMES ARISING FROM NATIONAL AND LOCAL SERIOUS CASE REVIEWS

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THEMES ARISING FROM NATIONAL OR LOCAL SERIOUS CASE REVIEWS - ADULTS

Impact of accumulative community anti-social behaviour on vulnerable adults – importance of reviewing all information and risk assessment of these on the individual Pilkington Leicestershire (2008).

Importance of collating and reviewing safeguarding concerns when they arise in a single provider setting- Summervale, Leicester (2012).

Importance of sharing relevant information about vulnerable adults, at points of transfer of care. Applying the Mental Capacity Act 2005 working with vulnerable adults in residential settings. Leicester, JG SILP (2012).

Sourcing appropriate care arrangements when agencies remove main carer, MS Review (2010).

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WINTERBOURNE VIEW HOSPITAL – SCR PUBLISHED 2012.

Winterbourne View Hospital was aPrivate hospital providing long termcare for adults with Learning Disabilities and autism.

An undercover BBC reporter secured employment as a support worker atWinterbourne View Hospital. Whofilmed colleagues tormenting, bullying and assaulting patients. Findings were exposed on Panorama

11 care workers who admitted a totalof 38 charges of neglect or abuse of patients at a private hospital have been jailed.

SCR taken forward by Gloucestershire SAB, Independent Author Margaret Flynn

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WINTERBOURNE REVIEW FINDINGS NHS commissioners -there was no overall

leadership. Even though the hospital was not meeting its contractual requirements in terms of the levels of supervision provided to individual patients, commissioners continued to place people there.

Families felt dis-empowered: influencing placing decision making.

Mental Capacity Act 2005 principles not followed, particularly for adults not detained under the provisions of the Mental Health Act 1983.

Whistle-blowing: concerns were not addressed by Winterbourne View Hospital nor Castlebeck Ltd

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WINTERBOURNE REVIEW FINDINGS Clinical leadership and professional

responsibility, Low threshold for detaining patients under section 3 Of the Mental Health Act and the safeguards of a second, Independent doctor supporting the application and the independent decision by an Approved Mental Health Professional were overridden.

Volume and characteristics of safeguarding referralsWhich were known to South Gloucestershire Council Adult Safeguarding were not treated as a body of significant concerns.

Recognition and response to other alerts: notifications to the Health and Safety Executive; the hospital’s inattention to the complaints of patients or relatives; restraint incidents excessive; high level of police presence responding to incidents and repeated absconding.

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HOW NATIONAL LEARNING IS BEING APPLIED LOCALLY Joint LLR Agency Winterbourne action plan

across local agencies:

Commissioning of placements for adults with long term disabilities being more community focused.

Active review of quality of local learning disabilities services.

Whistleblowing procedures – reinforced embedded

Large Scale Safeguarding Investigations – procedures in place

Empowerment and advocacy for service users.

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ADULT SERIOUS CASE REVIEWS – MATE CRIMES AND DISABILITY HATE CRIMES – ADULTS LEARNING

DISABILITIES

Stephen Hoskin:

died 2006 Cornwall

A 39 year old man with learning disabilities – his “friends” beat him, imprisoned him, drugged and tortured him. His body was found at the base of railway viaduct.

Over 40 missed opportunities across agencies to protect him.

Gemma Hayter: died 2010 Warwickshire

Had a significant learning disability,

was found dead on a disused

railway embankment. Gemma

considered the 5 convicted of her

murder as “friends”.

They had forced her to drink urine

from a beer can, beaten with a mop

and stripped before being left for

dead.

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STATUTORY FRAMEWORK- DOMESTIC HOMICIDE REVIEWDHR’s were established on a statutory basic under section 9(3) of the Domestic violence, Crime and Victims Act (2004).Came in force April 2011, a DHR should be taken forward when:

Death of a person aged 16 years or over has, or appears to have, resulted from violence, abuse or neglect by-

a person to whom s/he was related or with who s/he had been having an intimate personal relationship or

A member of the same household as himself, held with a view to identifying the lessons to be learnt from the death.

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DOMESTIC HOMICIDE REVIEWS COMMONTHEMES IDENTIFIED AS LESSONS TO BE LEARNED- HO 2013

Between 13 April 2011 and 31 March 2013, 54 completed reports were received by the Home Office. The emerging themes:

The importance of a consistent approach to risk identification, assessment and management for all professionals was identified in a number of reports. DASH risk assessment needs to be applied consistently across agencies.

Agencies need to make informed decisions – preferably with victim consent - to share information and only share when it is safe to do so, to ensure that the victim is not placed at higher risk. Importance of staff understanding good information sharing practice.

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DOMESTIC HOMICIDE REVIEWS COMMON THEMES IDENTIFIED AS LESSONS TO BE LEARNED- HO 2013

Domestic Violence and abuse were not always identified - agencies were focusing on addressing, for example, the mental health or substance misuse of the adult, identifies the importance of asking questions about DV during assessment.

Inadequate information sharing between agencies -where a perpetrator is released on bail or from prison. Some reviews highlighted the importance of compliance with existing processes and procedures specifically in relation to bail management ( including breach of bail ) as this is critical in protecting victims and managing suspects.

In a smaller number of reports there were cases where opportunities were missed to refer cases to Children’s Services. This included those cases where children were in households where domestic violence and abuse occurred between adults but the impact on the children was not necessarily considered.

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NEXT STEPS

Community Safety Partnerships have reviewed the report and local position and are strategically leading the DV agenda.

Ensure that staff in your agency or service have the appropriate training in Domestic Violence to include risk assessment and management. http://www.caada.org.uk/marac/RIC_for_MARAC.html

Royal College of General Practitioners have developed a DV e-learning training course for GPs. http://elearning.rcgp.org.uk/course

The National Institute for Health and Care Excellence (NICE) guidance on preventing domestic violence, 2014 Vulnerable groups | Guidance and guideline topic | NICE

Training tools are being developed for health visitors on domestic violence and are expected to be launched in 2015.

The NOMS Multi-Agency Public Protection Arrangements (MAPPA) team plan to observe level 2 and 3 meetings on Category 2 violent offenders to look for best practice of risk assessment risk management planning and sharing of information and this will include management of offenders with complex needs.

Midwives should undertake routine enquiry by asking all pregnant women whether they are at risk of, or are suffering/suffered from domestic violence.

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FRAMEWORKS – INFORM DECISIONS

What are the legal powers? What does my agency AND inter-agency

policies and safeguarding procedures tell me?

What are my civil duties? What do information sharing protocols or

agreements allow me to do? Am I carefully balancing the rights of adults

and children? What are the best interests of child or

adult? Do I need legal advice?

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IN CONCLUSION, SAFEGUARDING RELIES ON: Good assessment, information sharing

and review of information Accessing good supervision Early intervention and support Following local multi-agency procedures Effective partnership working Good risk management and review Working within Legal Frameworks Good Record Keeping Standards.

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REFERENCES & BIBLIOGRAPHY Hull Safeguarding Adults Partnership Board. A decade of serious case

reviews: our vision for adults safeguarding: 2014 www.safeguardingadultshull.com

Manthorpe J & Martineau S, First Annual Report: national panel of independent experts on serious case reviews adult safeguarding 2014 Kings College London

OFSTED, Ages if concern: learning lessons from serious case reviews: a thematic report of Ofsted’s evaluation of serious case reviews (april 2007 to March 2011). 2011 www.ofsted.gov.uk

Home Office, Multi-agency Statutory Guidance for the Conduct of Domestic Homicide reviews: revised, august 2013 home office

For SCR or DHR reports referenced log onto relevant LSCB or SAB website.