Learning from Serious Case Review Child N

Child N (published 13 June 2016)

Cumbria LSCB has commissioned a Serious Case Review (SCR) into the death of Child N in Cumbria in 2012 – the SCR focusses specifically on how agencies worked together and individually between March 2011 and December 2012 just prior to her death.

A  Serious Case Review takes place “where abuse of a child is known or suspected; and either - (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child”.

Child N’s story

Child N died in December 2012 aged 13 months. The post mortem x-rays carried out 2 days after Child N’s death revealed healing fractures to Child N’s tibia and fibula. The post mortem also revealed other possible injuries to Child N. During Child N's short life the family were only known to ‘universal’ services:  schools and a range of health services. Child N’s mother had a complex childhood and had been a looked after child herself because she was at risk of Child Sexual Exploitation.

Lessons to be learned from Child N

  1. Professionals working with pregnant and new mothers need to consider the long term impact of unresolved childhood trauma and abuse on future parenting capacity.

  2. Professionals should use family history, chronology and genealogy to identify patterns of risk.

  3. When immobile infants are presented multiple times with what appear accidental injuries – professionals should consider further enquiries and/or a Child Protection Referral, and/or an Early Help Assessment (EHA).  (It is worth noting that should an EHA be considered and parents/carers refuse to co-operate and any help and support offered that in itself may raise the level of concern).

  4. Multi-agency assessments should include understanding of the whole family and regular visitors to the home, alongside observations of multi-agency professionals who are involved with the family. A full & detailed history on fathers, partners (male and female) & other significant adults (male and female) in the family should be sought when gathering information.

  5. Complex profiles need to be discussed through supervision and reflective support. Use reflective techniques in supervision to ensure that complex and changing family dynamics are continually considered.

Dissemination of Learning

The LSCB will conduct a number of workshops and a conference to raise the profile of the lessons in this and the other SCR being published.

Sharing learning from serious case reviews in order to improve safeguarding practice is vital. We use the recommendations from case reviews to improve safeguarding of children & young people.

If you would like to discuss SCR or any of its contents then please speak to your line manager, your representative on the LSCB or contact the LSCB Office. Cumbria House, 3rd Floor, 107-117 Botchergate, Carlisle, Cumbria, CA1 1RZ. Email LSCB@cumbria.gov.uk

Child N - SCR Reportthis external link will open in a new window

LSCB response to Child N Reportthis external link will open in a new window

Lessons to be Learned from Child Nthis external link will open in a new window



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