Learning from Serious Case Review Child R

Child R (published 18 July 2016)

Cumbria LSCB commissioned an SCR into the death of Child R in Cumbria in October 2014 Ė the SCR focusses specifically on how agencies worked together and individually from the beginning of Child Rís last year at his Primary School in September 2011 to October 2014.  

Child R's Story

Child R was aged thirteen and died at home, whilst in the care of his father. The cause of his tragic and untimely death was morphine poisoning, after being given a morphine tablet by his father who mistakenly believed it to be a suitable painkiller for his sonís headache. Child Rís father pleaded guilty to the manslaughter of his son and received a four year custodial sentence. Child Rís school reported that he could sometimes be anxious and timid but was also a humorous and popular student who had a supportive circle of friends.  His parents separated after only a few months, following their sonís birth in 2001. Child R stayed with his mother until the age of three when he went to live with his father who eventually obtained a residence order in 2009.

It is widely believed that Child R and his father could have benefitted from Early Help and the findings of this case are centred on that premise.

Lessons to be learned from Child R

  1. Transition plans should:

    • Include well-defined success criteria

    • Include a defined timescale for completion and review

    • Record the voice of the child

  2. Attendance plans should:

    • Be child focused

    • Be robustly followed through with parents in line with school policy and practice and local authority guidance

    • Reviews are held in line with agreed policy and practice

    • Drift is avoided

    • Medical/health evidence of absence on health grounds is corroborated to inform attendance plans

    • Parents/Carers and students should be actively involved in plans around transition and attendance and have a direct voice in these processes

    • Consultation should take place with the local authority Inclusion Service in line with current policy and guidance

  3. School staff should consider undertaking an Early Help Assessment as part of a wider package of support when a student's absence reaches or exceeds the Department of Education (DfE) threshold for 'Persistent Absence'.

  4. Where an Early Help Assessment is undertaken because of persistent absence due to health needs the School Nurse must be involved.

  5. When a parent or significant family member (regardless of their level of contact with the child) has mental health and/or substance misuse issues practitioners must always consider and take account of the impact of this on the emotional wellbeing of the child.

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 R Ė SCR Reportthis external link will open in a new window

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

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

  • Contact us
  • Disclaimer