Learning from Serious Case Review Child L

Child L (published 17 June 2016)

Cumbria LSCB has commissioned a Serious Case Review (SCR) into the death of Child L in Cumbria in 2011 – the SCR focusses specifically on how agencies worked together and individually from the birth of the parents’ first child in October 2009, until the date of Child L’s death in July 2011. Due to his short life the panel also agreed to focus on Child L‘s sibling as part of the review.

Child L's story

Child L was born prematurely at 31 weeks in May 2011 and was admitted to the Special Care Baby Unit Medical. Child L died at home in July 2011 only 43 days old. During his short life he had been examined several times and one examination identified a possible heart murmur. Experts concluded that he died from cardiac arrest which on balance of probabilities was secondary to some form of head injury.   Child L’s mother had a complex background had experienced neglect, and had been a looked after child.

Lessons to be learned from Child L

  1. Professionals need to establish that the family’s actions agreed in the Child protection/ Family in Need or Early Help plan have been completed by the family.

  2. Initial and ongoing assessments must be thorough, timely, gather multi-agency information, inform decision-making and take account of historic context of the family. (single agency)

  3. On completion of a single agency assessment professionals must consider who else needs to know this information, and whether or not there needs to be a multi-agency response (e.g. Early Help) (single agency)

  4. Care leavers are a vulnerable group who may require more support in order to parent effectively.

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 L - SCR Reportthis external link will open in a new window

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

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

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