Lessons to be learned from child deaths and injury through abuse and neglect

An new report on child deaths and serious injury examines the problems of inter-agency working. Jenni Whitehead looks at some of the implications for schools

The DCSF has recently published Analysing Child Deaths and Serious Injury through Abuse and Neglect: What Can We Learn? A Biennial Analysis of Serious Case Reviews 2003-2005. Serious case reviews are carried out when abuse and neglect are known or suspected factors when a child dies (or is seriously injured or harmed). This is the third biennial analysis and involved a near-total sample of 161 cases. The aim of these studies is to gather learning to improve multi-agency working and to analyse ‘interacting risk factors’. Practitioners need to understand how one risk factor interplays with another, and the inter-related nature of incidents over periods of time.

Why is this study important to education staff?
Schools and education services have been shown, repeatedly, to be best placed to pick up on early indicators of possible abuse. Most of the 53% of children in the survey who were aged over one would have been registered with a school or have had nursery placements.

Key findings and learning points:

• Two-thirds of the 161 children died and a third were seriously injured.
• A total of 47% of the children were aged under one, but 25% were over 11 years, including 9% who were over 16. Many older children were ‘hard to help’ and failed by agencies.
• A total of 12% of children were named on the child protection register, and 55% of the children were known to children’s social care at the time of the incident.
• The families of very young children who were physically assaulted (including those with head injuries) tended to be in contact with universal services or adult services rather than children’s social care.
• In families where children suffered long-term neglect, children’s social care often adopted what the authors of the report call the ‘start again syndrome’ – a focus on the present and failure to to take account of the past that impedes clear and systematic understanding of the case.
• In the cases where the information was available, well over half of the children had been living with domestic violence, or parental mental ill health, or parental substance misuse. These three problems often coexisted.
• Many of the cases were known to adult services, illustrating the importance of all adult services having appropriate child protection training and for such services to acknowledge children’s needs as paramount.

The reviews often showed confusions and misunderstandings of thresholds and many showed a preoccupation with eligibility criteria to services rather than a primary concern for the child. The study shows that there was often a reluctance to challenge other professionals or agencies. Some good examples of challenge were recorded but it was shown that even where this existed it was difficult for challenge to be sustained and differences of opinion or judgement were rarely pursued to a satisfactory conclusion. This part of the study demonstrates the importance of challenging another agency, especially at the point of referral. If in your ‘professional judgement’ there is a need to make a child protection referral, stand firm and if you feel that you are not being taken seriously or that the possible risk to the child is being minimised take the matter further – either speak to a person in a higher position or seek advise from your education designated officer.

Contact with families
Eighty-three per cent of the families were known or had been known previously to children’s social care. However, only half were receiving a service at the time of the incident and only 12% were on the child protection register. This shows that for many children universal services such as schools are key in their knowledge of children and the families.

In many of these cases the families were known as hostile to helping agencies and workers described feeling frightened to visit the home. If professionals are frightened to go to a child’s home it has to be asked how the children are coping in the home. I would suggest that children are less likely to disclose abuse to professionals who appear frightened of the child’s parents. Professionals who did contact the families were often met with apparent or disguised cooperation from the parents, causing a delayed understanding of the severity of harm to the child and creating situations where cases were either closed or were allowed to drift. It is really important then, that education staff continue to make their concerns known to children’s social care and if necessary take their concerns to a higher level.  Where parents made it hard for professionals to see children or where parents engineered the focus away from the allegations of harm the children went unheard and unseen. If a member of education staff, such as home school liaison staff, visit the family home of a registered child and they are unable to get to see the child the allocated social care worker should be contacted as soon as possible. A number of studies have shown a correlation between lack of access to the child and an increased level of dangerousness for the child. The family appears to shut down to all professionals at a point that the child is at most risk. Named persons must inform their staff to let them know immediately if they have not seen a registered child when they have visited the home. In many of the cases the family made frequent moves making it difficult for services to keep track of events. This flight pattern made it difficult for accurate record-keeping and caused new situations to be dealt with as unrelated to previous concerns. It is in these cases that services are most likely to develop what the report describes as a ‘start again syndrome’ If a school is making a referral and there have been previous concerns and/or referrals schools should always make children’s social care aware of the history to avoid incidents being dealt with in isolation. It is often the relationship between incidents that holds the key to proper understanding of a child’s experience of family life. The reviews showed that verbal communication was more effective in respect of sharing information with another agency. Considering the present increase in experimentation with electronic referral systems this finding is particularly worrying. If your local authority uses an electronic referral system, back up your referrals with a telephone call. If I am supporting a school that is having difficulty in getting children’s social care to accept and act on a referral I know that the most successful way through is to get people round a table talking to each other face to face.

‘Hard to help’ children
Twenty-five per cent of the children were over 11 years old and 9% were over 16 and the review reports that services failed these older ‘hard to help’ children. Many of these young people had a long history of loss, rejection and abuse and the report found some common elements in the older children including:

• Parents or carers with their own history of abuse and rejection, most of whom misused substances and had mental health difficulties.
• By adolescence most were typically harming themselves, neglecting themselves, and misusing substances.
• It was difficult to contain these young people in school and in placement. There were numerous placement breakdowns featuring running away. Going missing increased the risk of sexual exploitation and risky sexual activity. The causes of running away were not properly addressed.
• Persistent running away sometimes led to discharge home, so that at the time of the incident which prompted the serious case review, the young person may have been receiving low-level services only.
• Agencies appeared to have run out of helping strategies and were sometimes reluctant to assess these young people as mentally ill and/or with suicidal intent.
• Time was wasted arguing about which agency was responsible for which service and whether thresholds were met, thereby delaying the provision of services that the young people needed.
• There was a lack of coordination of services for these young people ‘in transition’ and failures to respond in a sustained way to their extreme distress which occurred in parallel to their very risky behaviour.

The report describes ‘agency neglect’ as a common factor in respect of these young people.

Domestic violence

Finally, there was evidence of domestic violence in two-thirds of families, and mental health problems or substance misuse among well over half of the parents or carers. The coexistence of all three potentially problematic parental behaviours was evident in a third of these families. Domestic violence has repeatedly shown up in research as being a strong warning signal of child abuse; however, professionals may find it difficult to refer to child protection agencies where there is no direct evidence of physical abuse of the children. Schools can and often do play a role in alerting services to domestic violence and can offer a parent suffering such abuse by their partner access to information about domestic violence services and access to a telephone from where a parent can safely self refer. However, schools should always report their knowledge of domestic violence to children’s social care with or without the parent’s consent.

Essential reading

This report is well written and I would recommend it as essential reading to named persons.

Analysing Child Deaths and Serious Injury through Abuse and Neglect: What Can We Learn? A Biennial Analysis of Serious Case Reviews 2003–2005 Authors: Marion Brandon, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black.