Learning from Serious Case Review Child BF

Child BF (published 15 May 2020)

Cumbria LSCB commissioned a Serious Case Review (SCR) regarding Child BE in 2017.  Due to ongoing parallel criminal proceedings, which have now concluded it has not been possible to publish the SCR report until now.

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 BF's Story

Child BF was placed on a child protection plan prior to her birth due to professionals concerns about her parents’ ability to care for her. BF lived with her parents and another male who was not a family member. When BF was three months old she received non accidental injuries comprising of two hemorrhages. Child BF’s father has since been convicted of grievous bodily harm and received a custodial sentence.

If you work with children and families in Cumbria, there may be additional specific actions and lessons for your agency and your role. Please ask your manager, or contact your representative on the Cumbria Local Safeguarding Children Board, to find out more.  

Lessons to be learned from Child BF

  1. In cases where there are concerns about the capacity of parents to meet their children’s needs and where the parents are showing increasing vulnerabilities such as depression or relationship problems, continued non-engagement with assessments and support should be recognised as significantly increasing the risk to the child. 
  2. When lack of engagement is recognised in cases where the parents have vulnerabilities, an approach that provides additional support is good practice.
  3. In cases where an unborn baby of first time parents is thought to be at risk of neglect due to the predisposing vulnerabilities and risks, the possibility that the baby may be at risk of physical harm should also be considered.
  4. Professionals should ensure that they apply robust professional curiosity in relation to fathers; particularly when they disengage from services and from their parenting role with their child. This curiosity should be supplemented by robust challenge to fathers regarding their parenting role.
  5. Without a prompt and decisive response to a pre-birth referral there will be babies going home from hospital without the required assessment and parenting work being completed. The time available prior to the child’s birth needs to be utilised to ensure there is an understanding of the risks and protective factors and a plan that enables those involved to work towards providing preventive and protective interventions as required.
  6. Where an assessment indicates a significant change in a parent that increases the risk factors they present, this assessment should be shared expeditiously with appropriate professionals who are involved in the Child Protection Plan and PLO.
  7. Professionals transferring cases involving vulnerable parents to colleagues in other areas must satisfy themselves that all relevant information is shared and accurately recorded, and that there is a shared understanding of the vulnerabilities and risks, particularly if there is a view that a referral to the Safeguarding Hub is required.
  8. It is important for all professionals and agencies that hold relevant information on a child or their family to be invited to contribute to strategy meetings, child protection conferences and core groups. Conference chairs should make particular efforts to ensure that the relevant GP is invited and receives the record of meetings.
  9. Where a child presents at Accident and Emergency and Non-Accidental Injury is one potential cause of the presentation and a referral to Children’s Services has been made, early consideration should be made to notifying the police.

Dissemination of Learning

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

If you would like to discuss this briefing or any of its contents then please speak to your line manager, your representative on the CSCP or contact the CSCP Office, 2nd Floor Cumbria House, 117 Botchergate, Carlisle, CA1 1RD. Email CSCP@cumbria.gov.uk

Child BF - SCR Report this external link will open in a new window

CSCP Response to Child BF Reportthis external link will open in a new window


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