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Complexity and Challenge: a Triennial Analysis of Scrs 2014-2017 Final Report

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Complexity and Challenge: a Triennial Analysis of Scrs 2014-2017 Final Report Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report March 2020 Marian Brandon, Peter Sidebotham, Pippa Belderson, Hedy Cleaver, Jonathan Dickens, Joanna Garstang, Julie Harris, Penny Sorensen and Russell Wate Table of Contents List of figures 8 List of tables 8 Acknowledgements 10 Executive summary 12 Introduction 12 Methods 13 Key Findings 14 Numbers of SCRs 14 Pathways to harm 14 Pathways to harm – children, parents and the wider environment 15 Child vulnerabilities and risks 15 Parental and environmental vulnerabilities and risks 16 Pathways to prevention and protection 17 Using family and community resources 17 Opportunities for preventive or protective intervention by statutory agencies 18 Effective multi-agency working 20 Supportive systems and processes 20 Learning from reviews for practice 21 Recommendations and disseminating learning 21 Impact and change 21 Chapter 1: Introduction 23 1.1 Complexity and challenge 23 1.1.1 Pathways to Harm, Pathways to Protection 23 1.1.2 Complexity in families’ lives 24 1.1.3 Challenges for professionals 25 1.2 Methods 27 1.2.1 Aims and Objectives 27 1.2.2 Methodology 27 1.3 Guide to Chapters 29 2 Chapter 2: Patterns and trends of maltreatment 30 2.1 Sources of information and approach to analysis 30 2.2 The number of SCRs undertaken 2014-17 31 2.3 Geographical distribution of the cases 2014-17 33 2.4 The nature of the death or serious harm 35 2.4.1 Categories of death 35 2.4.2 SCR deaths compared to national child deaths 37 2.4.3 Categories of non-fatal serious harm 38 2.4.4 Source of harm to the child/young person 39 2.5 Neglect 40 2.6 Characteristics of the children and families 42 2.6.1 Age and gender of the child 42 2.6.2 Ethnicity of the family 43 2.6.3 Where were the children living? 44 2.6.4 Children’s social care involvement 45 2.7 Background characteristics of the family 49 2.7.1 Parent and family characteristics 49 Chapter 3: Neglect 54 3.1 Methods 54 3.1.1 Categories of Neglect 56 3.2 Circumstances of death or serious harm 57 3.3 Background context 58 3.3.1 The complex and cumulative nature of neglect 60 3.3.2 Parent and carer criminal activity 64 3.3.3 Adolescent neglect 65 3.4 Opportunities for preventive or protective intervention by the family and wider community 66 3.4.1 Parents – understanding their experiences 66 3.4.2 Assessing key roles and relationships: fathers and male partners 68 3.4.3 The wider family – kinship care 70 3.4.4 Neighbourhood and community support 72 3 3.5 Opportunities for preventive or protective intervention by statutory and other agencies 73 3.5.1 Supporting consistent, relationship-based work with families 80 3.5.2 Supporting purposeful intervention 82 3.5.3 Identifying, assessing and managing risk 84 3.5.4 Anticipation and identifying spiralling risk 86 3.6 The multi-agency workforce 89 3.6.1 Silo working within agencies 90 3.6.2 Enabling effective multi-agency working 91 3.6.3 Effective information sharing 97 3.6.4 Fractured perspectives 98 3.7 Systems and processes that may support such interventions 100 3.7.1 Service landscapes 101 3.7.2 Co-location and other joint service responses 103 3.7.3 Tools and resources 111 Chapter 4: Vulnerable adolescents 113 4.1 Introduction 113 4.1.1 Adolescent SCRs 113 4.2 Going missing 114 4.3 Exploitation 120 4.3.1 Child criminal exploitation 120 4.3.2 Child sexual exploitation 125 4.4 Harmful Sexual Behaviour 129 4.4.1 Sexting 133 4.5 Social media and technology-assisted harm 134 4.6 Opportunities for prevention 138 4.6.1 Education 138 4.6.2 Relationships 139 4.6.3 Loneliness 141 4.6.4 Early help and support 144 4.7 Opportunities for protection 145 4 4.7.1 Suitable placements for vulnerable adolescents 145 4.7.2 Working together and sharing information 147 4.7.3 Written agreements 150 4.8 Conclusion 153 Chapter 5: Messages from care and court cases 154 5.1 Introduction 154 5.2 The ten ‘care and court’ cases 157 5.3 Children’s needs and voices 158 5.3.1 Ethnicity 163 5.4 Local authority and inter-agency systems 165 5.4.1 Workloads and resources 166 5.4.2 Evidence, thresholds and inter-agency working 167 5.4.3 Inter-agency understanding of the legal framework 169 5.5 Court principles and process 170 5.5.1 Parental and kinship care 171 5.5.2 The role of the court 173 Chapter 6: The impact of SCRs for practice 179 6.1 SCR models 179 6.2 Recommendations and implementation survey 181 6.2.1 Survey respondents 181 6.2.2 How well are models of review working? 182 6.3 Learning about recommendations 187 6.3.1 The number of recommendations and reviews 188 6.3.2 Types of recommendations 188 6.3.3 Monitoring implementation and quality assurance 192 6.3.4 Quality assurance 193 6.4 Dissemination of learning 194 6.4.1 Shared learning across different strategic boards 196 6.4.2 Types of cases, themes and learning 197 6.5 Key learning points from local reviews 199 6.5.1 Working Together 199 5 6.5.2 Recognition, assessment and response in relation to specific topics 202 6.6 Local thematic analyses prompted by SCRs 203 6.7 Impact 204 6.7.1 Local change 204 6.7.2 National change 207 6.7.3 Overarching barriers and enablers to impact from SCRs 208 6.8 The quality of the review and final report 214 6.8.1 Accessibility, clarity and analysis 214 6.8.2 Reflecting the child as a person 215 6.9 Looking ahead 215 6.9.1 Concerns over the SCR industry and the expense incurred 216 6.9.2 Dispelling the ‘myth’ of SCRs 217 Chapter 7: Complexity and challenge: implications for practice and policy 219 7.1 Introduction 219 7.2 Working with neglect 219 7.2.1 Messages for policy and practice 220 7.3 Working with adolescents 221 7.3.1 Messages for policy and practice 221 7.4 Working with care and court cases 223 7.4.1 Messages for policy and practice 223 7.5 Concluding points 224 References 226 List of acronyms 240 Appendix A: Methodology 242 Appendix B: Classification of deaths 247 Appendix C: Neglect protocol (from earlier biennial analyses) 250 Appendix D: Neglect sub-sample characteristics 251 Appendix E: Adolescent cases (25) 254 Appendix F: Care and court cases (10) 258 Appendix G: Review models 261 Appendix H: Topics noted as ‘top three learning points’ 262 6 Appendix I: Topics for LSCB thematic reviews 2014-17 264 Appendix J: Brief case summary sheet 265 Appendix K: Researcher summary 267 Appendix L: List of 278 SCR reports used for analysis 269 Appendix M: Coding framework 274 Appendix N: Quality template 275 7 List of figures Figure 1: Pathways to harm, pathways to protection 24 Figure 2: Numbers of SCRs 30 Figure 3: Annual numbers of SCRs 31 Figure 4: Proportion of SCRs involving non-fatal serious harm compared to total number of seriou case reviews per year 33 Figure 5: Geographical distribution of SCRs and children in need 34 Figure 6: Categories of death 36 Figure 7: Frequency of neglect in the general population 41 Figure 8: Age and gender of child, and nature of incident 43 Figure 9: Section 47 child protection enquiries and child protection conferences 46 Figure 10: Looked after children in SCRs 47 Figure 11: Adverse family circumstances in cases of neglect (n=208) 61 Figure 12: To what extent do you feel the following recommendation targets make a difference to practice? 189 Figure 13: To what extent do you feel the following recommendations types make a difference to practice? 190 List of tables Table 1: Annual number of SCRs 32 Table 2: Geographical distribution of the cases 2014-17 34 Table 3: Category of death 36 Table 4: Sub-categories for death related to maltreatment 37 Table 5: Categories of serious harm in non-fatal cases 39 8 Table 6: Source of harm to the child/young person 40 Table 7: Age of child at time of harm or fatality 43 Table 8: Ethnicity of the family 44 Table 9: Where living at time of harm or fatality 45 Table 10: Children's social care involvement 46 Table 11: Index child with a child protection plan (current or past) 47 Table 12: Parental characteristics - frequency noted in SCR final reports (n=278) 50 Table 13: Family characteristics - frequency noted in SCR final reports (n=278) 51 Table 14: Child experiences and features 52 Table 15: Child disability prior to incident 53 Table 16: Sample for neglect analysis 54 Table 17: SCR final reports analysed for criminal exploitation 122 Table 18: Family history of the adolescents who displayed harmful sexual behaviour 130 Table 19: Brief summaries of the ten 'care and/or court' cases 155 Table 20: Ethnicity of the child for the whole sample compared to the care /court cases 158 Table 21: SCR methodology 180 Table 22: SCR methodology use by year 181 Table 23: How well do these SCR models work to support learning? 182 Table 24: How do you monitor the implementation of your action plan or its equivalent? 193 Table 25: What are the ways in which you disseminate learning from SCRs to the workforce? 195 Table 26: Is learning shared across strategic Boards? 196 Table 27: Source of evidence for local practice change as a result of SCRs 205 9 Acknowledgements The research team would like to extend their thanks to the Department for Education for their funding, support and careful oversight of this study, particularly Duncan Prime and John Leppard.
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