Hertfordshire Safeguarding Children Board SCR Group Report 2011-2012

1. Hertfordshire Safeguarding Children Board SCR group and CDOP: 1st April 2011 - 30th August 2012 October 2012

2. SCR group HSCB is required to carry out a SCR if: • a child dies and abuse or neglect is known or suspected to have been a factor • to consider carrying out a SCR where a child has been seriously harmed; abuse or neglect is known or suspected to have been a factor, and the case gives rise to concerns about the way local professionals and services worked together to safeguard the child

3. Referrals • eleven referrals to the SCR sub-group • no SCRs - three cases identified with issues in multi-agency working - PCRs initiated (two completed) • two PCRs initiated in 2010/11 were completed in the 2011/12 period • 2 PCRs initiated recently in the 2012/13 period

4. PCR approach Facilitated workshops for practitioners and managers identifying lessons learnt on: • an individual basis • a local basis • a strategic basis

5. Recent PCRs: issues • risks associated with ‘non-diagnosable’ mental health problems • domestic violence and young teenage mothers, especially those leaving care • vulnerabilities of all care leavers • non-accidental injury to babies

6. Recent PCRs: issues (cont) • vulnerabilities of children with disabilities - professionals focusing on a parent’s needs rather than those of the child • lack of Ofsted regulation in semi-independent accommodation

7. Learning themes • improved information sharing identified in all reviews with multi-agency chronologies and common shared IT platforms often suggested • in all cases the need for specialist training was identified and in one, awareness-raising/publicity identified

8. Learning themes cont • the need for improved escalation procedures and better understanding of them • common use of assessment thresholds across agencies

9. Specific learning • improve interface between adult mental health services and children’s services • Improve the tracking of patients who move between GP practices • improve the commissioning process for semi-independent accommodation

10. Specific learning cont • better processes and procedures around CIN - training being rolled out • improved assessment - the graded care profile to be adopted as a primary tool in the assessment of neglect

11. Other work • a review of GP notes to ensure that no issues were missed in the case of a non-accidental injury to a baby in a domestic violence incident • conference chairs to include safe-sleeping recommendations pre-birth conferences • HPFT updated risk assessments for children in relation to adults who self-harm

12. CDOP • reviews all deaths of children and young people up to the age of 18 who were normally resident in HSCB area • identify any modifiable or avoidable factors or learning which could help to prevent similar deaths in the future

13. CDOP • 2011 - 4th year of CDOP • 66 deaths reported • 62 reviewed • 3 awaiting inquest • 1 late notification • 2010 – 58 deaths

14. Modifiable factors • 12 deaths with modifiable factors (19%) - close to the national figure of 20% (6 SUDIs) • down on 2010 where 32% of the deaths had modifiable factors (including 9 SUDIs) • all deaths with modifiable factors found were in children under age five • comparable with the 2010 figures with all but one in under fives group • high proportion of cases with modifiable factors identified in both 2010 and 2011 were cot deaths with additional factors such as co-sleeping smoking, drug or alcohol use were identified

15. Category of death

16. Safer sleeping campaign • recommended safer sleeping campaign - launched April 2012. • based on findings in 2010 and 2011 that co-sleeping was a common finding in sudden unexpected death in infancy (cot death), often together with smoking and/or drug or alcohol use.

17. Looped blind cords • publicity about dangers of looped blind cords in causing strangulation. • prompted by two similar deaths, one occurring 2011 and one early in 2012 • Backed by parents

18. Water safety • campaign on water safety prior to 2012 summer holidays, • following the deaths of three Hertfordshire children in private swimming pools, since the start of the CDOP process (one during 2011). • publicity backed by parents of the child who died in 2011

19. Other work • bereavement support continues to be monitored • rapid response continues to provide comprehensive service • contributing to national learning by responding to and reporting to ‘virtual’ national CDOP group • attendance at regional groups and FSID conference