Presentation to Swindon Safeguarding Children Board ...

Presentation to Swindon Safeguarding Children BoardConference12 October 2016Helen Davies
2 Serious Case Reviews
ChildD aged 2 weeks March 2013 – March 2015Child S aged 8 weeks April – October 2015Focus on learning for organisations – systemsNot yet published
Common themes
Cosleeping on sofaWell known to agencies – child protection plans/interim supervision orderNeglectMaternal ill healthMothers’ traumatic childhoods/older children in care
Positives
Promptvisits to mothers and babies after hospital dischargeSafe sleeping addressedIn 2015:Multiagency workingStrong commitmentFocuson children/ siblings –advocatesIdentification of neglectEffective safeguarding procedures – core groupsCare proceedings
Learning
Gapsin communicationGPs and social workersBetween hospitalsBetween hospital and health visitor/midwifeBetween hospital and social workerHospital checks re CP planHospital not thinking childFailure to convene discharge planning meetings
Lackof chronology on social work fileMother’s mental health diagnosisMother’s alcohol and drug useNature of mother’s seizuresIdentity of male partners and their parenting capacityFather’s role in familyViability of grandmotherMeasuring change and outcomes (health visiting)All relevant information in hospital records not known to midwives
Learning
Gaps in assessment
Identification of capacity to change
Impactof mother’s childhood on parentingImpact of her lifestyleApparent changes taken at face valueFalse optimism
Learning (cont)
Mothers/impact on staff
Needycare leaverDistracted by her own needsDisguised complianceImpact of traumatic pregnancy and major surgery/effects of strong painkillersImpact of period in ICU on health and functioning
Learning (cont)
CP Processes
Fewcore group meetingsImplementation of CP plan not addressed at reviewsPaediatrician not at strategy meetingNo pre birth conference
Learning (cont)
Escalation
Noescalation byConference chairsHealth visitorCommunity midwife
Learning (cont)
Legal processesAmple evidence to use it (D)Delays in convening meeting before action (7 months)Delays in completing required assessmentsRemoval in context of neglect
Learning (cont)
Organisational issues
Changesof social workers and managersHealth visitor workload/supervisionWorkload of safeguarding midwifeDelay in community paediatric assessmentCover for vulnerable baby when health visitor not availableHospital IT systems
Learning (cont)
Questions
Whatchanges are necessary in light of these findings?What recommendations would you make to the Safeguarding Children Board?What might be the barriers to making the changes?