Agenda item

Report by the Director of Children’s Services

5.1       Reg Hooke, Chair of the East Sussex Local Safeguarding Children Board (LSCB) introduced the report by explaining that it is a statutory duty of the LSCB to conduct a Serious Case Review (SCR) where a child has either died or has been seriously injured and it is suspected there has been abuse or neglect (and that there is likely to learning from the case for relevant agencies).   If there are recommendations, an action plan is then formulated which is managed and overseen by the LSCB to ensure the learning is taken on.   

5.2       The Committee were also informed about some of the key findings of the Wood Report (Alan Wood was appointed by the Government in January 2016 to lead a fundamental review into the role and functions of LSCBs).    The review was prompted in part by the absence of a national framework for learning and that learnings from SCRs were not being effectively shared more widely.   There was also a concern that the accreditation and standardisation of the independent reviewers who conduct the SCRs was variable across the country, as were the review approaches and methodologies adopted across the country by different LSCBs.   Against this backdrop the Wood report was submitted in March of this year, with the Government response being issued the following May.   The Government largely accepted the findings of the Wood report that, amongst other recommendations, there should be a national learning framework which would have the role of collecting and disseminating the learnings for local SCRs; that this framework should be overseen by a national body and that there needs to be in future the capacity to commission and carry out National SCRs.   As things stand it is not clear how these proposed changes will impact at the local level.

5.3       Douglas Sinclair, Head of Children's Safeguards & Quality Assurance then took the Committee through a presentation on the two serious case reviews contained within the report.  As a general point, the Committee were first informed that it was the view of both the Panel and the Independent Author that whilst there was learning points from both cases, neither death could have been predicted or prevented.    

Comments and Questions

5.4       The Committee then discussed the report and debated a number of issues which are summarized below.

·                  The Committee questioned why some agencies are not meeting the targets set by the LSCB and what is being done to ensure that they do so in future.  For example, a concern was raised about individual GP practices that are not complying with the LSCB’s recommendations.  In response the Committee were informed that in common with many services where there are a significant number of individual practices, ensuring compliance can be a challenge.  It is therefore a constant process for the LSCB of monitoring and checking.   With regard to the particular issue of GP practices, this is being flagged up with the Clinical Commissioning Groups.  There is also a GP designated lead who is actively delivering training for local GP practices.

·                  A query was raised about the limited resources available to public bodies to implement LSCB recommendations. In response the Committee were informed that whilst the LSCB accept the financial situation is challenging for all public bodies, it is the role of the LSCB to ensure that relevant agencies are complying with their statutory duties.  There are also two sub-groups (East and West) which act as multi-agency liaison groups which are comprised of operational managers.  These groups provide a forum for agencies to discuss their services and any pressures their services maybe experiencing. 

·                  The appropriateness of the wording being applied to both SCRs that ‘the death of the child was neither predictable or preventable’ was questioned, as some Members felt it was potentially misleading.  In response the Committee were informed that the LSCB understood why the Committee had raised this issue as the Board itself has recently explored the use of this wording in relation to another SCR.  Although it was clarified that the purpose of the wording was to flag up whether there are systematic failings in the processes followed by relevant agencies which meant they failed to predict and prevent an incident.  The terminology was not meant therefore to indicate that nothing at all could have been done to prevent the death of a child or serious harm to them – as there are individual perpetrators who are responsible for their actions.   The LSCB’s role is to constantly seek to reduce the chances that such tragedies will happen by reviewing the processes followed by relevant agencies.

·                  It was clarified to the Committee that the role of the LCSB is not to attach blame, as each individual organisation will have its own disciplinary procedures they will apply as appropriate.   Instead it is the role of the LCSB to identify learnings and to look to the future so as to prevent similar incidents happening again.  

·                  It was noted that in relation to Child P, there was evidence, or at least a strong suspicion, that on three separate occasions the mother’s address was inadvertently released to the father.   It was also noted that due to lengthy court proceedings relating to Child P, the associated case papers were very extensive and that as a result significant information may have become lost.  With this in mind, clarification was sought from the LSCB regarding its recommendations to agencies about ensuring sensitive information is kept secure – and why this was not already being done by agencies as a matter of course.   In response, the Committee were informed that whilst it is vital organisations have in place robust systems for keeping sensitive information secure, agencies should not just rely on this as being sufficient  – thought must be given at all times to building in safeguarding when conducting risk assessments.   With regard to extensive case papers where involvement may stretch over a number of years, the Department are very clear that a chronology must be provided so it is very easy to identify Council involvement in complex cases.   This also helps the department identify more easily whether there is an emerging pattern of incidents/behaviour requiring further action.

5.5       After being invited by the Chair to speak, Cllr Tidy, Lead Member for Children and Families assured the Committee that the LSCB undertakes detailed, careful investigations into the SCRs it conducts.   Cllr Tidy also noted the recommendation of the Wood Report to have SCRs conducted at a national level and raised the question of whether such reviews would impact on the timely delivery of reviews.  Consideration will also need to be given as to how the learnings from such national reviews would be implemented locally.  

5.6       RESOLVED:  to note the findings and learning from the Serious Case Reviews contained within the report.

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