Non-accidental injuries to a ten-month-old in 2017. Learning and recommendations include: a need to ensure that every child subject to a multi-agency plan has a safety plan in place that is commonly understood by professionals, relevant family members and the child where appropriate; ensure action is taken to enhance the ownership of child in need plans amongst constituent agencies; support the development of critical thinking skills to enhance professional curiosity and analytical approaches to decision making; ensure gaps in understanding of sexual abuse and specialist services is addressed; request briefing from key organisations working primarily with babies how the issues of risk of abusive head trauma is being addressed and in particular, how consciousness is raised for professionals; and ensure that at all routine health contacts it will be evidenced that safe handling is discussed, and consistent and research-based information given to carers.
      
 Title:  Child E: serious case review. LSCB: Cheshire East Safeguarding Children’s Partnership Author: Cheshire East Safeguarding Children’s Partnership Date of publication: 2021  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            Child E  Serious Case Review  February 2021  Page 1 of 4                                                                           Child E Serious Case Review Executive summary  In 2017 Child E suffered significant non‐accidental injuries and a Serious Case Review was conducted. Cheshire East Safeguarding Children Partnership fully accepts all the findings and recommendations from this. The summary circumstances of the experience of Child E can be described as a child who suffered a significant non‐accidental injury at the age of ten months. The baby was taken to hospital where medical investigations revealed these to be non‐accidental injuries. No adult who had had responsibility for the care of Child E was able to offer a suitable explanation as to how the injuries could have occurred and a police investigation commenced.  Between the age of six and eight months, a number of agencies were involved with the family for Child E who was subject to a child in need plan during this period, following a child and family assessment. The child in need plan was ceased six weeks prior to the injury. The Serious Case Review was Independently Chaired and authored and all the services involved in the case contributed. The Serious Case Review made the following recommendations which reflect the focus for learning: That the Cheshire East Safeguarding Children Partnership  1.  are reassured that every child subject to a multi‐agency plan has a safety plan in place that is commonly understood by professionals, relevant family members and the child where appropriate 2.  takes action to enhance the ownership of child in need plans amongst constituent agencies 3.  support the development of critical thinking skills to enhance professional curiosity and analytical approaches to decision making 4.  are reassured that the highlighted gaps in understanding of sexual abuse and specialist services is addressed 5.  That the views of the Family Support Service with regard to consistent application of  threshold are specifically considered within a wider strategic context  6.  request a.  briefing from key organisations working primarily with babies how the issues of risk of abusive head trauma is being addressed and in particular, how consciousness is raised for professionals. b.  That at all routine health contacts it will be evidenced that safe handling is discussed, and consistent and research‐based information given to carers. The publication of this Serious Case Review has had to be delayed to allow for other processes to be completed.  This executive summary will focus on the practice learning and what has been undertaken to apply that. Actions undertaken by the Cheshire East Safeguarding Children Partnership in response to the Serious Case Review Recommendations That the Cheshire East Safeguarding Children Partnership  1.  are reassured that every child subject to a multi‐agency plan has a safety plan in place that is commonly understood by professionals, relevant family members and the child where appropriate  2. takes action to enhance the ownership of child in need plans amongst constituent agencies Over 800 Senior Leaders, Team Managers and Practitioners from across the partnership; and 14 key partner leads from Cheshire Police, Education and Health, who are responsible for leading and Page 2 of 4                                                                 supporting the practice to embed within their own organisations and practitioners have been trained in Signs of Safety. The feedback and post course evaluations on this training were very positive. The principles are now embedded in all Cheshire East Safeguarding Children Partnership training and specific Signs of Safety training has continued.    Plans for children now reflect the Signs of Safety model including safety plans, safety goals, Words and Pictures that are more accessible for the child and family and understood by them.   3.  support the development of critical thinking skills to enhance professional curiosity and analytical approaches to decision making Evidence based face to face course developed considering critical thinking and professional challenge in Safeguarding and provided with the Cheshire East Safeguarding Children Partnership training programme. Adult service practitioners have access to the training. All Signs of Safety training includes critical thinking skills within all aspects of practice, over 1300 professionals have now attended courses that include this. 4.  are reassured that the highlighted gaps in understanding of sexual abuse and specialist services is addressed A risk assessment document for assessing adults who pose a risk of sexual harm has been developed. This was informed by Police, Probation and Adults Forensic Services. It provides guidance and a format for which Social Workers can assess the sexual risk that an adult pose to a child.  Not all adults that pose a risk have a conviction and this assessment tool is to support safety planning. It has been disseminated across Children Social Care. 5.  That the views of the Family Support Service with regard to consistent application of threshold are specifically considered within a wider strategic context A Threshold of Need guidance was completed and communicated to all partner agencies. Signs of Safety has been introduced within the Integrated Front Door to ensure children receive the right level of help and protection. Early Help services have been re‐designed to focus on Early Help assessment and planning. Fortnightly auditing meetings of contacts, no further actions and repeat contacts received at the Front Door have been introduced. Family Service Managers, Health and Police participate. This support decision making around application of threshold through multi‐agency reflective discussions. All Family Service Managers have completed the professional challenge training and understand the application of the escalation process. Family Service Managers contribute to weekly meetings considering the step‐up step down of cases. The Local Authority had a peer review of their arrangements at the Front door in 2019 to provide independent assurance that it operated safely and decisions for the child were appropriately reached The Ofsted Inspection of children’s social care services in November 2019 reported that “When needs or risks increase, cases are stepped up appropriately from early help to children’s social care. This escalation is timely and ensures that children receive more specialist support when needed. Page 3 of 4                                    When professionals from partner agencies have concerns about children, they make appropriate contacts to children’s social care”. 6.  Request a)  briefing from key organisations working primarily with babies how the issues of risk of abusive head trauma is being addressed and in particular, how consciousness is raised for professionals. b)  That at all routine health contacts it will be evidenced that safe handling is discussed, and consistent and research‐based information given to carers. All relevant health providers have given assurance that the National guidance for Safe Handling are being worked to by practitioners and recorded in parents’ records. Workshops have been conducted within Children’s Social Care and the Cheshire East Safeguarding Children Partnership has promoted the guidance in its Frontline bulletin.  Safe handling/don’t shake information is now included in every parent held record book.  Health Visitors now have to record at every visit that they have discussed this. Involved health professionals discuss with parents from pre‐birth to post‐birth. Page 4 of 4  