2019 Triennial Analysis of Serious Case Reviews: Key messages for education professionals. The presentation includes links to related Research in Practice resources which will be useful for learning and development activities based on the findings of this report.

1. 2019 Triennial Analysis of Serious
Case Reviews
Messages for Education
Professionals
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2. Workshop objectives
› Review main learning from the report in
three key areas:
− Neglect and poverty
− Vulnerable adolescents
− Information sharing and multi-agency
working
› Identify implications for the education sector
› Support staff to develop their knowledge,
skills and practice to keep children and young
people safe
› See https://seriouscasereviews.rip.org.uk/
for further information
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3. Key themes
› Findings based on:
− Quantitative analysis of 368 SCRs notified to DfE 2014-2017,
− Detailed analysis of 278 SCR reports that were available for review
− Qualitative analysis of a sample of 63 SCR reports.
› Complexity and challenge: complexity of the lives of children and
their families, and challenges faced by practitioners seeking to
support them.
› Service landscape: challenges of working with limited resources,
high caseloads, high levels of staff turnover and fragmented services.
› Poverty: the impact of poverty, which created additional complexity,
stress and anxiety in families.
› Child protection: once a child is known to be in need of protection
the system generally works well.
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4. Neglect and its relationship to poverty
› Neglect featured in 75% of all the SCRs examined
› Neglect is the most common category of abuse for children on child
protection plans
› Poverty leads to additional complexity, stress and anxiety and can
heighten the risk of neglect
› Most children living in poverty do not experience neglect. However
the co-existence of poverty and neglect can escalate adverse
outcomes
› Recognition of poverty and its impact on parenting was often missing.
If recognised, poverty was often perceived as an outcome not a cause
of a family's needs and difficulties
› Professionals working in deprived communities can become
desensitised when working with families in poverty and accept lower
standards or care
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5. Adverse family circumstances in
cases of neglect
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Table 1: Parental and family adversity in SCRs where neglect
was a feature (Rates are likely to be an underestimate as they
depend on whether a factor was recorded in the SCR report; in some
cases the question may not have been asked, in others the SCR
author may not have felt the factor was relevant.)

6. Learning points
› Education staff need training in recognising and responding to signs
of neglect, poverty and risks of harm to children and young people
− A common feature in neglect cases was a period of low-level concerns
followed by a sudden escalation in risk, triggering a series of events that
swiftly became unpredictable
− Parents living in poverty have fewer social, emotional and physical
resources to call on. Shame, hopelessness and previous negative
experiences of social work intervention may hinder their seeking or
accepting help
› Providing immediate support for children in poverty is important;
but rectifying the physical manifestations of poverty does not
equate with children being safe
− Early help assessments and services play a vital role in identifying what
help a child and family require to prevent needs escalating
− In making referrals to early help or children’s social care, it is important to
use language that describes issues clearly and accurately and provides
evidence of the lived reality of life for the child
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7. Learning points
› Teachers and other school staff are in a unique position to notice a child’s
appearance, signs of distress or worrying behavioural changes:
− Careful recording and sharing of these observations over time is essential
› Developing a trusting relationship with children is key:
− After-school activities and clubs offer opportunities for adults to form
trusting relationships with children and for children to be heard and
concerns acted upon
− Particular attention should be paid to children with communication or
learning difficulties; they may find it difficult to express their experiences
− All school staff should have a good understanding of the impact of trauma,
or loss/separation on children’s behaviour. The harm children have
suffered in the past can affect their later behaviour
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8. Vulnerable adolescents
› Nearly one in three SCRs involved children aged 11 and over
› Risk-taking/violent behaviour by the young person and child sexual
exploitation (CSE) were the most common causes of serious harm in
adolescent cases
› Outside infancy, suicide was the most common category of deaths
related to maltreatment
› Adolescents about whom there are safeguarding concerns often have
early experiences of abuse and neglect, separation or loss and time
spent in care
› Teenagers spend less time at home and more with their peers. While
harm can continue to come from within the family during
adolescence, there is increased potential for extra-familial risk and
harm
› Both virtual and local communities provide spaces for exploitation
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9. Adolescent risk
Extra-familial risks include:
› Going missing
› Criminal exploitation (eg, moving drugs (county lines),
violence, gangs, trafficking)
› Child sexual exploitation (CSE)
› Harmful sexual behaviour (HSB)
› Radicalisation
› Social media and technology-assisted harm
› Suicide and self-harm
› Loneliness
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10. Complex and Contextual Safeguarding
(Firmin et al, 2019)
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› Complex Safeguarding
− This encompasses a range of
safeguarding issues related to
criminal activity involving
vulnerable children or
adolescents, where there is
exploitation and/or a clear or
implied safeguarding concern.
− Includes child criminal
exploitation, county lines,
modern slavery including
trafficking and child sexual
exploitation (CSE).
› Contextual Safeguarding
− This is an approach to
safeguarding children and young
people which responds to their
experience of harm outside the
home – for example, online, in
parks or at school.
− It provides a framework for local
areas to develop an approach that
engages with the extra-familial
dynamics of risk in adolescence.

11. Learning points
› Practitioners can become reactive when working with adolescents
who have a history of disturbed or disturbing behaviour:
− Children who have had traumatic experiences are not quickly made safe;
prolonged and persistent engagement is necessary
− Understanding an adolescent’s early years, current and changing family
situation and wider social networks is vital. School staff are in a good
position to understand family networks and relationships
− Schools and education settings should ensure concerns about a child are
accurately recorded and taken seriously by those receiving the information
− Signs of loneliness or exploitation can manifest as withdrawal and lack of
engagement at school. Schools may see this as ‘troublesome’ behaviour and
so focus on the presenting behaviour rather than explore what is driving it
− Non-fatal self-harm is strongly associated with completed suicide and should
be referred to health services for a thorough specialist assessment
− Teachers and school staff should receive ongoing education and support on
how to keep children safe online
− School staff also need ongoing training and support in relation to
exploitation and radicalisation
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12. Learning points
› Adolescents who are missing from care, home or education are
vulnerable to different forms of exploitation:
− Working with adolescents who are vulnerable to exploitation requires time to
build relationships and trust. Schools and youth charities are in a good
position to sustain that work over a number of years
− When children return after going missing, the Designated Safeguarding Lead
should be proactive in working with partner agencies and identify what
support they can provide within the school
− Boys may be less likely to disclose abuse, but the risks for male victims of
CSE are no less serious than for females. Staff should always ask
themselves if their response would be different if the victim was a girl
− Young people vulnerable to radicalisation require opportunities to explore
their concerns without fear of criminalisation
− Being a victim and perpetrator of HSB are closely related, particularly when
offences are committed as part of a group; support and safeguarding are
required for both aspects
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13. Information sharing and multi-agency working
› Schools and other education settings are an integral part of the
multi-agency safeguarding system and it is vital that no setting or
service perceives itself as being outside of that system
› When schools try to manage incidents in-house to avoid
criminalising young people, this can leave other professionals less
able to safeguard adolescents
› Delays in sharing information can hamper effective safeguarding
› Poor liaison between schools and others can lead to
misunderstandings
› The use of clear and descriptive language is integral to effective
information sharing
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14. Learning points
› Education settings are in a unique position to notice how children are
because they have almost daily contact with the same child
› Good quality record keeping and communication of relevant issues
with other agencies help to identify patterns of events, concerns,
strengths and unmet needs:
− Records and referrals should be written in clear, descriptive and jargon-free
language that accurately expresses concerns and captures the lived
experience of the child
− Maintaining and sharing chronologies is useful for evidencing changes and
alerting staff to the possibility of cumulative vulnerability and spiralling risks
− Disagreements are to be expected and are not unhealthy. Local escalation
policies should set out clearly how disagreements will be handled and
resolved
− Senior leaders should foster a culture of professional curiosity and challenge
to support staff development
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15. Reflective questions
› How does your education setting ensure teachers and other staff do
not become desensitised to children’s experiences of poverty and
signs of neglect?
› How does your education setting build children and adolescents’
efficacy in expressing their experiences? Are there sufficient
opportunities for staff to build trusting relationships that enable these
conversations?
› What training have teachers and other school staff received around
different forms of exploitation and how to respond?
› How are staff made aware of issues relating to adolescent neglect and
the links between behavioural issues in adolescence and earlier
childhood experiences? Do your behaviour policies take account of
young people’s vulnerabilities?
› How does your school or setting support children who are on a multi-
agency plan?
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16. Further reading
› Brandon M, Sidebotham P, et al (2019) Complexity
and Challenge: A Triennial Review of Serious Case
Reviews 2014-2017. London: Department for
Education.
› Department for Education (2018) Keeping children
safe in education: Statutory guidance for schools and
colleges. London: DfE.
› Firmin C, Horan J, Holmes D and Hopper G (2019)
Safeguarding during adolescence – the relationship
between Contextual Safeguarding, Complex
Safeguarding and Transitional Safeguarding.
Dartington: Research in Practice.
› HM Government (2018) Working together to
safeguard children. London: Department for
Education.
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