Summary of themes emerging from the 2019 Triennial Analysis of Serious Case Reviews 2014-17, presenting key messages for local safeguarding partnerships. 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
1
Messages for Local Safeguarding
Partnerships

2. Workshop objectives
› Review main learning from the report
concentrating on four key areas:
− Neglect and poverty
− Vulnerable adolescents
− Multi-agency working
− Enabling children to have a voice
› Identify implications for local
safeguarding partnerships
2

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
3

4. Complexity and challenge
1. Complexity of
children’s and families’
lives:
› Neglect in context of
poverty
› Cumulative harm
› Emerging extra-familial
threats in adolescence
› Better assessments for
children’s long-term care
and in court processes
2. Challenges facing
professionals:
› Lack of reflective
supervision
› Enabling discussion of
different views in multi-
agency working
› Using chronologies
effectively
› Fragmented working
4

5. Neglect and poverty
› Neglect was the category of abuse in 75% of all SCRS and in 50 out
of 84 children were subject to a child protection plan
› SCR findings associated with neglect include: poor dental hygiene;
incomplete vaccinations; missed appointments; poor school
attendance; developmental delay
› Poverty leads to additional complexity, stress and anxiety and can
heighten the risk of neglect
› Most children living in poverty do not experience neglect
› The impact of poverty is not always fully understood or captured in
recording or assessments
› Parents living in poverty often have fewer resources to draw upon
(social, emotional and physical). Shame and hopelessness can be
barriers to seeking/accepting help
5

6. Adverse family circumstances in
cases of neglect
6
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.)

7. Learning points
› Links between domestic abuse, substance misuse and poverty are
complex and often inter-dependent. It is not enough to address a
single issue without addressing the underlying issues
› Normalisation and desensitisation:
− Professionals who work in areas of high deprivation may no longer
notice the warning signs of poverty and neglect
− Supervision/case management is crucial in supporting practitioners
to identify poverty and work proactively
› Professionals can be reluctant to name neglect:
− Often seen as a barrier to family engagement
− A multi-agency approach allows for the triangulation of differing
views and perspectives
› Many families were living in unstable and inadequate housing
− Housing services may have valuable information to offer
7

8. Adolescent neglect
› The link between adolescent neglect and complex adolescent
behaviour is not well understood across the multi-agency network:
− This leads to fragmented and reactive responses, leaving young people at
risk
› When each involvement with a family is treated as a discrete event,
information is not accumulated and professionals do not develop a
comprehensive understanding of the child’s life experiences
› The report identifies the need for:
− Joint working agreements for adolescents with complex health needs,
especially around transition to Adults’ Services
− Better transition protocols that contain sufficient details to identify young
people not in receipt of support from disabled children teams
8

9. Vulnerable adolescents
 115 (31%) of the 368 SCR
notifications involved children
aged 11 and over
 65 of those SCRs related to
deaths and 50 involved serious
harm
 47 deaths (72%) were
maltreatment related
 Risk-taking/violent behaviour
by the young person and child
sexual exploitation (CSE) were
the most common causes of
serious harm in adolescent
cases
9
› Local neighbourhoods were a
source of significant risk
› Young people were often not in
school, going missing and
seeking a sense of belonging
away from the family home
› Emerging threats outside the
home include:
− Going missing
− Criminal exploitation (eg,
moving drugs, violence
gangs, trafficking)
− Child sexual exploitation
− Harmful sexual behaviour
− Radicalisation

10. Complex and Contextual Safeguarding
(Firmin et al, 2019)
10
› 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
› It is important to recognise the relationship between adolescents’
prior experiences and their risk of harm
› An adolescent going missing is a powerful signal that all is not well.
Timely multi-agency responses and effective return home and
prevention interviews are needed
› Prolonged and persistent professional engagement is needed to
support adolescents, including:
− A balance of preventative work and crisis management
− Trauma-informed and relationship-based practice
› Agencies should find ways to understand and record patterns in
adolescent group and individual behaviour
› Practitioners can feel unprepared for working with adolescents.
Relevant up-to-date training is essential
› Criminal activity may be an indicator of wider exploitation and
vulnerability. Responses need to recognise vulnerability and not focus
solely on criminal processes
11

12. Multi-agency working
› The number of different agencies involved in delivering care can
result in fragmented and uncoordinated services. ‘Silo-working’ may
occur within and between agencies
› Information sharing is crucial:
− Some SCRs show a reluctance among practitioners to pass on information
and confusion about what they can and cannot share
− When families move area, key information from Adults’ and Children’s
Services may be lost/not passed on
− The police held information about parents/families with a history of criminal
convictions, but this was not routinely shared
› It is important to have a lead professional who acts as the main
contact for the child or family and coordinates interventions
› Effective multi-agency plans depend on all relevant agencies being
represented at meetings
› Referral forms, assessment tools and incident-logging tools should
use language that explicitly depicts issues in ways that do not dilute
impact and harm
12

13. Care and court cases
› There are many competing imperatives within care proceedings:
− The principle of ‘no order’
− A duty to protect children from harm
− A legal priority to place children with kin
› The increasing number of care proceedings and speeding up the
process have had some negative impacts on outcomes for children
− Timescales should not undermine the need for a thorough assessment of
all carers, including kinship carers
› Some professionals had limited understanding of the legal framework
and were unclear about their roles/responsibility for children on
supervision orders
13

14. Enabling children to have a voice
14
 The absence of the child’s voice and their lived experience is a
recurrent theme in the report
 Understanding the emotional world of a child requires a rounded
rather than incident-led approach
 Children have more contact with adults as they enter school. School
staff need to inquire what lies behind changes in a child’s behaviour
 Ethnicity may be recorded but the implications for the day-to-day
lives of the children are often not explored:
 Professionals should be supported to be confident in exploring cultural and
spiritual beliefs to fully understand the daily life for the child
› Practitioners need to be alert to when a pregnant mother’s
circumstances may put the baby at risk, and consider how best to
safeguard mother and baby before and after delivery

15. Implications for the future commissioning of
local child safeguarding practice review (LCSPRs)
15
› The following were considered important for reviews:
 Considering from the outset what the partnership is trying to achieve
 Not just applying one model to every review
 Effective involvement of family members and practitioners
 The skills and quality of the lead reviewer
 Multi-agency training and the distribution of briefings or bulletins
were the most popular methods of dissemination
 LCSPR/SCR recommendations:
 need to be specific, contextual and at a systems level
 were felt to have most impact when they were either targeted at single
agencies or clearly at a multi-agency level
 mattered less than having a committed, motivated team or champion to
take them forward

16. Impact and change
16
› It was rare to find evidence of national change resulting from SCRS
› Demonstrating change was challenging; evidence came primarily from audits
and action plans
› Learning was thought to have added weight and be easier to embed
when it came from a local review
› Keeping learning real, local and close to home was helped by
involving practitioners in the review process
› SCRs were thought to act as an accountability check on the system
and the quality of leadership and practice
› Barriers to achieving impact included:
− A preoccupation with process
− Action plans that prompt a tick-box response rather than a focus
on systemic change
− Organisational change and a depleted organisational memory
− Shifting priorities

17. Reflective questions (strategic)
 How are local safeguarding partners working
effectively across partnerships?
 Do local strategic plans and service commissioning
take account of the local picture of child poverty and
neglect?
 Are these delivered in a way that enables practitioners
to support families living with an increased risk of
neglect, alongside other complex needs?
 How are local data and knowledge being used to
provide a more effective safeguarding service?
 What processes are in place to ensure that new or
revised protocols are embedded in practice?
 Are you clear about your role in commissioning and
quality assurance?
17

18. Reflective questions (practice)
 Do agency assessments take into account how
poverty is impacting on families?
 Do multi-agency practitioners have the tools to help
them recognise and respond to neglect?
 How well embedded are reflective supervision / case
management processes in the key agencies?
 How effective are local transition processes between
children and adult services? How do you monitor
this?
 How successful is the role of lead professional in
your area?
 How are you evidencing the lived experiences of
infants who are pre-verbal, and children and
adolescents with speech and language difficulties?
 18

19. Further reading
› Brandon M, Sidebotham P, et al (March 2019)
Complexity and Challenge: A Triennial Review of
Serious Case Reviews 2014-2017. London:
Department for Education.
› 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.
› Research in Practice (2019) Neglect in the context of
poverty and austerity: Frontline briefing. Dartington:
RiP.
19

20. Contact details
20
www.rip.org.uk
ask@rip.org.uk
@researchIP