A criminal investigation was initiated but neither foster carer was charged with criminal offences.Key issues: Child PB became looked after aged 12 due to behavioural problems. The parents separated when Alex was 5. Keywords: child sexual abuse, foster carers, placement breakdown, runaway adolescents> Read the overview report, Death of 3-year-old Child S, cause unknown, in summer 2014, 6 months after moving to a London borough.Background: Child S’s mother had a history of long term substance misuse. Samantha shares her experience of mental health problems during the Coronavirus lockdown. Prof Andrew McDonnell, an expert in autism at Birmingham City University, who develops training to reduce the use of restraint, said it was a "cruel punishment". Learning: identifies learning lessons in relation to multi agency working maintaining the child as the focus.Recommendations: focused outcomes and plans for children; the value of multi-agency working; undertaking a thematic audit on working with violence and aggression; and developing a strategy to hear the voice of a child for children subject to multi agency procedures. It is a shocking physical abuse statistic that approximately 2 million injuries occur each year from physical abuse, for which only a third will seek medical help. During this process they moved from one local authority area to another. Child L had contact with Child and Adolescent Mental Health Services (CAMHS) and Children's Social Care (CSC). After the placement in foster care ended, the mother was housed in her home town some distance from the foster carer.Learning: importance of assessing the accuracy of current or historical concerns reported by others; the need to respond flexibly to requests to house families in other local authority areas; to consider what formalised support is required following a move out of a baby and mother foster placement.Recommendations: to make arrangements for appropriate medical and health advice to be available at strategy meetings; to consider how new professionals working with a family are made aware of the case history and reasons for decision making.Keywords: adverse childhood experiences, family violence, housing, parenting capacity, unknown men> Read the overview report, Death of a 23-month-old infant due to non-accidental injuries whilst in foster care in June 2013.Key issues: Child T was a looked after child who was placed with foster carers in March 2013 as a result of injuries sustained whilst in his mother's care. Child L, aged 5 months, half-sister to Child J, had a mouth injury and bruising 10 months earlier and had been subject to a Child Protection enquiry but after a Child and Family assessment the case was closed.Learning: the need for practitioners to be aware of the significance of early life experiences, drug use and mental health problems in parents and their impact on the children; the need to understand normal child development which would have improved the quality of decision making; inter-agency cooperation; the need for effective supervision and managerial oversight. This includes the number of children who are the subject of a child protection plan or on a child protection register 2. police forces record data on the number of offences committed children 3. criminal courts record data on the number of offenders convicted of child abuse offences 4. local registrars, cor… The young person reported the assault in November 2015, at the age of 18.Learning: understanding of risk and how that can be managed needs to be better; agencies need to identify persons who present a risk to children and flag those persons within their agencies to enable them to be managed in a multi-agency fashion; parents and carers need to be equipped to identify grooming, especially when a risk is known or perceived.Recommendations: ensure that organisations can effectively flag and monitor persons identified as presenting a danger to children; ensure that staff feel confident in identifying and referring persons who present a danger to children; review how effective disclosures can be achieved from children and young persons where there is a lack of verbal disclosure.Keywords: child sexual abuse, disclosure, siblings, professional curiosity, information sharing> Read the overview report, Death of a 7-week-old infant from non-accidental injuries caused by shaking in February 2016. Areas of good practice identified include: support and commitment by Young Person's school and GP.Recommendations include: development of an awareness raising and educational campaign about young people who use and supply drugs; guidelines to strengthen professional knowledge about referral thresholds and pathways for young people who abuse or procure drugs.Keywords: child death, substance misuse, drugs, mental health> Read the overview report, Sexual abuse of a girl between the ages of 10- to 16-years-old. Mother and partner were arrested and prosecuted.Learning: risk and harm from control and coercion represents a different threat to other forms of domestic violence and abuse; intimidated adults and children are unlikely to disclose information; prior history of domestic violence and abuse is a significant indicator of higher risk in subsequent relationships.Recommendations: issues for national policy considerations include: guidance on coercion and control as a safeguarding issue and the implications for practice; guidance and arrangements for training for magistrates in regard to domestic violence and abuse.Keywords: physical abuse, family violence, disclosure, voice of the child.> Read the overview report, Death by suicide of a teenage girl in January 2019.Learning: early help for young people suffering self-harm and/or suicidal tendencies needs development to promote multi-agency working; responses to a young person disclosing sexual abuse may be more effective if they feel included in discussions regarding decisions and potential outcomes; training required to assist social workers exercise their right to disclose information confidentially.Recommendations: to enhance the use of the self-harm referral pathway and refer young people when support is needed; to ensure similar enquiries are managed by the police in a sensitive manner when a young person feels unable to proceed with a prosecution and victims are better informed if there is no intention to speak to the alleged perpetrator.Keywords: child sexual abuse, self harm, threshold criteria, voice of the child, suicide.> Read the overview report, Death of a 14-year-old young person from an aggressive malignant tumour.Learning: Child F’s voice was heard but was not understood and acted on; evidence of poor inter-agency communication and information sharing; the need to manage conflict and work with challenging carers whilst not losing focus on the child; quality of care issues raised by Child F received an inadequate response by Children’s Social Care.Recommendations include: children cared for by the Local Authority should be provided with advice either from an independent legal advisor or advocate when they are in disagreement with professionals or carers; raise awareness regarding prevalence and symptoms of brain tumours in children and young adolescents; foster carer recruitment, training and supervision should encompass lessons from this review. This is to ensure that the needs of children in SGO placements are met wherever they are placed.Keywords: kinship foster care, physical abuse, school attendance, home environment, family functioning, medical assessment.> Read the overview report, Neglect of four siblings over a period of several years.Learning includes: when professionals do not have an understanding of the family history, relationships and functioning it is difficult to have a clear picture about what daily life is like for the children; significant decisions should be informed through key assessments being completed, including pre-birth parenting assessment and risk assessments.Recommendations include: seek assurance that the model used in assessing risk within conferences is being used effectively; seek assurance in the practice of Independent Child Protection Chairs and their management of conferences; consider establishing a practice by which CP plans should not be removed at the first review unless there are evidenced circumstances; seek assurance that the professional resolution and escalation procedure is understood and effectively applied in all partner organisations.Keywords: child neglect; non-accidental head injury; heroin; neonatal abstinence syndrome; optimistic behaviour; teenage pregnancy.> Read the overview report, Institutional abuse of children at Medway Secure Training Centre (STC) in 2015.Learning includes: create safe working cultures within organisations, including safe recruitment, policies, training and supervision of staff; ensure statutory agencies’ arrangements for responding to allegations about adults who are in positions of trust are effective in protecting children from abuse; ensure appropriate, child focussed commissioning practice by national organisations responsible for contracts for service provision within the secure estate; consideration needs to be given to ensure the advocacy service is fully accessible and there are no barriers to children raising their concerns.Recommendations include: re-launch awareness programme and training on safer recruitment processes and audit to ensure these messages are embedded; consider STC staff undertaking training in Adverse Childhood Experiences (ACEs) to better understand children’s needs and behaviours; consider the implementation of regular formal supervision processes for staff.Keywords: institutional child abuse; whistleblowing; physical restraint; recruitment; secure accommodation; commissioning of services. 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