Neglect and serious case reviews (PDF, 735KB) - nspcc

3. A thematic analysis of neglect
harm. The final category considers the longer term consequences of living with neglect
when the young person takes their own life.
1. Malnutrition: Extreme deprivation by withholding food or water from the child,
where the child died or was close to death (8 cases).
2. Medical neglect: The child died or was seriously harmed or nearly died because the
parents did not comply with medical advice or administer medications (5 cases).
3. ‘Accidents’ with some elements of forewarning: Accidents, both fatal and resulting
in serious harm, occurred within a context of chronic, long-term neglect, lack of
supervision, and an unsafe environment (9 cases).
4. Sudden unexpected death in infancy: Unexplained infant deaths within a context of
neglectful care and a hazardous home environment (10 cases).
5. Physical abuse combined with neglect: Physical assault, both fatal and resulting in
very serious injury, in a context of chronic, neglectful care, where the assumptions
about neglect masked this danger to the life of the child (7 cases).
6. Suicide of a young person: A long-term history of neglect or extreme isolation
having a catastrophic impact on the young person’s mental wellbeing (7 cases).
These six themes were drawn from the cases and not constructed from the definition in
Working Together (HM Govt. 2010). However it is interesting how closely they connect
with this official definition, with the exception of the theme of physical abuse combined
with neglect. Another difference is ‘accidents’ with elements of forewarning which
similarly do not feature in Working Together.
Having established this framework, further analytical work was then undertaken,
examining cases applicable to each category. The selection of cases was based on
pragmatic consideration about the availability of source documents and also on their
relevance to each of the identified themes. Analysis involved both revisiting previously
completed case summaries where neglect was prominent (for 2003–09) and creation
of new summaries for SCRs from 2009–11. The case summary structure included an
outline of the case, the child and family background, the child’s experience, agency
involvement, and lessons learned.
Four researchers were involved in the analysis, and regular team meetings were held
to discuss and identify emerging themes. Results are presented in the form of case
vignettes. Care was taken to change identifying details and to use a combination of
sources, so that each vignette was based on a number of cases which shared similar
features. Thus each vignette, as presented, is a composite but credible case, and the
actions, circumstances and agency responses do not refer exclusively to the history of
any one child. Instead they allow for the investigation of key themes, in a manner which
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