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

More documents

Recommendations

Info

Neglect and Serious Case Reviews themeS aNd learNiNg poiNtS children not seen as individuals within a large family minimised its impact and had an over optimistic view of their ability to care safely. The situation was exacerbated by the fragmented nature of health and social care involvement in terms of key workers and managers. Amid this confusion and lack of clarity, the risks to the new baby in the family went unrecognised. • Sudi prevention: strategies for targeted intervention: At no point had the presence of interacting risk factors associated with SIDS been assessed and the possibility of intervention considered. The GP and health visitor were aware of Daniel’s vulnerability due to prematurity. However, records do not indicate that this was linked with other risk factors, which included parental smoking, parental alcohol misuse and co-sleeping, to identify the need for any specific intervention in that area. This was a recurring theme, which is illustrated in the vignette above. The risks associated with the known history of neglect of the older siblings were not reassessed in relation to the new infant. As one SCR commented ‘the children were not seen as individuals and their individual needs, nutrition and sleeping arrangements were not recorded by any professional’. The potentially life threatening nature of the neglect would have been especially relevant to a newborn baby, whose particular vulnerability was not considered or treated with urgency in spite of a neglect plan being in place. interacting risk factors in relation to Sudi risk Our previous work (especially Brandon et al 2008) has emphasised the importance of an interacting risk perspective. This holds true for these cases of SUDI, where interacting risk factors, for example prematurity, parental smoking, alcohol misuse, deprivation, and co-sleeping, would have elevated the risk to the infants. However, there was little indication that a combination of risk factors was considered in this light. parental substance misuse in the context of neglect 62 Parents tended not to be honest with professionals about the extent of their alcohol or drug dependency, and its impact was therefore often underestimated by professionals involved with the family. In one case a mother’s keenness to stop drug taking meant that professionals minimised her continuing substance misuse and its impact on the children. In another, drug misuse was addressed narrowly without thinking of the pattern of drug use on a child’s safety, and there was ‘a tendency for professionals to concentrate on one feature of drug misuse (heroin) without an understanding of the more complex effects of chaotic or polydrug/alcohol misuse – a combination of drugs that is likely to induce drowsiness/deep sleeping and impair parenting capacity’.
Sudi riSKS aNd targeted iNterveNtioN 3. A thematic analysis of neglect Whilst stating that these deaths were not predictable, these serious case reviews did allude to missed opportunities to intervene which may have made a difference. Although the presence of neglect had been recognised, the potentially fatal outcome for the infant had not. The kind of issues arising are summarised below: • In one case advice about reducing the risk of SIDS was not formally recorded in midwifery or health visiting records, so may or may not have been delivered to the parents. • Lack of basic health promotion regarding cigarette smoking and SUDI risk, for example in one case there was no evidence that the ‘reducing risks of cot death’ leaflet (designed to be given if anyone in household smokes) was given. • An SCR relating to an incident that took place over the Christmas period highlighted that although there was a need to be especially alert to alcohol abuse by the parents and the children being put at risk, there was no evidence of any assessment by the health visitor in respect of this. The report writer suggests that this should have been part of the child protection plan. • In a further example, the health professionals had recognised the possibility of cosleeping as a potential risk, advice had been given accordingly. However, in this case professional judgement had been made that the benefits of parental care for the child outweighed what were understood to be the possible rather than probable dangers of co-sleeping. • Another overview report describes how although these issues had been discussed with the mother, who stated that a Moses basket had been provided for the baby its existence was not checked, as access to the bedroom was refused. In the event, she revealed following the baby’s death that he had slept with her. Sudden infant death is one of the more preventable of child deaths, and indeed since the ‘Back to Sleep’ campaign of the early 1990s there has been a dramatic reduction in incidence. However, a higher proportion of residual sudden infant deaths now occur among more vulnerable families living in areas of high deprivation (Blair et al 2006, Wood et al 2012). A recent case-control study of SIDS in south west England showed that many of these deaths occurred in a potentially hazardous sleeping environment, including sofa sharing with an adult who had recently consumed alcohol or narcotics (Blair et al 2009). The authors conclude that the major influences on risk ‘are amenable to change and specific advice needs to be given, particularly on use of alcohol or drugs before co-sleeping and co-sleeping on a sofa’. These are new findings and efforts need to be made for this knowledge to become incorporated into professional practice. One example of innovative work in this respect is a recent campaign in Lancashire developed in response to the high number of Sudden Infant Deaths across the county. The campaign centred around safeguarding messages, aiming to raise awareness of associated risk factors as well as the preventative measures 63
Page 1 and 2:
Neglect aNd SeriouS caSe reviewS A
Page 3 and 4:
Contents Executive Summary 7 1. The
Page 5 and 6:
tableS Tables and Figures appeNdix
Page 7 and 8:
iNtroductioN Key fiNdiNgS Executive
Page 9 and 10:
fiNdiNgS how ofteN iS Neglect evide
Page 11 and 12: Neglect iN all ScrS from 2009-11 To
Page 13 and 14: Sudden unexpected deaths in infancy
Page 15 and 16: maintaining a healthy, safe relatio
Page 17 and 18: 1. The context of neglect and serio
Page 19 and 20: Summary 1. The context of neglect a
Page 21 and 22: 2.2 reSultS 2. Neglect in the lives
Page 23 and 24: There are encouraging signs of a dr
Page 25 and 26: figure 2.1: age distribution of chi
Page 27 and 28: 2. Neglect in the lives of children
Page 31 and 32: what did Neglect co-exiSt with? 2.
Page 35 and 36: figure 2.2: incidence of cp plan fo
Page 37 and 38: Summary 2. Neglect in the lives of
Page 39 and 40: what did Neglect coexiSt with? 2. N
Page 41 and 42: 3. A thematic analysis of neglect h
Page 43 and 44: As discussed in Chapter 2, it was n
Page 45 and 46: • There had been a lack of proper
Page 47 and 48: In reading the set of serious case
Page 49 and 50: The SCRs drew our attention to undu
Page 51 and 52: or more of a burden to his mother,
Page 53 and 54: parental learning disability Parent
Page 55 and 56: event prompting the serious case re
Page 57 and 58: themeS aNd learNiNg poiNtS ‘an ac
Page 59 and 60: 3.5 SuddeN uNexpected death iN iNfa
Page 61: agency involvement: learning: There
Page 65 and 66: event prompting the Serious case re
Page 67 and 68: learning: themeS aNd learNiNg poiNt
Page 69 and 70: uising and rough handling An unders
Page 71 and 72: event prompting the Serious case re
Page 73 and 74: themeS aNd learNiNg poiNtS the long
Page 75 and 76: situation or dangers posed by, for
Page 77 and 78: Sudden unexpected deaths in infancy
Page 79 and 80: 4 Implications for policy and pract
Page 81 and 82: maiNtaiNiNg a healthy, Safe relatio
Page 83 and 84: Bibliography Blair, P., Sidebotham,
Page 85 and 86: Bibliography Ofsted (2008) Learning
Page 87 and 88: Appendix Table A.2 Category of abus
Page 89 and 90: 3. extreme Neglect / deprivatioNal
Page 92: Photography by Jon Challicom, posed
show all

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

Create successful ePaper yourself

Delete template?

Save as template?