Local Child Safeguarding Practice Reviews

March 2022

A statement from Independent Chair of the Buckinghamshire Safeguarding Children Partnership, Sir Francis Habgood QPM regarding the Serious Case Review for Family T

Buckinghamshire Safeguarding Children’s Board (BSCB) commissioned a Child Safeguarding Review in July 2018 in respect of female twin siblings aged 14 weeks who sustained significant non accidental physical injuries. The review covered the period from September 2017, the date when the mother was known to be pregnant, to June 2018 when the babies’ injuries were discovered. A separate multi-agency learning review was completed to identify opportunities for practice learning during the period the mother was in care (from age 14 to 17). That learning review informed this process.

The report identifies a number of key learning points and makes nine recommendations about wider partnership arrangements. The recommendations form part of an action plan which is now owned by the Buckinghamshire Safeguarding Children’s Partnership (which replaced the BSCB in summer 2019). All of the recommendations have been accepted, some actions have already been completed and work is progressing on the outstanding recommendations.

The publication of this report was delayed until criminal proceedings were concluded. The father pleaded guilty to assaulting Twin 2 in a manner likely to cause unnecessary suffering or injury to health contrary to Section 1 of the Children and Young Person Act 1933. No charges were brought in relation to the injuries to Twin 1. The criminal process has not delayed the implementation of the learning.

I am confident that the learning from this review will help to improve the safeguarding of children in Buckinghamshire and embed effective multi-agency working.

Sir Francis Habgood

Independent Chair, Buckinghamshire Safeguarding Children Partnership

January 2021

A statement from Independent Chair of the Buckinghamshire Safeguarding Children Partnership, Sir Francis Habgood QPM regarding the Serious Case Review for Baby N. 

This is a tragic and complex case that occurred in December 2018. The report concludes that the loss cannot be attributed to the actions of any one agency or the parents.  The case involved a number of organisations across three counties, moves by the family and the challenge of working with a family who were living in one area and accessing services across local authority borders.

The report highlighted the need to ensure that any decisions about home visits were based on timely and evidence based risk assessments and that effective supervision is in place.

The Serious Case Review makes a number of recommendations in the report. These include better understanding about the housing needs of vulnerable families who live on borders, supporting the wider partnership in understanding the impact of neglect on a child’s lived experience and endorsing the planned Healthcare Trust training on professional curiosity and unconscious bias. The report has also been shared with the neighbouring Safeguarding Children’s Partnership to ensure that lessons are shared.

The Partnership will now monitor the implementation of the recommendations and ensure that lessons are embedded. Our thoughts and sympathies are with baby N’s family.

Sir Francis Habgood

Independent Chair, Buckinghamshire Safeguarding Children Partnership

December 2020

A statement from Independent Chair of the Buckinghamshire Safeguarding Children Partnership, Sir Francis Habgood QPM regarding the Serious Case Review for Child V. 

In January 2019 the Buckinghamshire Safeguarding Children’s Board (BSCB) commissioned a Child Safeguarding Review in respect of the death of a two year, seven month old child, referred to as Child V. She and her older siblings were subject to Child Protection plans at the time of her death. The review covered the period from Child V’s mother’s early pregnancy in November 2015 to December 2018 when she sadly died due to a cardiac arrest likely to be caused by a natural but undetermined cause.

During the two years and seven months of her life Child V experienced neglect and delayed development. Information provided to the review evidenced that the social, emotional and developmental needs of Child V and her three siblings were not met. The review found that the response of agencies was fragmented and there was a lack of effective multi agency assessment. The impact of long term neglect on Child V and siblings was not adequately recognised and intervention to improve their life experience had limited impact.

The review also found that practitioners cared about Child V and Siblings and wanted their lives to improve. School and health worked particularly hard to ensure that records were kept and the children seen as often as possible. However, without a clear multi-agency plan to respond to emerging concerns any change was not sustained.

All of the organisations that had contact with Child V and her family were asked to provide chronologies and professionals met to explore issues relating to multi agency practice and opportunities for learning. These formed the basis of the review and enabled a fuller understanding of the circumstances of the case.

At the time of this review Buckinghamshire County Council (as was then) were developing an improvement plan for Children’s Social Care in response to their latest inspection by Ofsted. The findings and learning from this review helped to inform the improvement plan and progress has been updated to the Improvement Board on a regular basis.

The report identifies a number of key learning points and makes ten recommendations about wider partnership arrangements. The recommendations form part of an action plan which is now owned by the Buckinghamshire Safeguarding Children’s Partnership (which replaced the BSCB in summer 2019). All of the recommendations have been accepted and some actions have already been completed. Work continues to implement the outstanding actions. The new Partnership has a robust process in place to ensure that learning is embedded.

Reading this report highlights the challenges that are faced by some families and the need for agencies to place the voice of the child and family at the centre of everything they do, not just at an individual level but also at a system level. I am confident that the learning from this review will help to improve the safeguarding of children in the future and embed effective multi-agency working.

Sir Francis Habgood QPM

June 2020

Independent Chair of the Buckinghamshire Safeguarding Children Partnership, Sir Francis Habgood said:

“The Serious Youth Violence: Thematic Serious Case Review makes 11 recommendations for a number of agencies across the County.

“Serious youth violence and knife crime has become a feature of many urban environments. It was important for Buckinghamshire to have undertaken this Thematic Serious Case Review to ensure that our practices and policies are robust enough to manage future challenges.

“I am pleased that work has already begun on recognising opportunities to reduce the early risks highlighted in the report. This will enable us to better support young people and families.”

“This does require a better multiagency approach and all partners are committed to ensuring that happens by supporting agencies to deliver on these recommendations and providing strong scrutiny.”

May 2020

A statement from Independent Chair of the Buckinghamshire Safeguarding Children Partnership, Sir Francis Habgood QPM:

“The investigation following the tragic death of Baby S in April 2016 found no cause for blame in this case.

“However, there is always valuable learning to be gained from any Serious Case Review, allowing organisations to continually improve their service design and practice.

“Following this Review, I will be writing to agencies to remind them of the importance of maintaining detailed information records. This will help to ensure we have the fullest understanding possible of details and context surrounding future cases.

“Our thoughts and deepest sympathies are with the family of Baby S for their terrible loss.”

Working Together 2023 provides clear criteria about when the Buckinghamshire Safeguarding Children Partnership (BSCP) should conduct a Local Child Safeguarding Practice Review (LCSPR).

BSCP partner agencies should ensure that Serious Incidents which may meet the criteria for an LCSPR are also brought to the attention of the BSCP LCSPR Sub Group using this form.

For cases that do not meet the criteria for a LCSPR, the Sub Group will consider where another form of partnership or learning review may be appropriate to ensure lessons are learned.

Where partners feel a serious incident does not meet the definition for a LCSPR, but cannot be dealt with internally by the referring agency alone, then the Sub Group can consider making a recommendation on whether there should be a wider review involving more than one agency. This form should also be used for referring such cases.

The BSCP have produced LCSPR Learning Leaflets for all practitioners to refer to on the following topics

•  Child Sexual Exploitation (CSE)
•  Disguised Compliance
•  Domestic Abuse
•  Health Sector including Paediatrics and Accident and Emergency
•  Neglect