Magistrate sacked over views on adoption to same sex couples plans legal action

First topic message reminder :


Richard Page, 69, who served as a magistrate in Kent, told the BBC last year it would be better for a man and a woman to be the adopted parents.

The Judicial Conduct Investigations Office deemed this serious misconduct.

His lawyers say they will bring an employment tribunal for discrimination over his religious beliefs.

Mr Page, who served in Sevenoaks and Maidstone, sat on the Kent Central family panel and was a magistrate for 15 years. He was sacked earlier this month.

This followed a BBC interview in March 2015 in which he had said that it was his duty as a magistrate to act on the evidence alone, and that there had not yet been a proper analysis of the effects that placing children with same-sex couples had on the child's well-being.



http://www.bbc.co.uk/news/uk-england-kent-35796557


A child is better off in a stable home environment with a mother and a father... so it stands to reason that an adopted child should only be placed in the best environment for them too, which would be with mother and my father adoptive parents.

Tommy Monk wrote:

I'm saying I'm on the side of what's in the child's best interests... and that would only have any chance of being served by only being placed with a mother and a father when adopted out.

So you agree with countries that have the worst human rights abuses then.

Not exactly the best or glowing recommendations of nations is it?

Half of the EU countries don't allow it...!!!


And only 11 countries in the rest of the world allow it!!!


Only a mother and father would be best!

Tommy Monk wrote:Half of the EU countries don't allow it...!!!


And only 11 countries in the rest of the world allow it!!!


Only a mother and father would be best!

And which EU countries is this Tommy

Religious based ones by any chance?

Are you placing religious beliefs now as the bases for your stance?

So at every turn you favour countries not progressed, why is that Tommy?
Are you yearning for a return to the dark ages

What is best for a child is loving parents, no matter if gay or heterosexual

That is a fact

The study clearly suggests otherwise dodge... and when a childs best interests are in question and such damaging potential at risk... we should definitely be erring on the side of caution... only a hoe environment with a mother ad father has any chance of providing a normal and natural family structure that is in the best interests of a child to grow up in!!!


That is the facts!!!

Tommy Monk wrote:


The study clearly suggests otherwise dodge... and when a childs best interests are in question and such damaging potential at risk... we should definitely be erring on the side of caution... only a hoe environment with a mother ad father has any chance of providing a normal and natural family structure that is in the best interests of a child to grow up in!!!


That is the facts!!!

The law states otherwise and countless studies say otherwise Tommy
The worst part about all this is why have we not seen countless children taken back into care in the Uk from gay parents?
That is damning to your backward cause and shows children of gay parents grow up in loving and health environments
So on every fact you are simply and utterly wrong, mainly because you hold backward views and back nations that hold human rights abuses as well as your evidence.

Those are the facts

Here you go Tommy.

Here is a list of the most serious cases involving children last year, from neglect, to violence and death.

How many were homosexual parents?





A chronological list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2015. To find other case reviews search the national repository.


2015 - Blackpool - Child BV
Death of a 1-month-old infant in Winter 2014. Ambulance service found Child BV unresponsive in 2-year-old sibling’s bedroom, lying between the bed and wall.
Background: both parents had consumed large quantities of alcohol the previous day and could not remember how or why BV was not asleep in usual place. Family were known to universal services only. Father attended Accident and Emergency and visited GP prior to BV’s birth and disclosed that he was a regular heavy drinker.
Key issues: alcohol use and the safe care of children; engaging with fathers; sharing of information about excessive parental alcohol use between professionals; safeguarding requirements for nursery providers; and safe sleep support.
Recommendations: safe sleep assessments by health professionals; campaigning to raise awareness of the risks of alcohol use when caring for young children; and engaging with new and expectant fathers.
Model: Welsh Model for case reviews.
Keywords: infant deaths; alcohol misuse; sleeping behaviour; nurseries.
Read the overview report

2015 – Essex – Child G
Serious brain injury to a 3-month-old girl in May 2013. Mother pleaded guilty to child neglect. The mother's partner was convicted of causing the injuries. Both received custodial sentences.
Background: prior to Child G’s birth her half-sibling had been subject to a child protection plan under the category of neglect. In the months before and after Child G’s birth, mother had attended hospital a number of times due to injuries to Child G’s half-sibling. Child G's mother had diagnosed learning difficulties and "extremely low" IQ classification. She had a history of difficult family relationships and mental health issues. Mother’s partner was known to the probation service and other local authorities due to a history of violence towards women and children.
Key issues: issues identified include the challenge of sharing information about vulnerable families across GP's, midwives and health visitors; the need to focus of the role of fathers/partners through pregnancy and early years; and the need for offender managers to report any safeguarding concerns when an offender starts a new relationship.
Recommendations: include the development of a system to allow tracking of offenders convicted of offences against children and reviewing and monitoring of information sharing in health services.
Keywords: brain injury, child neglect, unknown men, family violence, adults with learning difficulties, mental health
Read the overview report

2015 - Hull - Child W
Death of a 16-year-old girl on 16 November 2013 at a hostel where she was living. Coroner recorded the cause of death as hanging but unclear whether Child W intended to take her own life.
Background: Child W was removed from her birth family and adopted at 10-years-old with her younger brother. Adoptive parents struggled to cope with their behaviour. Prior to her death, there were concerns around self-harm, substance misuse and an alleged rape.
Learning: findings include: W was assessed as needing “intensive therapeutic support” but this support was not provided.
Recommendations: adoption support plans need to clearly detail how and by whom therapeutic needs will be met; attachment needs of adopted children should form part of specialist therapeutic services ; and local authorities should ensure that staff are clear about local guidance and support for homeless 16 and 17-year-olds.
Keywords: adoption support services; placement breakdown; hostels; homeless adolescents; self-harm
Read the overview report

2015 - Nottinghamshire - Child H
Death of a 4-month-old girl in December 2012. Child H died of unknown causes but had a number of injuries which were thought to be non-accidental.
Background: the family was known to a number of agencies due to the serious domestic abuse the mother had experienced with her previous partner, who was the father of Child H and her sibling. Mother had a history of mental health problems, abusive relationships and alcohol misuse.
Learning: identifies learning, including: holding a common assessment framework (CAF) meeting earlier would have helped clarify concerns, responsibilities and what needed to change and professionals should consider the impact of historic experiences of domestic violence.
Recommendations: share the learning from the review and commission a multi-agency case file audit of children subject to a common assessment framework (CAF) where domestic abuse is an issue.
Model: uses the Significant Incident Learning Process (SILP) to review the case.
Keywords: infant deaths, family violence, non-accidental injuries
Read the overview report

2015 - Salford - Child N
Overdose by a 17-year-old female leading to a profound brain injury. Review examines services provided to Child N between the ages of 14 and 17-years-old across two local authorities.
Background: N was a ‘child in need’ but children’s services lost contact after she left supported lodgings to move in with her boyfriend. He was 5-years her senior and they met in a sexual exploitation “hotspot”. N had a troubled adolescence with issues of self-harm, substance misuse and going missing. Mother proactively sought professional help to cope with N’s behaviour.
Learning: good practice highlighted includes the support provided by N’s senior school. Missed opportunities include: social workers should have worked to repair family relationships and greater consideration should have been made relating to child sexual exploitation.
Recommendations: include: early help services must be proactive in working with families with adolescents; local authorities must exercise their legal duties relating to homeless adolescents; and that a clear pathway of mental health services for 16-18-year-olds is created and disseminated to all agencies.
Keywords: homeless adolescents, child sexual exploitation, mental health services, self-harm
Read the overview report

2015 - Southwark – Child R
Rape of a 15-year-old girl in early spring 2014. The girl, who was in foster care at the time of the assault, reported that she had met the man in a hotel after a friend gave him her telephone number. The man involved was arrested and found guilty of a lesser offence against another young person.
Background: family history of: housing instability, drug dealing, child neglect and physical abuse. Child R was made subject to a child protection plan in 2009 and taken into care in 2010 after reporting that her mother had beaten her.
Key issues: whilst in care Child R had periods of: going missing, highly disruptive behaviour, multiple placements and exclusions from school.
Recommendations: makes recommendations covering: looked after children reviews and exploration of options for keeping children safe in emergency situations by police and children’s services. 
Model: uses the Welsh Model for case reviews.
Keywords: organised abuse, foster care, placement breakdown 
Read the overview report

2015 – Tri-Borough (Hammersmith and Fulham, Kensington and Chelsea, Westminster) - Sofia
Death of a 1-year-old girl in October 2013 from asphyxiation due to choking on food. Autopsy findings found Sophia was significantly underweight and there were signs of historic untreated injuries. Parents may be charged with neglect.
Background: mother had no permanent address and received services from 7 local authorities. Sofia and her mother were known to medical staff, social workers, housing professionals and the police. There were no signs of physical injury or neglect and Sophia was not considered to be at continuing risk of significant harm. When Sophia was 3-months old they moved and were not seen by a professional until her death. Father was allegedly living overseas but was later found to be living with the family illegally on an expired visa.
Learning: findings include: complexity of legislation and lack of understanding around provision of housing and benefits for a European National; homelessness during pregnancy not being a trigger for assessment and not being considered a safeguarding issue after birth; assessments made on mother's intention rather than child's experience; strategy discussions conducted via telephone excluding some agencies; a focus on physical manifestations of neglect over more complex indicators; and avoidant families becoming ‘lost’ to services.
Model: SCIE's Learning Together systems model
Keywords: infant deaths, child neglect, transient families, hidden men
Read the overview report

November 2015 - Kingston – Family A
Death of a 4-year-old girl and two 3-year-old twin boys who were smothered by their birth mother on 22 April 2014. The mother was given a hospital order in November 2014 after admitting manslaughter by diminished responsibility.
Background: Children P, Q and R all had spinal muscular atrophy type 2 (SMA2), a life shortening condition which causes severe muscle weakness. Due to the children's complex health needs many different health agencies were involved with the family.
Key issues: include: the parents' opposition to some medical interventions due to concern about the pain it may cause their children; the mother's low mood; staff commitment and the complexity of the case resulting in working outside professional boundaries; a focus on the possibility of using legal interventions rather than considering the wider child protection process.
Recommendations: parents should be offered counselling and information when their child is diagnosed with a disability and LSCBs should ensure that there is senior management involvement to consider the impact on the safety of the children in cases when the full care package isn't taken up over a prolonged period.
Model: uses a systems approach to focus on the strengths and weaknesses of the multi-agency system.
Keywords: child deaths, disabled children, maternal depression
Read the overview report

October 2015 - Hampshire – Child F (Stanbridge Earls School)
Reviews the response of agencies to allegations of sexual assaults against a 14-year-old disabled girl by other pupils at an independent residential school.
Background: the girl, who had delayed social and emotional development, engaged in sexual activity with other pupils at the school. Staff were made aware of the sexual activity by her GP, but judged it to be consensual and a confidential medical matter. The girl later told her parents and further information came to light that suggested the sexual activity had been non-consensual. The police investigated the incident, the boy involved was arrested and the girl was also required to leave the school "for her own protection". Following a series of further child protection allegations the school was made the subject of an inquiry and due to declining pupil numbers closed in September 2013.
Key issues: the complexity of the regulatory safeguarding frameworks that apply to independent schools and confusion over how they work with Local Safeguarding Children Boards (LSCBs); a lack of awareness of how disability and gender imbalance impacted on female pupils' vulnerability to potential exploitation or bullying and a lack of information sharing between national and local agencies involved in the case.
Recommendations: Hampshire LSCB to: set out the responsibilities of school trustees to ensure safeguarding is assured and promoted; ensure that parents are always promptly and appropriately informed of safeguarding concerns and to ensure that child protection services in home and school localities work together in cases where children are in out-of-authority residential education.
Keywords: Independent schools, residential care, harmful sexual behaviour, children with disabilities
Read the overview report

October 2015 - Luton – Child D
Death of an 11-week-old girl in January 2013, as the result of serious injuries consistent with violent shaking. Post mortem found subdural and retinal haemorrhages and signs of damage to the brain and spinal cord. Father was found guilty of Child D’s manslaughter.
Background: mother experienced abuse in the family as a child and, as a result, was made the subject of a child protection plan in 2006. During the review process a number of professionals expressed concerns that mother might have a learning difficulty; none of the professionals who had been in contact with mother in the 5-years previously felt she had a learning difficulty. Findings from a detailed assessment following Child D’s death identified mother as having an IQ score which placed her in the lowest 3% of the population and identified significant difficulties with memory recall. Father was seen by GP as a young adolescent, in relation to problems with his temper, depressed mood and verbal aggression. Following the incident father admitted assaulting mother on two occasions, neither of which was reported to professionals prior to Child D's death. Following Child D’s death, mother reported that Child D has been bruised on three occasions when in the care of father. One of these bruises was seen by 4 health professionals prior to Child D’s death.
Key issues: identifies themes including: how vulnerable young people who might need additional support when they become parents are identified and helped; the value of information, including social information, being held in GP records; engagement of the father and assessment of his role; professional responses to bruises in small babies; working arrangements between health visitors and GPs; and assessment of parental learning difficulties and their impact on parenting.
Recommendations: makes various recommendations.
Keywords: non-accidental head injury, adults abused as children, parents with learning difficulties, fathers
Read the overview report

October 2015 - Somerset – Child Y
Significant injuries to a 3-week-old child in October 2013. MRI scan indicated that Child Y had survived a subdural haemorrhage. Parents were arrested on suspicion of causing Grievous Bodily Harm; both parents were on police bail at the time review was published.
Background: father had been in care as a child and had a history of depression and anxiety and domestic abuse in relation to a former partner with whom he fathered two children. Father had no contact with either child and one of the children had been adopted. Mother had a history of domestic abuse as a child and was assaulted by her father when 10-weeks pregnant with Child Y.
Key issues: prior to the incident, father was noted to have been handling Child Y roughly by GP but was later observed by midwife to be handling Child Y more gently.
Learning: issues with maternity guidelines relating to domestic abuse in pregnancy including the absence of timely review, inconsistencies in advice given and insufficiently robust safeguarding supervision; importance of early handling and safety advice for parents; impact of the rule of optimism and clinical focus of midwifery services impacting consideration of social risk factors; and importance of identifying the role and impact of fathers.
Recommendations: increased home rather than clinic visits for new born babies, particularly for teenage and vulnerable parents; answerphones should not be relied on to disseminate information; and social care staff should be made aware of the implications of a further pregnancy where a parent has had a previous child adopted.
Model: uses a mix of traditional methodology and a new learning approach.
Keywords: non-accidental head injury, fathers, information sharing, domestic abuse
Read the overview report

September 2015 - Solihull – Child S
Death of a 22-month-old boy on 20 February 2013. Child S was taken to hospital after his mother found him lifeless. A post mortem examination established that he had suffered severe abdominal injuries. Mother and father were both convicted of causing or allowing the death of a child in December 2014.
Background: Child S had been the subject of referrals prior to his birth and had been subject to a child protection plan for emotional abuse since August 2012.
Key issues: mother had a history of substance misuse and mental health issues and father had a history of domestic abuse and drug dealing.
Learning: points identified include difficulties in working with individuals who disguise their compliance resulted in an overly optimistic view of outcomes for the child; problems were caused by misunderstanding between agencies about what and how information about adults who may post a risk to children could be shared; poor attendance by some agencies at initial child protection conferences.
Recommendations: development of clear joint information protocols for the police and children's social work services and a review of the booking system for initial child protection conferences to ensure a minimum notice period is given to professionals across all agencies.
Keywords: infant deaths, domestic abuse, substance misuse
Read the overview report

August 2015 – Anonymous – Child F
Death of a 5-month-old baby in September 2014. Child F was found unresponsive by mother after mother and baby had fallen asleep on a sofa when staying overnight at mother’s friend’s home. Ambulance crew noticed the smell of alcohol on mother and called police. Mother was arrested on suspicion of neglect, having thought to have unintentionally rolled on top of her baby; criminal investigation concluded with no charges being preferred.
Background: little is known about child F's father, beyond his extensive criminal history. Mother entered local authority care when 10-years-old, where she remained until discharge at age 18. Maternal history of: chronic neglect; disrupted placements; significant alcohol and drug misuse; domestic abuse; and offending.
Learning: identifies emerging lessons and reflections, including: the consequences of adverse childhood experiences such as chronic neglect and the inclination of individuals to deny or diminish these experiences; workload, difficulty in collating information or anxiety about challenging service users inhibiting professional recognition or exploration of patterns of behaviour such as missed appointments; invisibility of men; and obstacles to information sharing.
Recommendations: makes various recommendations covering: NHS, community health services and probation services.
Keywords: alcohol misuse, adults neglected as children, co-sleeping.
Read the overview report

August 2015 – Stockton-on-Tees – Child H
Serious harm caused to a 12-year-old, identified in July 2013 when serious concerns were raised over poor home environment and Child H’s presentation, including impaired vision. Child H was taken into the care of the local authority and mother and mother’s partner were charged and sentenced to 30-months imprisonment for child cruelty.
Background: Child H was diagnosed with Juvenile Idiopathic Arthritis (JIA) when 5-years-old. JIA can lead to eye problems, which, if not detected and treated early, can cause permanent visual damage, including blindness. Child H was found to have early indicators of uveitis at an ophthalmology appointment in 2011; Child H did not attend any further ophthalmology appointments until July 2013. Children’s social care received three referrals between 2011 and 2013 and concerns had been raised regarding Child H’s presentation, hygiene and attendance at school and medical appointments.
Key issues: the system for screening children with complex eye problems is not designed around the needs of the child: the appointment system implied Child H was making informed choices about not attending, rather than parents’ non-attendance being seen as an indicator of neglect.
Learning: children with medical needs necessitating a range of specialists, require a lead professional to maintain coordination of services, in particular, the role of the school nurse should be developed to engage with children and parents and to assist schools in understanding the impact of specific conditions.
Recommendations: makes various recommendations and includes a multi-agency action plan.
Keywords: child neglect, children with a chronic illness, start-again syndrome
Read the overview report

July 2015 – Anonymous – Subject Child
Death of a 6-7-week-old-girl in May 2012. Subject child was found by mother with her face pressed up against the back of the settee at home where she had earlier fallen asleep. Mother had just woken from sleep after having drunk alcohol earlier in the day.
Background: mother was arrested in 2011 for being drunk in charge of a child, leading to half-brother being placed in foster care. Half-brother was returned to mother’s care following assessments that recommended that there was no role for a social worker. Mother has a chronic abdominal condition, requiring abstinence from alcohol use to avoid the condition worsening and leading to hospitalisation.
Key issues: history of domestic abuse, alcohol misuse and referrals to children’s services concerning the care of half-brother.
Learning: assessment of the impact of chronic alcohol misuse usually takes place when the parent is no longer intoxicated, leading to insufficient understanding of potential risks to the child; lack of professional knowledge of parents’ persistent or long term medical conditions compromising understanding of the impact on parenting capacity; and professional response to incidents without consideration of previous concerns, leading to missed patterns and possibility of continued ineffective responses.
Keywords: alcohol misuse, risk assessment
Read the overview report

July 2015 – Peterborough – Child J
Significant, non-accidental injuries to a 5-month-old boy, identified in November 2013; injuries were diagnosed as suggestive of physical and sexual abuse. Father was charged with neglect, to which he admitted and received a community sentence; he denied and was not charged with sexually abusing child J.
Background: Child J’s mother had two older children, both of whom were living in foster care at the time of child J’s birth; Child J was discharged from hospital to foster care when 2-days-old before being placed in the full-time care of his father when 4-months-old.
Key issues: paternal history of: depression; committing domestic abuse; offending with minor convictions; drug and alcohol use; and allegations of inappropriate sexual behaviour. A number of injuries were identified by various professionals in the month prior to the incident.
Learning: identifies themes, including: optimistic thinking driving plans for Child J to be placed with his father to the exclusion of thorough exploration of risk; insufficient information sharing between agencies; and lack of holistic assessment of family leading to unacceptable evaluation of risk.
Recommendations: makes various recommendations including monitoring the use of escalation procedures.
Keywords: physical abuse, fathers, assessment
Read the overview report

July 2015 – St Helens – Child JSH
Death of a 17-year-10-month-old boy found hanged at home in January 2014. Inquest found that Child JSH had intentionally taken his own life.
Background: history of: domestic abuse; anti-social behaviour; violent behaviour leading to arrests; sexually intimidating behaviour toward members of school staff and female pupils; and stalking and threatening behaviour toward a fellow pupil with whom child JSH had a relationship. Child JSH was described as having had few close friends but a wide network of associates on social media and a high-profile locally in relation to fighting and anti-social behaviour. Police had intelligence that child JSH was receiving threats via social media 2-3-weeks prior to his death.
Learning: identifies four key findings, including: remaining child-centred in responses to older children who present with criminal and harmful sexual behaviours (HSB); and meeting the needs of children who experience severe behavioural difficulties through the system of mental health referral and triage. Identifies wider learning around: the risks presented by social media in relation to developing networks that promote and encourage HSB.
Methodology: systems methodology.
Keywords: suicide, harmful sexual behaviour, child and adolescent mental health services (CAMHS)
Read the overview report

June 2015 – Cambridgeshire – Child K 
Death of a 2-year-old boy in January 2014. Primary cause of death was bacterial pneumonia infection with secondary causes of dehydration, failure to thrive, norovirus and cerebral palsy.
Background: following his death, mother received a police caution for cruelty against Child K contrary to Section 1 of the Children and Young Person’s Act 1933. Child K and his sibling had been subject to a child protection plan for neglect for a month prior to the incident. 
Key issues: maternal history of: childhood abuse, time spent in the care of the local authority, offending, self harm and homelessness. Father was nine years older than mother and also had a history of childhood abuse and time spent in the care of the local authority. Child K was born 24-weeks prematurely, which affected his lung development causing chronic lung disease. Child K had additional complex needs resulting from a hole in his heart, concerns about his hearing and vision and a bleed in his brain resulting in him developing cerebral palsy. 
Learning: analyses key themes, including: the impact of Child K's disabilities on assessment of risk and inconsistency in the level of professional concern; inconsistent perceptions of mother's understanding of Child K's needs or of her ability and commitment to meeting them; and lack of professional understanding of the interaction between Early Help, Early Support and Children in Need systems. 
Recommendations: makes various recommendations, including the provision of training on neglect and disability. 
Keywords: children with a chronic illness, child neglect 
Read the overview report
June 2015 - Havering – Child Y, Child X and Child W
Chronic neglect and emotional abuse of 3 siblings aged 15-years-old, 11-years-old and 6-years-old, and the sexual abuse of 1 or more of the siblings.
Background: children were subject to child in need status and child protection plans at various points in their lives due to concerns around neglect. Concerns were first identified shortly after the birth of the first sibling in 1998, and eventually resulted in the local authority arranging for them to live with their grandparents in 2009. Concerns continued, and in September 2013 the siblings were taken into local authority care.
Key issues: the prioritisation of keeping the children in their family above child protection needs; a lack of communication between professionals and the family about concerns and the actions that needed to be taken; the lack of explicit reference to neglect in some assessments of the children's needs; the absence of a plan or appropriate monitoring of support once care of the children was transferred to their grandparents and delays in taking action due to the grandparents' "false compliance".
Recommendations: develop a multi-agency pathway for identifying and responding to children who may have weight faltering and develop a multi-agency case review and planning process for individual highly complex cases.
Model: uses a hybrid methodology, drawing on a variety of theoretical approaches and techniques.
Keywords: child neglect, emotional abuse, kinship care
Read the overview report
June 2015 - Kingston - Child B
Suicide of a 15-year-old South Korean boy in July 2014. Child B jumped from the top floor of an indoor shopping centre and died in hospital.
Background: Child B moved to the UK aged 6 to live with his father and older brother; contact with their mother was sporadic. Child B was made the subject of a child protection plan, when 10-years-old, for physical and emotional abuse and was briefly looked after. From 2012 the family were receiving support after the father had an accident at work and they became homeless. On the day he killed himself Child B spoke of wanting to take his own life.
Learning: Child B's voice and experience were not present in any reviews; limited exploration of the impact of mother’s absence; and copy and pasting of old information into new reports.
Methodology: systems approach.
Keywords: suicide, adolescent boys, physical abuse
Read the overview report
Read the executive summary
May 2015 - Blackpool – Child BT
Death of a young child in 2014. Initial post mortem proved inconclusive; second post mortem concluded that cause of death was inhalation of stomach contents with the underlying cause being poisoning by Methadone.
Background: Mother pleaded guilty to manslaughter; father went to trial and was found guilty of manslaughter and child cruelty. Family was known to children's services and both BT's sibling and step-sibling had previously been subject to child protection plans.
Key issues: both parents were engaging in drug treatment but mother was known, and father suspected, to have periods of illicit drug use. Both had a history of offending and problems with financial management. Father was suspicious of social care involvement and was rarely seen during home visits.
Learning: professionals in the area were used to working with complex families, which may have led to the 'normalisation' of issues; information on risk factors was not shared by all professionals and professionals did not always refer the family to children's social care when appropriate.
Recommendations: all agencies should fully engage with the Multi-Agency Safeguarding Hub (MASH); family assessments should involve the whole family, including the father; and parental non-compliance with drug services should result in immediate action to bring multi-agency professionals together.
Model: systems methodology
Keywords: addicted parents; poisons and poisoning; neglect
Read the overview report
May 2015 – Bury – Baby I (Case I13)
Serious injury of a 6-week-old boy in October 2013. Baby I was made the subject of an emergency protection order following an examination that revealed he had sustained two broken ribs and a knee fracture.
Background: Mother and Father had been in a relationship for 3-months before Mother became pregnant with Baby I. Paternal history of: drug misuse; suicide attempt in adolescence; and self-reported thoughts of harming baby I to stop him crying. Maternal history of: psychotic depression, previous suicide attempts and incidents of self harm. Father was recorded as mother’s carer.
Key issues: issues identified include: insufficient exploration and understanding of the impact of high energy drink consumption on father’s mood and anger responses; and practitioners’ belief that father belonged to a particular sub-culture possibly inhibiting them from challenging father’s behaviour as they wished to appear non-judgemental.
Model: uses some elements of the Social Care Institute for Excellence (SCIE) Learning Together model.
Keywords: parents with a mental health problem, substance misuse
Read the overview report
May 2015 - Enfield - CH
Life imprisonment of a 15-year-old boy convicted of killing a 21-year-old man. CH stabbed Mr Z, a stranger, following a confrontation on a residential street.
Background: CH was subject to a child protection plan at the time of the incident. His case was being coordinated by Haringey children and young people’s services as a transfer case conference had not been arranged following family’s move to Enfield one year earlier. Family history of: mental health problems; alcoholism; domestic abuse; criminal behaviour and anxiety around their immigration status (they were originally from Jamaica). CH had a history of offending, self-harming; and running away from home. He had previously been subject to a care order.
Key issues: mother's problems distracted from the needs of her children; support for the family ended abruptly following the cessation of a care order; and domestic abuse between mother and female partner was not treated as seriously as heterosexual partner violence.
Recommendations: information coordinators should be appointed within teams working with families with complex needs, to compile a family history and facilitate information sharing; the Safeguarding Board should create a simple chronology tool that could be completed across agencies; and the Safeguarding Board should explore custodial and residential approaches to working with young people with severe behavioural problems.
Read the overview report
April 2015 – Croydon – Child M
Death of a 14-year-old black boy in September 2012, as the result of a fatal stab wound to the heart. Child M was stabbed by another teenager, following an altercation. Child S was found guilty of murder and sentenced to life imprisonment, to serve a minimum of 14-years; the Judge referred to the incident as a “revenge killing”.
Background: At the time of the incident, Child M had been missing from home for nine weeks. Child M attended college a week after he was first reported missing. Police and children’s social care were informed and told that Child M did not want to return home as he was scared he would be beaten by his stepfather; neither agency visited the college nor investigated this disclosure and Child M was allowed to leave college without confirmed arrangements for his care.
Learning: passive response from police and children’s social care to a missing 14-year-old child; passive attitude of police to communicating with parents; and insufficient involvement of mother’s partner in assessments.
Recommendations: makes various recommendations covering: professional challenge and escalation; communication between schools and colleges and other agencies during school/college holidays; and whether child protection services received by older children are robust and the extent to which gender and ethnicity effect them.
Keywords: adolescents, runaway children, escalation
Read the overview report
April 2015 – Croydon – Josh 
Death of a 3-year-old boy in March 2013. Mother carried Josh into the path of an oncoming train, killing them both. 
Background: Mother had a history of severe anxiety disorder and had been receiving treatment from her GP and various mental health services in the months preceding Josh’s death.
Key issues: procedural failure responding to a children’s social care referral made by Mother’s psychiatrist; a culture of overreliance on children’s social care for actions regarding a child; and perceived inconsistent and misleading advice from mental health services leading Mother and Family to continue accessing private mental health providers as they lost trust in NHS providers.
Model: review was undertaken using the Significant Incident Learning Process (SILP).
Keywords: adult mental health services, suicide, referral procedures
Read the overview report
April 2015 – Fife and Edinburgh Child Protection Committees – Child MK
Death of a male child in January 2014. MK was reported missing by his mother on 16th January; his body was found on 17th January following a police search. Mother pleaded guilty to culpable homicide and was sentenced to 11-years imprisonment.
Background: MK entered foster care in July 2012 following a notification received by social work services that mother had left her children unattended. MK returned to the care of his mother under a supervision order in August 2013. Family was receiving support from Fife Social Work Services on a voluntary basis at the time of the incident.
Learning: identifies areas for future learning and action including: Scottish government should consider the need for the development of national guidance for the transfer of non-child protection cases across local authority areas; and NHS Fife should review how information, which is below the child protection threshold but which impacts on child wellbeing, is shared between GPs and health visitors.
Keywords: assessment, case transfer
Read the executive summary
April 2015 - Lambeth – Child I
Death by drowning of a 20-month-old boy in July 2013. 
Background: Child I and his two older siblings were subject to child protection plans under the category of neglect at the time of the incident. Parents both had learning difficulties and at times reacted with anger and hostility to professional interventions. Child I was found face down in the bath; mother reported she had left Child I in the bath, informing father she had done so, before leaving the house. Parents were subject to police investigation as alleged perpetrator and witness throughout the case review process.
Key issues: professional emphasis on investigating physical injuries at the expense of considering indicators of neglect; and overreliance on written agreements with parents to support child protection arrangements. 
Model: Social Care Institute for Excellence (SCIE) Learning Together model
Keywords: adults with learning difficulties, neglect and interagency cooperation
Read the overview report
April 2015 – Lancashire – Child L and Adult L
Death of a 6-year-old boy and his mother and the attempted suicide of his father in April 2013. Father was diagnosed with a psychotic mental illness and detained under the Mental Health Act 1983.
Background: Child L and parents were not known to any specialist services. Previous contacts with health services for injuries to Child L and Adult L were judged to be accidental. The day before the father consulted his GP about feeling in low mood and hearing voices. There had been no previous mental health issues. GP requested an assessment by a mental health practitioner and a meeting was scheduled for the next day.
Learning: identifies good practice including the GP’s referral to mental health services and school support to pupils and families after the deaths. 
Key issues: missed opportunities for sceptical and curious enquiry by health professionals; no enquiry about Child L by GP; ‘shortcoming of human inference’ leading mental health specialists to think a GP would rate a case high risk to get a quick assessment; use of a telephone triage system for mental health assessment.
Methodology: joint serious case review and domestic homicide review. Uses a systems framework to present the key learning.
Recommendations: questions for consideration cover: overcoming cognitive influence and human bias in information sharing; ensuring sufficient enquiry and recording of any presentations for medical treatment; use and availability of tools and frameworks for assessing risk.
Keywords: parents with a mental health problem, family annihilation/familicide
Read the overview report
Read the executive summary
April 2015 - Lancashire – Child N
Death of a 4-year-old boy and his mother in May 2014 as the result of a house fire in Liverpool. Coroner's verdict was that Child N had been unlawfully killed and mother had taken her own life after deliberately starting the fire.
Background: parents separated acrimoniously prior to Child N's birth. Mother requested a termination, but was refused due to the late stage of her pregnancy. After the birth, the mother briefly went missing which resulted in Child N spending a short time in foster care. Due to concerns about his safety and on-going contact disputes, Child N’s care was subject a number of court proceedings. The court’s decision in the second case resulted in the father, who lived in Lancashire, being granted a residence order and the mother a contact order. During the fourth and final set of proceedings, whilst Child N was on a contact visit, the mother made allegations of child sexual abuse which resulted in Child N staying with her in Liverpool.
Key issues: family history of: maternal mental health problems, domestic violence and multiple parental allegations and counter allegations of poor care and abuse. Challenges identified include: language and translation issues when communicating with maternal grandparents; and the lack of means for professionals to enforce court imposed decisions regarding child contact.
Learning: parental mental health assessments should be shared with all professionals involved in the child's life; and when closing a case social workers should ensure they inform all professionals working with the child.
Recommendations: LSCBs to explore options to help frontline practitioners understand and assess behaviour of a parent who causes concern but does not have a recognised mental illness.
Keywords: filicide, suicide, parents with a mental health problem, contact
Read the overview report
April 2015 - Lincolnshire – Baby W
Death of a baby boy during the hours following his birth in September 2013. Mother was 16-years-old at the time of the incident; she had concealed or denied her pregnancy and given birth, unassisted in her bedroom at home. Post mortem revealed that Baby W died from a tissue blocking his airway; mother pleaded guilty to infanticide and was sentenced to a 2-year Youth Rehabilitation Order (YRO).
Background: mother was known to universal services only; she did not present with any physical symptoms of pregnancy prior to Baby W’s birth. During her pregnancy mother presented to GP a number of times with concerns of low mood and depression and self-referred to an Improved Access to Psychological Therapies (IAPT) service for support with her anger as a result of depression. Mother was asked and denied her pregnancy on a number of occasions, by professionals and family members.
Learning: identifies one missed opportunity to provide mother with age appropriate advice around sexual activity, contraception, sexual health and healthy relationships. Identifies lessons to be learnt, including: need for awareness raising and development of procedures and guidance around concealed or denied pregnancy; importance of young people receiving sexual health and contraception advice; and increased GP knowledge of the support that school nursing services can provide young people.
Recommendations: makes various recommendations.
Keywords: concealed or denied pregnancy, teenage pregnancy
Read the overview report
Read the executive summary
April 2015 - Tameside – Child M
Death of a 17-year-old girl in December 2013. Child M's body was found in a garden with a ligature around her neck; there was no evidence of any third party being involved. 
Background: Child M was never identified as a child in need or requiring protection, but did receive support from Child and Adolescent Mental Health Services (CAMHS), although she was never diagnosed with a mental health condition. She also received support from: young people's services (YPS); the Crisis Resolution Home Treatment Team (CRHTT) and a drug and alcohol treatment charity. 
Key issues: Child M had a significant history of self-harm, alcohol and drug misuse, truancy, school exclusions and verbal and physical violence. Child M disclosed to professionals an experience of being inappropriately touched by an adult and her feelings of distress over her father's use of alcohol and violent behaviour during her early childhood.
Learning: Child M’s school interpreted her age, intelligence and social background as evidence she had the capacity to change her behaviour, and so their response focussed on behaviour management rather than assessing her support needs; her parents were not always consulted or kept informed about professionals’ concerns for Child M’s welfare; and police were not aware that, due to her complex needs, a social worker rather than a volunteer appropriate adult should have been allocated to Child M whilst she was held in custody. 
Recommendations: the police and the council should confirm what arrangements are in place to ensure relevant protocols, including the use of appropriate adults, are known and used by both services.
Model: systems based approach
Keywords: suicide, self-harm, risk assessment
Read the overview report

Spam, Didge Judas.

Stormee wrote:
Spam, Didge Judas.

I think you will find you are spamming and trying to derail the thread.

Either stop acting like a child or I will report you again.

What was posted was relevant to the thread

I was never your friend either, thus impossible to be a traitor and so calling you out for being a vile human being was my pleasure

Tommy Monk wrote:


The study clearly suggests otherwise dodge... and when a childs best interests are in question and such damaging potential at risk... we should definitely be erring on the side of caution... only a hoe environment with a mother ad father has any chance of providing a normal and natural family structure that is in the best interests of a child to grow up in!!!


That is the facts!!!

So you're saying that all mother father relationships produce happy, well balanced kids?    Hardly.

Didge wrote:

Stormee wrote:
Spam, Didge Judas.

I think you will find you are spamming and trying to derail the thread.

Either stop acting like a child or I will report you again.

What was posted was relevant to the thread

I was never your friend either, thus impossible to be a traitor and so calling you out for being a vile human being was my pleasure

You have already spammed, derailed the thread yourself, ya weasel..

If you were even a bit of a man you would not consider reporting anyone.

Back on topic.
Would you want to be raised by two geezaz and have the wee wee taken out of you by other kidz?

Stormee wrote:

Didge wrote:

I think you will find you are spamming and trying to derail the thread.

Either stop acting like a child or I will report you again.

What was posted was relevant to the thread

I was never your friend either, thus impossible to be a traitor and so calling you out for being a vile human being was my pleasure

You have already spammed, derailed the thread yourself, ya weasel..

If you were even a bit of a man you would not consider reporting anyone.

Back on topic.
Would you want to be raised by two geezaz and have the wee wee taken out of you by other kidz?

Look you are a backward ignorant bigoted numpty, plain and simple and your words are meaningless

Unless you learn the rules and toe the line, then its your fault if you get your botty spanked
So grow up

I would be proud to be raised by any parents who were loving, if that was two men, I would be happy to be raised by them.

So the problem then is to tackle children who are being taught hate by idiots such as yourself, who seek to bully.

Of course I was brought up with boxing by my Irish uncles, so I doubt I would have any trouble with any idiots trying to bully me having same sex parents

HoratioTarr wrote:

Tommy Monk wrote:


The study clearly suggests otherwise dodge... and when a childs best interests are in question and such damaging potential at risk... we should definitely be erring on the side of caution... only a hoe environment with a mother ad father has any chance of providing a normal and natural family structure that is in the best interests of a child to grow up in!!!


That is the facts!!!

So you're saying that all mother father relationships produce happy, well balanced kids?    Hardly.

No... I'm saying that when considering placing children for adoption... only a mother and father couple will provide the best and most normal and natural environment that a child could have... so in the name of 'equality'... every child should expect to be treated to the same level of consideration when being placed for adoption!


It is blatantly unfair on the children to force some to grow up in an abnormal and unnatural 2 mum or 2 dad type home environment while providing a much better and normal and natural mum and dad type home environment for others!

Tommy you really have no leg to stand on with regard to this issue as you didn't answer or my questions! (Which is unlike you I have to say)

Storm: so then, what if a beloved member of your family came out? Would you disown the,?

Didge wrote:

Stormee wrote:

You have already spammed, derailed the thread yourself, ya weasel..

If you were even a bit of a man you would not consider reporting anyone.

Back on topic.
Would you want to be raised by two geezaz and have the wee wee taken out of you by other kidz?

Look you are a backward ignorant bigoted numpty, plain and simple and your words are meaningless

Unless you learn the rules and toe the line, then its your fault if you get your botty spanked
So grow up

I would be proud to be raised by any parents who were loving, if that was two men, I would be happy to be raised by them.

So the problem then is to tackle children who are being taught hate by idiots such as yourself, who seek to bully.

Of course I was brought up with boxing by my Irish uncles, so I doubt I would have any trouble with any idiots trying to bully me having same sex parents

Would you have always felt that way Didge?

Miffs2 wrote:

Didge wrote:


Look you are a backward ignorant bigoted numpty, plain and simple and your words are meaningless

Unless you learn the rules and toe the line, then its your fault if you get your botty spanked
So grow up

I would be proud to be raised by any parents who were loving, if that was two men, I would be happy to be raised by them.

So the problem then is to tackle children who are being taught hate by idiots such as yourself, who seek to bully.

Of course I was brought up with boxing by my Irish uncles, so I doubt I would have any trouble with any idiots trying to bully me having same sex parents

Would you have always felt that way Didge?

Boxing, ya couldn't box kippers.

I don't believe you.

You are one of the reasons this place is in chaos with you insults

I notice Tommy is still avoiding my question....


because it destroys his point totally....

Tommy ...you hold the views of a fosilised bigoted numpty....

your so called "evidence is proven to be biased garbage...

no matter what YOU say your hate of gays shines through every post you make on the subject.....

fortunately your sort is destined for the dustbin of history....

Can't people just agree to disagree?

Eddie... I thought I did answer your question... and have you not seen all the various points I have made or read the findings of the study I posted link to...?



Vic... I didn't avoid answering any of your questions either... plus you can't remove the credibility of any study or opinion just by not liking it and calling it biased because it shows things you don't want to believe are true...!

Lord Foul wrote:I notice Tommy is still avoiding my question....


because it destroys his point totally....

Tommy ...you hold the views of a fosilised bigoted numpty....

your so called "evidence is proven to be biased garbage...

no matter what YOU say your hate of gays shines through every post you make on the subject.....

fortunately your sort is destined for the dustbin of history....

NAME CALLING INSULTS FROMA NEW MOD, you could not make it up.

Raggamuffin wrote:Can't people just agree to disagree?

Unfortunately... some cannot agree to disagree... they also want the opposing opinion banned/removed/destroyed...!


Only their opinion is 'right' and is the only opinion that is 'allowed' to be thought... or else!!!


All in the name of equality mind...!





Looking after the best interests of children comes second place to the progressive leftie agenda...!

Stormee wrote:

Miffs2 wrote:



Would you have always felt that way Didge?

Boxing,          ya couldn't box kippers.

I don't believe you.

You are one of the reasons this place is in chaos with you insults

You picking on me?

I is sad

Tommy Monk wrote:

Eddie... I thought I did answer your question... and have you not seen all the various points I have made or read the findings of the study I posted link to...?



Vic... I didn't avoid answering any of your questions either... plus you can't remove the credibility of any study or opinion just by not liking it and calling it biased because it shows things you don't want to believe are true...!

I gave my rasons for considering it biased and slanted at the beginning of the thread tommy....

Stormee wrote:

Lord Foul wrote:I notice Tommy is still avoiding my question....


because it destroys his point totally....

Tommy ...you hold the views of a fosilised bigoted numpty....

your so called "evidence is proven to be biased garbage...

no matter what YOU say your hate of gays shines through every post you make on the subject.....

fortunately your sort is destined for the dustbin of history....

NAME CALLING INSULTS FROMA NEW MOD, you could not make it up.

more bullshit from you Stormee..... see this shows your "game" up for what it is...

I didnt say Tommy was a "fosilised etc"

I said he held the views of a "fosilised etc" thereby attacking the post (and its associated values) rather than Tommy....

you need to get up earlier to catch me out chum.....

if you INSIST on playing this "lets disrupt a forum" game, you would do well to pick one with mods that are somewhat LOWER in intellectual acheivment than YOU.. (difficult I know)

Blimey...this thread has turned into a farce.
Is it so hard to understand that some people think that a Mother Father relationship whilst bringing up a child is the better one.....and some don't?

No point in throwing in realms of statistics that say children were abused by mums and dads....of course they were, some people would abuse children whether they were straight OR gay.....that's not the point.

Syl wrote:Blimey...this thread has turned into a farce.
Is it so hard to understand that some people think that a Mother Father relationship whilst bringing up a child is the better one.....and some don't?

No point in throwing in realms of statistics that say children were abused by mums and dads....of course they were, some people would abuse children whether they were straight OR gay.....that's not the point.

Exactly Syl.

Miffs2 wrote:

Didge wrote:


Look you are a backward ignorant bigoted numpty, plain and simple and your words are meaningless

Unless you learn the rules and toe the line, then its your fault if you get your botty spanked
So grow up

I would be proud to be raised by any parents who were loving, if that was two men, I would be happy to be raised by them.

So the problem then is to tackle children who are being taught hate by idiots such as yourself, who seek to bully.

Of course I was brought up with boxing by my Irish uncles, so I doubt I would have any trouble with any idiots trying to bully me having same sex parents

Would you have always felt that way Didge?

Well if I was raised by them, of course I would and why not have grown up with poor Catholic views of them Nems

Syl wrote:Blimey...this thread has turned into a farce.
Is it so hard to understand that some people think that a Mother Father relationship whilst bringing up a child is the better one.....and some don't?

No point in throwing in realms of statistics that say children were abused by mums and dads....of course they were, some people would abuse children whether they were straight OR gay.....that's not the point.

Nothing hard to understand about it Syl, but the subtext, and very often the outright wording, is that gays are simply not worthy to bring up children.  In fact, those saying as much have said quite disgusting things about gay people, so that's the context of what they are saying.

I see at of all the cases of abuse to Children, Tommy seems stuck over how many are heterosexual parents

What does that tell you Tommy?

Syl wrote:Blimey...this thread has turned into a farce.
Is it so hard to understand that some people think that a Mother Father relationship whilst bringing up a child is the better one.....and some don't?

No point in throwing in realms of statistics that say children were abused by mums and dads....of course they were, some people would abuse children whether they were straight OR gay.....that's not the point.

Surely you're NOT suggesting that all of this wasted bandwidth {5+ pages} will not reach the ears of that cretin judge that got young Tommy all stirred up about. Say it ain't SOOOO

Simple analogy... when wild animals are kept in zoos etc... isn't it considered best to provide the animals with as much a normal and natural home environment as possible...!?

Tommy Monk wrote:Simple analogy... when wild animals are kept in zoos etc... isn't it considered best to provide the animals with as much a normal and natural home environment as possible...!?

Its wrong to keep wild animals in zoo's

Didge wrote:I see at of all the cases of abuse to Children, Tommy seems stuck over how many are heterosexual parents

What does that tell you Tommy?

Still waiting Tommy

I mean after all, you should be able to show countless cases where gay parents have had their children taken into care in the UK???

Tommy Monk wrote:Simple analogy... when wild animals are kept in zoos etc... isn't it considered best to provide the animals with as much a normal and natural home environment as possible...!?

Why don't you answer a straight question with a straight answer?  Go one, frighten the hell out of us.

If there was a choice between a child going into care or being put with a loving, stable, homosexual couple, which would you chose?   No waffling, one or the other.

Tommy Monk wrote:

HoratioTarr wrote:

So you're saying that all mother father relationships produce happy, well balanced kids?    Hardly.

No... I'm saying that when considering placing children for adoption... only a mother and father couple will provide the best and most normal and natural environment that a child could have... so in the name of 'equality'... every child should expect to be treated to the same level of consideration when being placed for adoption!


It is blatantly unfair on the children to force some to grow up in an abnormal and unnatural 2 mum or 2 dad type home environment while providing a much better and normal and natural mum and dad type home environment for others!

What is 'normal'?

Normal is defined as something that is expected, or conforming to a standard.  Something habitual and traditional.

500 years ago, it was considered 'normal' to burn people at the stake or believe the earth was flat.

There are way too many 'normal' relationships that slaughter a child's psyche.   If they get love and stability from two males or two females, what does it matter?

sassy wrote:

Tommy Monk wrote:Simple analogy... when wild animals are kept in zoos etc... isn't it considered best to provide the animals with as much a normal and natural home environment as possible...!?

Why don't you answer a straight question with a straight answer?  Go one, frighten the hell out of us.

If there was a choice between a child going into care or being put with a loving, stable, homosexual couple, which would you chose?   No waffling, one or the other.

Bumped for Tommy

Try asking a straight question and not a loaded one...



How about you answer this for a taste...



Would you prefer a child to be brought up with a mother and father in a stable and loving home environment that is in the child's best interests... or not...!?

Tommy Monk wrote:Try asking a straight question and not a loaded one...



How about you answer this for a taste...



Would you prefer a child to be brought up with a mother and father in a stable and loving home environment that is in the child's best interests... or not...!?

I asked first Tommy, you never dare answer do you.

Tommy Monk wrote:Try asking a straight question and not a loaded one...



How about you answer this for a taste...



Would you prefer a child to be brought up with a mother and father in a stable and loving home environment that is in the child's best interests... or not...!?

I answered yours

I prefer the child to be brought up parents that love them and want to raise them in a loving and healthy environment not matter if they are gay or hetrosexual


Still waiting Tommy

I mean after all, you should be able to show countless cases where gay parents have had their children taken into care in the UK???

You asked the loaded question first...


You only asked me to answer a straight question... still waiting for it...!?

A normal and natural environment is the only healthy option available...

Tommy Monk wrote:You asked the loaded question first...


You only asked me to answer a straight question... still waiting for it...!?

Not loaded, I gave you countless examples of the worst case.

Could you not even find a single case with homosexual parents that neglected and abused their children from the list I gave you?

I think I just showed your argument has completely crashed and burned

Tommy Monk wrote:Simple analogy... when wild animals are kept in zoos etc... isn't it considered best to provide the animals with as much a normal and natural home environment as possible...!?

Why should some children be treated worse than animals by being deliberately placed in home environments that deny them the basic normal and natural environment of a mother and a father while all the others get this as standard requirement...?

Didge wrote:Here you go Tommy.

Here is a list of the most serious cases involving children last year, from neglect, to violence and death.

How many were homosexual parents?





A chronological list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2015. To find other case reviews search the national repository.


2015 - Blackpool - Child BV
Death of a 1-month-old infant in Winter 2014. Ambulance service found Child BV unresponsive in 2-year-old sibling’s bedroom, lying between the bed and wall.
Background: both parents had consumed large quantities of alcohol the previous day and could not remember how or why BV was not asleep in usual place. Family were known to universal services only. Father attended Accident and Emergency and visited GP prior to BV’s birth and disclosed that he was a regular heavy drinker.
Key issues: alcohol use and the safe care of children; engaging with fathers; sharing of information about excessive parental alcohol use between professionals; safeguarding requirements for nursery providers; and safe sleep support.
Recommendations: safe sleep assessments by health professionals; campaigning to raise awareness of the risks of alcohol use when caring for young children; and engaging with new and expectant fathers.
Model: Welsh Model for case reviews.
Keywords: infant deaths; alcohol misuse; sleeping behaviour; nurseries.
Read the overview report

2015 – Essex – Child G
Serious brain injury to a 3-month-old girl in May 2013. Mother pleaded guilty to child neglect. The mother's partner was convicted of causing the injuries. Both received custodial sentences.
Background: prior to Child G’s birth her half-sibling had been subject to a child protection plan under the category of neglect. In the months before and after Child G’s birth, mother had attended hospital a number of times due to injuries to Child G’s half-sibling. Child G's mother had diagnosed learning difficulties and "extremely low" IQ classification. She had a history of difficult family relationships and mental health issues. Mother’s partner was known to the probation service and other local authorities due to a history of violence towards women and children.
Key issues: issues identified include the challenge of sharing information about vulnerable families across GP's, midwives and health visitors; the need to focus of the role of fathers/partners through pregnancy and early years; and the need for offender managers to report any safeguarding concerns when an offender starts a new relationship.
Recommendations: include the development of a system to allow tracking of offenders convicted of offences against children and reviewing and monitoring of information sharing in health services.
Keywords: brain injury, child neglect, unknown men, family violence, adults with learning difficulties, mental health
Read the overview report

2015 - Hull - Child W
Death of a 16-year-old girl on 16 November 2013 at a hostel where she was living. Coroner recorded the cause of death as hanging but unclear whether Child W intended to take her own life.
Background: Child W was removed from her birth family and adopted at 10-years-old with her younger brother. Adoptive parents struggled to cope with their behaviour. Prior to her death, there were concerns around self-harm, substance misuse and an alleged rape.
Learning: findings include: W was assessed as needing “intensive therapeutic support” but this support was not provided.
Recommendations: adoption support plans need to clearly detail how and by whom therapeutic needs will be met; attachment needs of adopted children should form part of specialist therapeutic services ; and local authorities should ensure that staff are clear about local guidance and support for homeless 16 and 17-year-olds.
Keywords: adoption support services; placement breakdown; hostels; homeless adolescents; self-harm
Read the overview report

2015 - Nottinghamshire - Child H
Death of a 4-month-old girl in December 2012. Child H died of unknown causes but had a number of injuries which were thought to be non-accidental.
Background: the family was known to a number of agencies due to the serious domestic abuse the mother had experienced with her previous partner, who was the father of Child H and her sibling. Mother had a history of mental health problems, abusive relationships and alcohol misuse.
Learning: identifies learning, including: holding a common assessment framework (CAF) meeting earlier would have helped clarify concerns, responsibilities and what needed to change and professionals should consider the impact of historic experiences of domestic violence.
Recommendations: share the learning from the review and commission a multi-agency case file audit of children subject to a common assessment framework (CAF) where domestic abuse is an issue.
Model: uses the Significant Incident Learning Process (SILP) to review the case.
Keywords: infant deaths, family violence, non-accidental injuries
Read the overview report

2015 - Salford - Child N
Overdose by a 17-year-old female leading to a profound brain injury. Review examines services provided to Child N between the ages of 14 and 17-years-old across two local authorities.
Background: N was a ‘child in need’ but children’s services lost contact after she left supported lodgings to move in with her boyfriend. He was 5-years her senior and they met in a sexual exploitation “hotspot”. N had a troubled adolescence with issues of self-harm, substance misuse and going missing. Mother proactively sought professional help to cope with N’s behaviour.
Learning: good practice highlighted includes the support provided by N’s senior school. Missed opportunities include: social workers should have worked to repair family relationships and greater consideration should have been made relating to child sexual exploitation.
Recommendations: include: early help services must be proactive in working with families with adolescents; local authorities must exercise their legal duties relating to homeless adolescents; and that a clear pathway of mental health services for 16-18-year-olds is created and disseminated to all agencies.
Keywords: homeless adolescents, child sexual exploitation, mental health services, self-harm
Read the overview report

2015 - Southwark – Child R
Rape of a 15-year-old girl in early spring 2014. The girl, who was in foster care at the time of the assault, reported that she had met the man in a hotel after a friend gave him her telephone number. The man involved was arrested and found guilty of a lesser offence against another young person.
Background: family history of: housing instability, drug dealing, child neglect and physical abuse. Child R was made subject to a child protection plan in 2009 and taken into care in 2010 after reporting that her mother had beaten her.
Key issues: whilst in care Child R had periods of: going missing, highly disruptive behaviour, multiple placements and exclusions from school.
Recommendations: makes recommendations covering: looked after children reviews and exploration of options for keeping children safe in emergency situations by police and children’s services. 
Model: uses the Welsh Model for case reviews.
Keywords: organised abuse, foster care, placement breakdown 
Read the overview report

2015 – Tri-Borough (Hammersmith and Fulham, Kensington and Chelsea, Westminster) - Sofia
Death of a 1-year-old girl in October 2013 from asphyxiation due to choking on food. Autopsy findings found Sophia was significantly underweight and there were signs of historic untreated injuries. Parents may be charged with neglect.
Background: mother had no permanent address and received services from 7 local authorities. Sofia and her mother were known to medical staff, social workers, housing professionals and the police. There were no signs of physical injury or neglect and Sophia was not considered to be at continuing risk of significant harm. When Sophia was 3-months old they moved and were not seen by a professional until her death. Father was allegedly living overseas but was later found to be living with the family illegally on an expired visa.
Learning: findings include: complexity of legislation and lack of understanding around provision of housing and benefits for a European National; homelessness during pregnancy not being a trigger for assessment and not being considered a safeguarding issue after birth; assessments made on mother's intention rather than child's experience; strategy discussions conducted via telephone excluding some agencies; a focus on physical manifestations of neglect over more complex indicators; and avoidant families becoming ‘lost’ to services.
Model: SCIE's Learning Together systems model
Keywords: infant deaths, child neglect, transient families, hidden men
Read the overview report

November 2015 - Kingston – Family A
Death of a 4-year-old girl and two 3-year-old twin boys who were smothered by their birth mother on 22 April 2014. The mother was given a hospital order in November 2014 after admitting manslaughter by diminished responsibility.
Background: Children P, Q and R all had spinal muscular atrophy type 2 (SMA2), a life shortening condition which causes severe muscle weakness. Due to the children's complex health needs many different health agencies were involved with the family.
Key issues: include: the parents' opposition to some medical interventions due to concern about the pain it may cause their children; the mother's low mood; staff commitment and the complexity of the case resulting in working outside professional boundaries; a focus on the possibility of using legal interventions rather than considering the wider child protection process.
Recommendations: parents should be offered counselling and information when their child is diagnosed with a disability and LSCBs should ensure that there is senior management involvement to consider the impact on the safety of the children in cases when the full care package isn't taken up over a prolonged period.
Model: uses a systems approach to focus on the strengths and weaknesses of the multi-agency system.
Keywords: child deaths, disabled children, maternal depression
Read the overview report

October 2015 - Hampshire – Child F (Stanbridge Earls School)
Reviews the response of agencies to allegations of sexual assaults against a 14-year-old disabled girl by other pupils at an independent residential school.
Background: the girl, who had delayed social and emotional development, engaged in sexual activity with other pupils at the school. Staff were made aware of the sexual activity by her GP, but judged it to be consensual and a confidential medical matter. The girl later told her parents and further information came to light that suggested the sexual activity had been non-consensual. The police investigated the incident, the boy involved was arrested and the girl was also required to leave the school "for her own protection". Following a series of further child protection allegations the school was made the subject of an inquiry and due to declining pupil numbers closed in September 2013.
Key issues: the complexity of the regulatory safeguarding frameworks that apply to independent schools and confusion over how they work with Local Safeguarding Children Boards (LSCBs); a lack of awareness of how disability and gender imbalance impacted on female pupils' vulnerability to potential exploitation or bullying and a lack of information sharing between national and local agencies involved in the case.
Recommendations: Hampshire LSCB to: set out the responsibilities of school trustees to ensure safeguarding is assured and promoted; ensure that parents are always promptly and appropriately informed of safeguarding concerns and to ensure that child protection services in home and school localities work together in cases where children are in out-of-authority residential education.
Keywords: Independent schools, residential care, harmful sexual behaviour, children with disabilities
Read the overview report

October 2015 - Luton – Child D
Death of an 11-week-old girl in January 2013, as the result of serious injuries consistent with violent shaking. Post mortem found subdural and retinal haemorrhages and signs of damage to the brain and spinal cord. Father was found guilty of Child D’s manslaughter.
Background: mother experienced abuse in the family as a child and, as a result, was made the subject of a child protection plan in 2006. During the review process a number of professionals expressed concerns that mother might have a learning difficulty; none of the professionals who had been in contact with mother in the 5-years previously felt she had a learning difficulty. Findings from a detailed assessment following Child D’s death identified mother as having an IQ score which placed her in the lowest 3% of the population and identified significant difficulties with memory recall. Father was seen by GP as a young adolescent, in relation to problems with his temper, depressed mood and verbal aggression. Following the incident father admitted assaulting mother on two occasions, neither of which was reported to professionals prior to Child D's death. Following Child D’s death, mother reported that Child D has been bruised on three occasions when in the care of father. One of these bruises was seen by 4 health professionals prior to Child D’s death.
Key issues: identifies themes including: how vulnerable young people who might need additional support when they become parents are identified and helped; the value of information, including social information, being held in GP records; engagement of the father and assessment of his role; professional responses to bruises in small babies; working arrangements between health visitors and GPs; and assessment of parental learning difficulties and their impact on parenting.
Recommendations: makes various recommendations.
Keywords: non-accidental head injury, adults abused as children, parents with learning difficulties, fathers
Read the overview report

October 2015 - Somerset – Child Y
Significant injuries to a 3-week-old child in October 2013. MRI scan indicated that Child Y had survived a subdural haemorrhage. Parents were arrested on suspicion of causing Grievous Bodily Harm; both parents were on police bail at the time review was published.
Background: father had been in care as a child and had a history of depression and anxiety and domestic abuse in relation to a former partner with whom he fathered two children. Father had no contact with either child and one of the children had been adopted. Mother had a history of domestic abuse as a child and was assaulted by her father when 10-weeks pregnant with Child Y.
Key issues: prior to the incident, father was noted to have been handling Child Y roughly by GP but was later observed by midwife to be handling Child Y more gently.
Learning: issues with maternity guidelines relating to domestic abuse in pregnancy including the absence of timely review, inconsistencies in advice given and insufficiently robust safeguarding supervision; importance of early handling and safety advice for parents; impact of the rule of optimism and clinical focus of midwifery services impacting consideration of social risk factors; and importance of identifying the role and impact of fathers.
Recommendations: increased home rather than clinic visits for new born babies, particularly for teenage and vulnerable parents; answerphones should not be relied on to disseminate information; and social care staff should be made aware of the implications of a further pregnancy where a parent has had a previous child adopted.
Model: uses a mix of traditional methodology and a new learning approach.
Keywords: non-accidental head injury, fathers, information sharing, domestic abuse
Read the overview report

September 2015 - Solihull – Child S
Death of a 22-month-old boy on 20 February 2013. Child S was taken to hospital after his mother found him lifeless. A post mortem examination established that he had suffered severe abdominal injuries. Mother and father were both convicted of causing or allowing the death of a child in December 2014.
Background: Child S had been the subject of referrals prior to his birth and had been subject to a child protection plan for emotional abuse since August 2012.
Key issues: mother had a history of substance misuse and mental health issues and father had a history of domestic abuse and drug dealing.
Learning: points identified include difficulties in working with individuals who disguise their compliance resulted in an overly optimistic view of outcomes for the child; problems were caused by misunderstanding between agencies about what and how information about adults who may post a risk to children could be shared; poor attendance by some agencies at initial child protection conferences.
Recommendations: development of clear joint information protocols for the police and children's social work services and a review of the booking system for initial child protection conferences to ensure a minimum notice period is given to professionals across all agencies.
Keywords: infant deaths, domestic abuse, substance misuse
Read the overview report

August 2015 – Anonymous – Child F
Death of a 5-month-old baby in September 2014. Child F was found unresponsive by mother after mother and baby had fallen asleep on a sofa when staying overnight at mother’s friend’s home. Ambulance crew noticed the smell of alcohol on mother and called police. Mother was arrested on suspicion of neglect, having thought to have unintentionally rolled on top of her baby; criminal investigation concluded with no charges being preferred.
Background: little is known about child F's father, beyond his extensive criminal history. Mother entered local authority care when 10-years-old, where she remained until discharge at age 18. Maternal history of: chronic neglect; disrupted placements; significant alcohol and drug misuse; domestic abuse; and offending.
Learning: identifies emerging lessons and reflections, including: the consequences of adverse childhood experiences such as chronic neglect and the inclination of individuals to deny or diminish these experiences; workload, difficulty in collating information or anxiety about challenging service users inhibiting professional recognition or exploration of patterns of behaviour such as missed appointments; invisibility of men; and obstacles to information sharing.
Recommendations: makes various recommendations covering: NHS, community health services and probation services.
Keywords: alcohol misuse, adults neglected as children, co-sleeping.
Read the overview report

August 2015 – Stockton-on-Tees – Child H
Serious harm caused to a 12-year-old, identified in July 2013 when serious concerns were raised over poor home environment and Child H’s presentation, including impaired vision. Child H was taken into the care of the local authority and mother and mother’s partner were charged and sentenced to 30-months imprisonment for child cruelty.
Background: Child H was diagnosed with Juvenile Idiopathic Arthritis (JIA) when 5-years-old. JIA can lead to eye problems, which, if not detected and treated early, can cause permanent visual damage, including blindness. Child H was found to have early indicators of uveitis at an ophthalmology appointment in 2011; Child H did not attend any further ophthalmology appointments until July 2013. Children’s social care received three referrals between 2011 and 2013 and concerns had been raised regarding Child H’s presentation, hygiene and attendance at school and medical appointments.
Key issues: the system for screening children with complex eye problems is not designed around the needs of the child: the appointment system implied Child H was making informed choices about not attending, rather than parents’ non-attendance being seen as an indicator of neglect.
Learning: children with medical needs necessitating a range of specialists, require a lead professional to maintain coordination of services, in particular, the role of the school nurse should be developed to engage with children and parents and to assist schools in understanding the impact of specific conditions.
Recommendations: makes various recommendations and includes a multi-agency action plan.
Keywords: child neglect, children with a chronic illness, start-again syndrome
Read the overview report

July 2015 – Anonymous – Subject Child
Death of a 6-7-week-old-girl in May 2012. Subject child was found by mother with her face pressed up against the back of the settee at home where she had earlier fallen asleep. Mother had just woken from sleep after having drunk alcohol earlier in the day.
Background: mother was arrested in 2011 for being drunk in charge of a child, leading to half-brother being placed in foster care. Half-brother was returned to mother’s care following assessments that recommended that there was no role for a social worker. Mother has a chronic abdominal condition, requiring abstinence from alcohol use to avoid the condition worsening and leading to hospitalisation.
Key issues: history of domestic abuse, alcohol misuse and referrals to children’s services concerning the care of half-brother.
Learning: assessment of the impact of chronic alcohol misuse usually takes place when the parent is no longer intoxicated, leading to insufficient understanding of potential risks to the child; lack of professional knowledge of parents’ persistent or long term medical conditions compromising understanding of the impact on parenting capacity; and professional response to incidents without consideration of previous concerns, leading to missed patterns and possibility of continued ineffective responses.
Keywords: alcohol misuse, risk assessment
Read the overview report

July 2015 – Peterborough – Child J
Significant, non-accidental injuries to a 5-month-old boy, identified in November 2013; injuries were diagnosed as suggestive of physical and sexual abuse. Father was charged with neglect, to which he admitted and received a community sentence; he denied and was not charged with sexually abusing child J.
Background: Child J’s mother had two older children, both of whom were living in foster care at the time of child J’s birth; Child J was discharged from hospital to foster care when 2-days-old before being placed in the full-time care of his father when 4-months-old.
Key issues: paternal history of: depression; committing domestic abuse; offending with minor convictions; drug and alcohol use; and allegations of inappropriate sexual behaviour. A number of injuries were identified by various professionals in the month prior to the incident.
Learning: identifies themes, including: optimistic thinking driving plans for Child J to be placed with his father to the exclusion of thorough exploration of risk; insufficient information sharing between agencies; and lack of holistic assessment of family leading to unacceptable evaluation of risk.
Recommendations: makes various recommendations including monitoring the use of escalation procedures.
Keywords: physical abuse, fathers, assessment
Read the overview report

July 2015 – St Helens – Child JSH
Death of a 17-year-10-month-old boy found hanged at home in January 2014. Inquest found that Child JSH had intentionally taken his own life.
Background: history of: domestic abuse; anti-social behaviour; violent behaviour leading to arrests; sexually intimidating behaviour toward members of school staff and female pupils; and stalking and threatening behaviour toward a fellow pupil with whom child JSH had a relationship. Child JSH was described as having had few close friends but a wide network of associates on social media and a high-profile locally in relation to fighting and anti-social behaviour. Police had intelligence that child JSH was receiving threats via social media 2-3-weeks prior to his death.
Learning: identifies four key findings, including: remaining child-centred in responses to older children who present with criminal and harmful sexual behaviours (HSB); and meeting the needs of children who experience severe behavioural difficulties through the system of mental health referral and triage. Identifies wider learning around: the risks presented by social media in relation to developing networks that promote and encourage HSB.
Methodology: systems methodology.
Keywords: suicide, harmful sexual behaviour, child and adolescent mental health services (CAMHS)
Read the overview report

June 2015 – Cambridgeshire – Child K 
Death of a 2-year-old boy in January 2014. Primary cause of death was bacterial pneumonia infection with secondary causes of dehydration, failure to thrive, norovirus and cerebral palsy.
Background: following his death, mother received a police caution for cruelty against Child K contrary to Section 1 of the Children and Young Person’s Act 1933. Child K and his sibling had been subject to a child protection plan for neglect for a month prior to the incident. 
Key issues: maternal history of: childhood abuse, time spent in the care of the local authority, offending, self harm and homelessness. Father was nine years older than mother and also had a history of childhood abuse and time spent in the care of the local authority. Child K was born 24-weeks prematurely, which affected his lung development causing chronic lung disease. Child K had additional complex needs resulting from a hole in his heart, concerns about his hearing and vision and a bleed in his brain resulting in him developing cerebral palsy. 
Learning: analyses key themes, including: the impact of Child K's disabilities on assessment of risk and inconsistency in the level of professional concern; inconsistent perceptions of mother's understanding of Child K's needs or of her ability and commitment to meeting them; and lack of professional understanding of the interaction between Early Help, Early Support and Children in Need systems. 
Recommendations: makes various recommendations, including the provision of training on neglect and disability. 
Keywords: children with a chronic illness, child neglect 
Read the overview report
June 2015 - Havering – Child Y, Child X and Child W
Chronic neglect and emotional abuse of 3 siblings aged 15-years-old, 11-years-old and 6-years-old, and the sexual abuse of 1 or more of the siblings.
Background: children were subject to child in need status and child protection plans at various points in their lives due to concerns around neglect. Concerns were first identified shortly after the birth of the first sibling in 1998, and eventually resulted in the local authority arranging for them to live with their grandparents in 2009. Concerns continued, and in September 2013 the siblings were taken into local authority care.
Key issues: the prioritisation of keeping the children in their family above child protection needs; a lack of communication between professionals and the family about concerns and the actions that needed to be taken; the lack of explicit reference to neglect in some assessments of the children's needs; the absence of a plan or appropriate monitoring of support once care of the children was transferred to their grandparents and delays in taking action due to the grandparents' "false compliance".
Recommendations: develop a multi-agency pathway for identifying and responding to children who may have weight faltering and develop a multi-agency case review and planning process for individual highly complex cases.
Model: uses a hybrid methodology, drawing on a variety of theoretical approaches and techniques.
Keywords: child neglect, emotional abuse, kinship care
Read the overview report
June 2015 - Kingston - Child B
Suicide of a 15-year-old South Korean boy in July 2014. Child B jumped from the top floor of an indoor shopping centre and died in hospital.
Background: Child B moved to the UK aged 6 to live with his father and older brother; contact with their mother was sporadic. Child B was made the subject of a child protection plan, when 10-years-old, for physical and emotional abuse and was briefly looked after. From 2012 the family were receiving support after the father had an accident at work and they became homeless. On the day he killed himself Child B spoke of wanting to take his own life.
Learning: Child B's voice and experience were not present in any reviews; limited exploration of the impact of mother’s absence; and copy and pasting of old information into new reports.
Methodology: systems approach.
Keywords: suicide, adolescent boys, physical abuse
Read the overview report
Read the executive summary
May 2015 - Blackpool – Child BT
Death of a young child in 2014. Initial post mortem proved inconclusive; second post mortem concluded that cause of death was inhalation of stomach contents with the underlying cause being poisoning by Methadone.
Background: Mother pleaded guilty to manslaughter; father went to trial and was found guilty of manslaughter and child cruelty. Family was known to children's services and both BT's sibling and step-sibling had previously been subject to child protection plans.
Key issues: both parents were engaging in drug treatment but mother was known, and father suspected, to have periods of illicit drug use. Both had a history of offending and problems with financial management. Father was suspicious of social care involvement and was rarely seen during home visits.
Learning: professionals in the area were used to working with complex families, which may have led to the 'normalisation' of issues; information on risk factors was not shared by all professionals and professionals did not always refer the family to children's social care when appropriate.
Recommendations: all agencies should fully engage with the Multi-Agency Safeguarding Hub (MASH); family assessments should involve the whole family, including the father; and parental non-compliance with drug services should result in immediate action to bring multi-agency professionals together.
Model: systems methodology
Keywords: addicted parents; poisons and poisoning; neglect
Read the overview report
May 2015 – Bury – Baby I (Case I13)
Serious injury of a 6-week-old boy in October 2013. Baby I was made the subject of an emergency protection order following an examination that revealed he had sustained two broken ribs and a knee fracture.
Background: Mother and Father had been in a relationship for 3-months before Mother became pregnant with Baby I. Paternal history of: drug misuse; suicide attempt in adolescence; and self-reported thoughts of harming baby I to stop him crying. Maternal history of: psychotic depression, previous suicide attempts and incidents of self harm. Father was recorded as mother’s carer.
Key issues: issues identified include: insufficient exploration and understanding of the impact of high energy drink consumption on father’s mood and anger responses; and practitioners’ belief that father belonged to a particular sub-culture possibly inhibiting them from challenging father’s behaviour as they wished to appear non-judgemental.
Model: uses some elements of the Social Care Institute for Excellence (SCIE) Learning Together model.
Keywords: parents with a mental health problem, substance misuse
Read the overview report
May 2015 - Enfield - CH
Life imprisonment of a 15-year-old boy convicted of killing a 21-year-old man. CH stabbed Mr Z, a stranger, following a confrontation on a residential street.
Background: CH was subject to a child protection plan at the time of the incident. His case was being coordinated by Haringey children and young people’s services as a transfer case conference had not been arranged following family’s move to Enfield one year earlier. Family history of: mental health problems; alcoholism; domestic abuse; criminal behaviour and anxiety around their immigration status (they were originally from Jamaica). CH had a history of offending, self-harming; and running away from home. He had previously been subject to a care order.
Key issues: mother's problems distracted from the needs of her children; support for the family ended abruptly following the cessation of a care order; and domestic abuse between mother and female partner was not treated as seriously as heterosexual partner violence.
Recommendations: information coordinators should be appointed within teams working with families with complex needs, to compile a family history and facilitate information sharing; the Safeguarding Board should create a simple chronology tool that could be completed across agencies; and the Safeguarding Board should explore custodial and residential approaches to working with young people with severe behavioural problems.
Read the overview report
April 2015 – Croydon – Child M
Death of a 14-year-old black boy in September 2012, as the result of a fatal stab wound to the heart. Child M was stabbed by another teenager, following an altercation. Child S was found guilty of murder and sentenced to life imprisonment, to serve a minimum of 14-years; the Judge referred to the incident as a “revenge killing”.
Background: At the time of the incident, Child M had been missing from home for nine weeks. Child M attended college a week after he was first reported missing. Police and children’s social care were informed and told that Child M did not want to return home as he was scared he would be beaten by his stepfather; neither agency visited the college nor investigated this disclosure and Child M was allowed to leave college without confirmed arrangements for his care.
Learning: passive response from police and children’s social care to a missing 14-year-old child; passive attitude of police to communicating with parents; and insufficient involvement of mother’s partner in assessments.
Recommendations: makes various recommendations covering: professional challenge and escalation; communication between schools and colleges and other agencies during school/college holidays; and whether child protection services received by older children are robust and the extent to which gender and ethnicity effect them.
Keywords: adolescents, runaway children, escalation
Read the overview report
April 2015 – Croydon – Josh 
Death of a 3-year-old boy in March 2013. Mother carried Josh into the path of an oncoming train, killing them both. 
Background: Mother had a history of severe anxiety disorder and had been receiving treatment from her GP and various mental health services in the months preceding Josh’s death.
Key issues: procedural failure responding to a children’s social care referral made by Mother’s psychiatrist; a culture of overreliance on children’s social care for actions regarding a child; and perceived inconsistent and misleading advice from mental health services leading Mother and Family to continue accessing private mental health providers as they lost trust in NHS providers.
Model: review was undertaken using the Significant Incident Learning Process (SILP).
Keywords: adult mental health services, suicide, referral procedures
Read the overview report
April 2015 – Fife and Edinburgh Child Protection Committees – Child MK
Death of a male child in January 2014. MK was reported missing by his mother on 16th January; his body was found on 17th January following a police search. Mother pleaded guilty to culpable homicide and was sentenced to 11-years imprisonment.
Background: MK entered foster care in July 2012 following a notification received by social work services that mother had left her children unattended. MK returned to the care of his mother under a supervision order in August 2013. Family was receiving support from Fife Social Work Services on a voluntary basis at the time of the incident.
Learning: identifies areas for future learning and action including: Scottish government should consider the need for the development of national guidance for the transfer of non-child protection cases across local authority areas; and NHS Fife should review how information, which is below the child protection threshold but which impacts on child wellbeing, is shared between GPs and health visitors.
Keywords: assessment, case transfer
Read the executive summary
April 2015 - Lambeth – Child I
Death by drowning of a 20-month-old boy in July 2013. 
Background: Child I and his two older siblings were subject to child protection plans under the category of neglect at the time of the incident. Parents both had learning difficulties and at times reacted with anger and hostility to professional interventions. Child I was found face down in the bath; mother reported she had left Child I in the bath, informing father she had done so, before leaving the house. Parents were subject to police investigation as alleged perpetrator and witness throughout the case review process.
Key issues: professional emphasis on investigating physical injuries at the expense of considering indicators of neglect; and overreliance on written agreements with parents to support child protection arrangements. 
Model: Social Care Institute for Excellence (SCIE) Learning Together model
Keywords: adults with learning difficulties, neglect and interagency cooperation
Read the overview report
April 2015 – Lancashire – Child L and Adult L
Death of a 6-year-old boy and his mother and the attempted suicide of his father in April 2013. Father was diagnosed with a psychotic mental illness and detained under the Mental Health Act 1983.
Background: Child L and parents were not known to any specialist services. Previous contacts with health services for injuries to Child L and Adult L were judged to be accidental. The day before the father consulted his GP about feeling in low mood and hearing voices. There had been no previous mental health issues. GP requested an assessment by a mental health practitioner and a meeting was scheduled for the next day.
Learning: identifies good practice including the GP’s referral to mental health services and school support to pupils and families after the deaths. 
Key issues: missed opportunities for sceptical and curious enquiry by health professionals; no enquiry about Child L by GP; ‘shortcoming of human inference’ leading mental health specialists to think a GP would rate a case high risk to get a quick assessment; use of a telephone triage system for mental health assessment.
Methodology: joint serious case review and domestic homicide review. Uses a systems framework to present the key learning.
Recommendations: questions for consideration cover: overcoming cognitive influence and human bias in information sharing; ensuring sufficient enquiry and recording of any presentations for medical treatment; use and availability of tools and frameworks for assessing risk.
Keywords: parents with a mental health problem, family annihilation/familicide
Read the overview report
Read the executive summary
April 2015 - Lancashire – Child N
Death of a 4-year-old boy and his mother in May 2014 as the result of a house fire in Liverpool. Coroner's verdict was that Child N had been unlawfully killed and mother had taken her own life after deliberately starting the fire.
Background: parents separated acrimoniously prior to Child N's birth. Mother requested a termination, but was refused due to the late stage of her pregnancy. After the birth, the mother briefly went missing which resulted in Child N spending a short time in foster care. Due to concerns about his safety and on-going contact disputes, Child N’s care was subject a number of court proceedings. The court’s decision in the second case resulted in the father, who lived in Lancashire, being granted a residence order and the mother a contact order. During the fourth and final set of proceedings, whilst Child N was on a contact visit, the mother made allegations of child sexual abuse which resulted in Child N staying with her in Liverpool.
Key issues: family history of: maternal mental health problems, domestic violence and multiple parental allegations and counter allegations of poor care and abuse. Challenges identified include: language and translation issues when communicating with maternal grandparents; and the lack of means for professionals to enforce court imposed decisions regarding child contact.
Learning: parental mental health assessments should be shared with all professionals involved in the child's life; and when closing a case social workers should ensure they inform all professionals working with the child.
Recommendations: LSCBs to explore options to help frontline practitioners understand and assess behaviour of a parent who causes concern but does not have a recognised mental illness.
Keywords: filicide, suicide, parents with a mental health problem, contact
Read the overview report
April 2015 - Lincolnshire – Baby W
Death of a baby boy during the hours following his birth in September 2013. Mother was 16-years-old at the time of the incident; she had concealed or denied her pregnancy and given birth, unassisted in her bedroom at home. Post mortem revealed that Baby W died from a tissue blocking his airway; mother pleaded guilty to infanticide and was sentenced to a 2-year Youth Rehabilitation Order (YRO).
Background: mother was known to universal services only; she did not present with any physical symptoms of pregnancy prior to Baby W’s birth. During her pregnancy mother presented to GP a number of times with concerns of low mood and depression and self-referred to an Improved Access to Psychological Therapies (IAPT) service for support with her anger as a result of depression. Mother was asked and denied her pregnancy on a number of occasions, by professionals and family members.
Learning: identifies one missed opportunity to provide mother with age appropriate advice around sexual activity, contraception, sexual health and healthy relationships. Identifies lessons to be learnt, including: need for awareness raising and development of procedures and guidance around concealed or denied pregnancy; importance of young people receiving sexual health and contraception advice; and increased GP knowledge of the support that school nursing services can provide young people.
Recommendations: makes various recommendations.
Keywords: concealed or denied pregnancy, teenage pregnancy
Read the overview report
Read the executive summary
April 2015 - Tameside – Child M
Death of a 17-year-old girl in December 2013. Child M's body was found in a garden with a ligature around her neck; there was no evidence of any third party being involved. 
Background: Child M was never identified as a child in need or requiring protection, but did receive support from Child and Adolescent Mental Health Services (CAMHS), although she was never diagnosed with a mental health condition. She also received support from: young people's services (YPS); the Crisis Resolution Home Treatment Team (CRHTT) and a drug and alcohol treatment charity. 
Key issues: Child M had a significant history of self-harm, alcohol and drug misuse, truancy, school exclusions and verbal and physical violence. Child M disclosed to professionals an experience of being inappropriately touched by an adult and her feelings of distress over her father's use of alcohol and violent behaviour during her early childhood.
Learning: Child M’s school interpreted her age, intelligence and social background as evidence she had the capacity to change her behaviour, and so their response focussed on behaviour management rather than assessing her support needs; her parents were not always consulted or kept informed about professionals’ concerns for Child M’s welfare; and police were not aware that, due to her complex needs, a social worker rather than a volunteer appropriate adult should have been allocated to Child M whilst she was held in custody. 
Recommendations: the police and the council should confirm what arrangements are in place to ensure relevant protocols, including the use of appropriate adults, are known and used by both services.
Model: systems based approach
Keywords: suicide, self-harm, risk assessment
Read the overview report

Still waiting

Tommy Monk wrote:You asked the loaded question first...


You only asked me to answer a straight question... still waiting for it...!?

It was a straight question Tommy, but you are too much of a coward to answer it.

he is choking on your Spam.

Didge wrote:

Tommy Monk wrote:You asked the loaded question first...


You only asked me to answer a straight question... still waiting for it...!?

Not loaded, I gave you countless examples of the worst case.

Could you not even find a single case with homosexual parents that neglected and abused their children from the list I gave you?

I think I just showed your argument has completely crashed and burned

http://www.telegraph.co.uk/news/uknews/1522158/Gay-couple-jailed-for-abusing-their-foster-children.html

http://www.dailymail.co.uk/news/article-2305125/Gay-couple-accused-molesting-9-adopted-children-withdraw-guilty-

plea-decide-trial-fight-allegations.html

There are loads...use your search engine.
All it proves is gays AND straights abuse children.

Syl wrote:

Didge wrote:

Not loaded, I gave you countless examples of the worst case.

Could you not even find a single case with homosexual parents that neglected and abused their children from the list I gave you?

I think I just showed your argument has completely crashed and burned

http://www.telegraph.co.uk/news/uknews/1522158/Gay-couple-jailed-for-abusing-their-foster-children.html

http://www.dailymail.co.uk/news/article-2305125/Gay-couple-accused-molesting-9-adopted-children-withdraw-guilty-

plea-decide-trial-fight-allegations.html

There are loads...use your search engine.
All it proves is gays AND straights abuse children.

2 couples, is that it?

How about from the list of worst cases I gave from last year?

not two over the last 10 years you gave

Now how many heterosexual couples?

You wanna go down this road and lose?

Didge wrote:

Syl wrote:

http://www.telegraph.co.uk/news/uknews/1522158/Gay-couple-jailed-for-abusing-their-foster-children.html

http://www.dailymail.co.uk/news/article-2305125/Gay-couple-accused-molesting-9-adopted-children-withdraw-guilty-

plea-decide-trial-fight-allegations.html

There are loads...use your search engine.
All it proves is gays AND straights abuse children.

2 couples, is that it?

How about from the list of worst cases?

Now how many heterosexual couples?

You wanna go down this road and lose?

Not just two...I said use your search engine, there are plenty.

If you are trying to win an argument by counting numbers, have you taken into consideration that homosexuals have only been allowed to adopt or foster for a short time?

Thought not.

Syl wrote:

Didge wrote:

2 couples, is that it?

How about from the list of worst cases?

Now how many heterosexual couples?

You wanna go down this road and lose?

Not just two...I said use your search engine, there are plenty.

If you are trying to win an argument by counting numbers, have you taken into consideration that homosexuals have only been allowed to adopt or foster for a short time?

Thought not.

Yes I am show how small minded you were being as you present one case from 2006 and one from 2013, yet I asked oput of the cases from the worst ones last year presented.

The fact is its actually rare for such abuse cases with homosexuals couples.
One was not even adopted parents but I guess you did not even check that either

So again my questions still stand