The document discusses key messages from serious case reviews (SCRs) regarding inter-agency cooperation and information sharing. It notes that while guidance has existed for decades encouraging inter-agency working, SCRs still often find issues with information sharing across agencies. The document then summarizes several specific SCRs, finding common significant factors like domestic abuse, drug/alcohol misuse, and mental illness. It calls for improved information sharing to help agencies gain a fuller picture of risks.

1. Conwy and Denbighshire Local
Safeguarding Children Board
Information Sharing
Messages from Serious Case
Reviews
David Spicer, LLB,
Barrister
© David Spicer

2. It’s not easy

3. Inter-agency Co-operation
• Over 60 years from the first
government circular encouraging inter-
agency working (Dennis O’Neil)
• 40 years since detailed guidance (Maria
Colwell – Area Review Committees to
ACPCs to LSCBs).
• 8 years since major legislative reform
(Victoria Climbié)

4. Inquiries Recommended
• Should be better working together.
• Should be better sharing of
information.

5. CDLSCB
Serious Case Reviews
• Jane: baby 8 weeks. Serious physical
injuries. Stress; prematurity; special
needs.
• Child A; baby 4 months. Serious
physical injuries. Young parents.
Stressful pregnancy, distressing,
medical interventions.
• Child 3C; baby. 2 days. Mother gave
methadone. Long history of drug
misuse.

6. CDLSCB
Serious Case Reviews
• Child CS 5 years; Child AS 4 years
smothered by father. Mental illness.
• Child B teenager. Committed suicide at
home.

7. Serious Case Reviews
• Child B 6 - 10; sexual abuse in foster care.
• Children B; C; P; Z teenagers. Choked on
vomit. Drug and alcohol misuse; sexual
exploitation; domestic abuse.
• Children N; R. Teenage suicides;
domestic abuse.
• Children M1;M2. Serious physical and
sexual abuse. Longterm neglect, domestic
abuse.

8. Serious Case Reviews
• Children O; G. New babies. Serious
physical abuse. Young carers;
depression; domestic abuse.
• Child F new baby. FII. Previous baby
with fractured ribs; domestic abuse.
• Children E (4) serious sexual abuse.
Longterm neglect, domestic abuse.

9. Practice is within a
framework of statutory,
policy, practice and
guidance imperatives

10. Policy Imperative.
Practice imperative.
Legal imperative.

11. Within a context of what we
know …

12. Significant Factors
• Mental Illness.
• Domestic Abuse.
• Alcohol misuse.
• Drug misuse.
• Poor childhood experience of adults.
• Immature adults.
• Male not the father.
• Financial pressures / poor housing.

13. Ofsted’s evaluations of serious
case reviews 2007 to 2008
• 173 SCRs
• Salutary to be reminded that the most
common risk factor in the cases
reviewed was neglect.
• Distressing to read, for example, how
often nobody thought to ask a child
who was clearly unhappy what was
wrong.

14. Child M2
Aged just 3 years was
“his usual weary self”

15. Ages of Concern, learning lessons
from serious case reviews: A thematic
report of Ofsted’s evaluation of serious
case reviews from 1 April 2007 to 31
March 2011(26 October 2011)

16. Babies
• 608 children who had been the subject of
SCRs during 2007 to 2011 in England,
• 210 - 35% under 12 months old.
• Majority under 3 months of age.
• “practitioners underestimated the fragility
of the baby.”
• “ … means swift response is even more
essential.”

17. Teenagers
• 14 – 18 years: 25% SCRs.
• 2007 – 2008: 40% 11 to 18 year
olds

18. With both: “Too often …”
• Safeguarding procedures not
used early enough.

19. Why not?
• OFSTED – staff unaware of procedural
requirements
• Or
• Knew about them but failed to act in
accordance.

20. Child Welfare Policy to Practice
Government Formulates Policy
▼
Legislation to Implement Policy
▼
Guidance to Assist Implementation of
Legislation
▼
Procedures/Protocols
▼
Practice

21. What are the legal, policy and
practice imperatives
underpinning a procedural
requirement?
What are they expected to
deliver?

22. www.legislation.gov.uk
www.bailii.org
www.ccwales.org.uk/
publications-and-
resources/child-law

23. SCR
LAC sexually abused by
adopted son of foster mother
for 4 years from 6 years to 10
years old

24. Why did she not tell
someone?

25. Working Together 2006
Chapter 9
Safeguarding children who
may be particularly vulnerable

26. Working Together 9.11
• “Social workers are required to see
children in foster care on their own
for a proportion of visits, and
evidence of this should be
recorded.”
• Reflects statutory regulations.

27. Why?
What are the Policy and Practice
Imperatives behind the legal
and guidance requirement?

28. Working Together 9.11
• “Foster care is undertaken in the
private domain of carers' own
homes. This may make it more
difficult to identify abusive
situations and for children to find a
voice outside the family.”

29. Statutory Regulations and
Guidance
• To form a relationship and to
encourage sharing concerns.
• “a measure of child protection”.
• “This performs the child protection
element.”

30. Children Telling
• 25% told at the time
• 31% not told anyone by early adulthood
• Of those who told
• 55% told a friend
• 29% told mother or step mother
• 13% told a sibling
• 11% told father
• (Cawson et al 2000)

31. Reder and Duncan
(Reder and Duncan (1999) Lost
innocents: a follow-up study of fatal
child abuse, London: Routledge.)
• “… professional practice is based on a
covert preparedness for a worst-case
scenario.”

32. Child B
• (she) considered her social worker
to have shown ‘false friendliness’.
• Her social worker was ‘rushed’ and
she ‘never asked questions more
than once’.

33. Child B
• ‘for example, she would ask me
how I was and I would say fine’.
• ‘if she had asked me again for
example - are you really sure? I
don’t think I could have hidden
it and may have let it all out’.

34. Seeing alone
• Not just to give an
opportunity to disclose.
• Also to find out.

35. National Assembly for Wales
Health, Wellbeing and Local
Government Committee
Inquiry into Local Safeguarding
Children Boards in Wales
November 2010

36. Foreword
• During the course of the Inquiry, we
heard evidence of
• a disconnect between the strategic
work of LSCBs and the knowledge and
awareness of front-line practitioners;

37. Child CS and Child AS
• History of mental illness.
• ned that
• The authors were concerdespite the
fact that a flawed protocol existed
about communication between adult
mental health and children’s
professionals the local team were
unaware of its existence.

38. Suicide Strategy
• Great deal of work on strategy to
address.
• Agencies to develop services to deliver
strategy.
• To assist early identification of risk and
referral to specialist group.
• Training to equip staff across agencies
to identify risk.

39. Serious Case Review following
Suicide of 13 year old
• Frontline staff unaware of arrangements.
• No agency could identify any
development of service.
• One teacher had attended training.
• LSCB had no information on which
agency staff attended training and had
not required evidence of development of
services.

40. Check out that -
• Staff and managers are aware of
expectations.
• They have understood why.
• Policies and procedures are being
applied in practice as intended.

41. Child Sexual Exploitation

42. Child Protection Procedures
• Not followed for older children.
• Despite serious harm and risk of
death.
• Apply until 18 years old.
• Lack of interagency processes.

43. Child Sexual Exploitation
Procedures
• Not followed.
• Perpetrators free to abuse others.
• Suppliers of drugs and alcohol not
investigated.
• Contrast action against victims.
• Action against perpetrators criminal
and civil should be priority.

44. SCRs
• Ascertaining wishes and feelings
becomes -
• Deferring responsibility for decisions
and action (or inaction) to the child.
• Need to record judgment about what
child wants or does not want.
• Consider whole range of options
including secure accommodation.

45. Language used
• 11 years 7 months: “sexual relationship with an
older man.”
• “was not prepared to give any details regarding
her partner.”
• 13 years: “had sexual intercourse” with 24 year
substance user and registered sex offender.
• “having sex with an older man.”
• She “put herself in situations of harm.”
• 13 year old with 28 year old “boyfriend”.
• Identified in WG Guidance on Safeguarding
Children and Young People from Sexual
Exploitation January 2011.

46. Language Used – older
children
• Encourages desensitisation to
circumstances.
• Normalises experiences.
• Allocates responsibility to the
child.

47. Interagency Culture

48. Safeguarding Children is
Everyone's Responsibility

49. Safeguarding Children is
Everyone's Responsibility
• Safeguarding and Promoting
Welfare.
• s28 Children Act 2004
• s175 Education Act 2002

50. Policy
Children Act 2004
Government expects:
• Radical and fundamental cultural change.
• Whole system change.
• Programme of fundamental reform.
• Step change in how safeguard and protect
children.
• Strengthening child protection.
• Involving transformation of children’s
services.
• Shift emphasis to prevention and early
intervention.

51. s28 Duty
• To ensure all functions are carried out
having regard to the need to safeguard
and promote the welfare of children
• When arranging for others to deliver
services to ensure that they do so.
• All agencies have same duty.

52. Cultural shift required
• Agencies not to be seen as
different services.
• But different parts of a single
service for children.

53. Serious Case Reviews
No reflection of the radical
change expected in the
practice and inter agency
arrangements.

54. Health, Wellbeing and Local Government
Committee Inquiry 2010
• Recommendation 3:
• that the Welsh Government should
ensure that LSCB guidance addresses
the over-reliance on Social Services
Departments and re-states the
responsibility of all organisations at
national, regional and local levels to
working effectively together to
safeguard and protect children.

55. Inter Agency Processes
• Strategy meetings.
• Assessments.
• Child protection conferences.
• Core Group meetings.
• Individual and collective
responsibility for effectiveness and
ensuring all relevant information is
considered.

56. Testing and Challenging
Dangers of Consensus

57. Inter-agency Processes
• Responsibility on all:
• to ensure operating effectively.
• assessments completed and effectively
carried out.
• that contribute to enquiries and
assessments – proactively.
• To test and challenge.

58. Working Together 2006
Multi/Inter-agency in approach
8.14 Multi and inter-agency work to
safeguard and promote children’s
welfare starts as soon as there are
concerns about a child’s welfare, not
just when there are questions about
possible harm.

59. SCRs - Assessments
• Inadequate assessments accepted by
managers and interagency groups.
• Judgments not properly reasoned.
• Lack of forensic approach.
• What do we need to know?
• Evaluation and analysis - what does
information mean and why?
• Includes drawing appropriate inferences
and opinion on what is likely to happen.

60. SCRs
• Framework for Assessment not read.
• Inadequate plans with vague generalised
objectives.
• Lack of clarity about who is to do what, when
and how?
• No contingency arrangements.
• Changes occurred in crisis.
• Plans persisted with – despite lack of impact.
• Lack of interagency challenge.
• Lack of effective challenge through supervision.

61. Inadequate shorthand
• Problems will be addressed?
• Situation will be monitored?
• There will be engagement with the
family?
• The family will receive support?
• Mental health problems.
• Limited capabilities.
• Challenging behaviour.

62. What will the protected
child look like?

63. Failure to Review Failing
Strategy
• One of the most common, problematic
tendencies in human cognition … is
our failure to review judgements and
plans – once we have formed a view on
what is going on, we often fail to notice
or to dismiss evidence that challenges
that picture.
• (Fish, Munro and Bairstow 2009)

64. Groupthink
What drove thinking in
direction it took?

65. “Groupthink”
• Tendency of groups to avoid
dissension is a hazard.
• (Janis (1982) Groupthink: psychological studies
of policy decisions and fiascos, Boston, MA:
Houghton Mifflin, second edn)

66. Conformity
• High level of conformity in case
conferences.
• Group leaders therefore have to
challenge themselves to encourage
dissent and be open to challenge,
sometimes even appointing a ‘devil’s
advocate’ to diminish this tendency.
(Corby 1987; Birchall and Hallett 1995; Farmer
and Owen1995) Working with child abuse,
Milton Keynes: Open University Press.)

67. Assessments
• Better not to carryout and acknowledge
the impact.
• Than to do it inadequately and rely on
the conclusions.
• Just because it is called an assessment
doesn’t mean it is one.

68. Dr Henry Kempe
• “If you do not understand someone’s
behaviour, you do not have enough
history.”

69. Analysing child deaths and serious injury
through abuse and neglect: what can we learn?
DCSF(2008).
• “ If parents are experiencing difficulties
in their parenting tasks, then knowing
the parents’ own family history,
assessing their understanding of the
impact of what is happening to them on
their parenting children, and their
capacity to adapt and change becomes
crucial.”

70. SCRs
• History of parents insufficiently
researched.
• Childhood experiences.
• If in care – files not accessed.
• Previous relationships and children.
• Particularly if information is elsewhere
in Wales or United Kingdom.

71. It’s not easy

72. “Foster mother jailed for sadistic
torture.” April 2007
• Eunice Spry sentenced to 14 years
imprisonment.
• Over 20 years vicious abuse and neglect -
beating with metal poles, forcing sticks down
throat, forcing to eat dog faeces, told
possessed by Devil.
• Not attend school and not allowed to
socialise.
• Regular visits to the home.
• Came to light because a child “escaped and
told a friend.”

73. Dangers of Consensus
Agreed Court Outcomes

74. Danger
• When experts are jointly
instructed.
• Recommendations accepted with
insufficient challenge and testing.
• Community professionals
excluded from commenting or
even knowing.

75. SCR
• 4 children.
• Father convicted of sexual offence
against 6 year old visitor – 15 months.
• National agency expert jointly
commissioned to advise on
• What is likelihood of offending against
own children?
• Ability of grandparents to protect if had
care?

76. Court
• Opinion in report accepted –
• High risk to children outside family but
• Low to medium risk to own children
reducing to low if treated.
• Grandparents could be relied on to
protect.
• Agreed residence order to g/ps who to
supervise contact.

77. Real life
• At time of assessment father was
and had been seriously abusing
children.
• Continued to abuse.
• Sufficient to justify life sentence.
• Grandparents colluded with
opportunities to abuse.

78. No challenge
• Agency admitted little evidence base for
their work on risk.
• Received no information about outcomes
of previous cases advised on.
• No evidence base on assessing ability to
protect.
• Probation/MAPPA assessment that highly
dangerous not known or considered.

79. Child E
• “… no one had ever helped us … I was
lied to and let down by everyone….
workers were told to go away … and
they did. No one ever really tried to find
out what was going on – why didn’t
they try harder?”

80. Information Sharing

81. Jigsaw
• “Often it is only when information from a
number of sources has been shared and
is then put together that it becomes clear
that a child is at risk of or is suffering
significant harm.”
• Do not know what we do not know.
• Not always know significance.
• Do not know what others know or not
know.

82. Glimpses
What is it like living in the
household?
24 hours a day
7 days a week
52 weeks a year

83. Health, Wellbeing and Local Government
Committee Inquiry 2010
• During the course of the Inquiry, we
heard evidence of:
• problems with information sharing
across agencies.

84. What is the Problem?

85. • Is it too much information being shared
inappropriately?
• Is it too much action being taken
precipitously and without good cause?

86. Problem?
• Is it a question of law?
• Or good practice?
• Or both?
• More important – is the culture.

87. Culture
• Despite the emphasis in guidance on the law.
• Rare for individual practitioners to think
about whether they should share
information.
• And then conclude that the law prohibits
them from doing so.
• More common is not to think about sharing
and with whom.
• Culture is as important as protocols and
procedures.
• Includes issues of trust.

88. Climbié Report 2003
• Throughout this inquiry it was said that
when there is professional concern about
the welfare of a child, the free exchange of
information is inhibited by the Data
Protection Act 1998, the Human Rights Act
1998, and common law rules on
confidentiality.(17.115)

89. • What happened before late
2000 when HRA and DPA
implemented?
Victoria died on 25/02/00

90. • Did Parliament intend to
make vulnerable children
more vulnerable?

91. IRT : Information Sharing to Improve
Services for Children (August 2003)
• … you need to develop co-operative
ways of working with other agencies
and service providers to ensure that
you can all access all the relevant
information to help secure the best
outcome for the child.

92. Data Protection Act 1998.
Human Rights Act 1998.
Common law principles of
confidentiality.

93. Sharing Information
• Nothing in
• Data Protection Act 1998
• Human Rights Act 1998
• Common law principles
• To prevent appropriate sharing of
information to safeguard and promote
the welfare of vulnerable children and
inform sound judgments.

94. Ministers 2004
• Sharing information is a vital aspect of
safeguarding children and ensuring
they thrive, and
• It is an intrinsic part of the duty to co-
operate to safeguard and promote
welfare
• Under s28 Children Act.

95. Safeguarding and Promoting
Welfare
• Includes:
• Acquiring necessary information to
form judgments and shape services.
• Ensuring others have information
necessary to inform their judgements
and shape services.

96. Communication and
Terminology

97. Laming –
Information Management
• Competence in information
management is no less critical
… than competence in
diagnosis or … in treatment.

98. Assume you will be
misunderstood.
Assume you will
misunderstand.
Make clear
implications/inferences
to be drawn.

99. Karl Popper (1902 –1994)
• It is impossible to speak in such a way
that you cannot be misunderstood.

100. Sources - Test and Challenge
• Be clear about sources of information.
• Be clear about the basis of any
opinions or assessments.
• Receivers test and challenge.

101. SCR
• Offender Manager’s office interviews
informed assessment about
dangerousness and life style and
change.
• Inconsistent with actual behaviour and
serious risk.
• Relied on by child care staff to allow
contact.

102. Terminology
• “chronic”
• very serious?
• or
• long lasting?

103. Terminology
• “Morbidity”
• Concerned with death?
• or
• Concerned with sickness or disease?

104. Make no assumptions about
knowledge?

105. SCR
• Schedule 1 offender uncle.
• Judge:
• “… it is now quite clear that there is not a
shred of evidence against him.
• It verged on the incredible that he should
have had the opportunity to groom and then
to abuse his niece on “more than one
occasion” without the parents or the other
children becoming aware that something had
happened. He is entitled to be wholly and
publicly exonerated.”