Learning from a Serious Case Review

Over the weekend, I came across the Serious Case Review (SCR) into the death of a young person referred to as ‘Chris’, published recently by Newham LSCB.  I was drawn to it particularly as a social worker, and someone based in the area to which it refers. It is a profoundly moving document, highlighting real moments of good practice in work to support Chris and his family, while also indicating areas of work where people and agencies fell short in their roles and responsibilities. It is first and foremost an opportunity to learn about the lives of Chris and his family, to identify opportunities for learning from his tragic death, and to make recommendations to reduce the likelihood of similar events happening again.

Let me say straight away that I do not want to somehow ‘claim’ such a document for a particular cause. That would be grossly insensitive and unprofessional. The SCR does not comment specifically on any issues of CPV other than the report that his mother experienced an assault sufficient to warrant calling the police. We read of breakdowns in family communication, necessitating moves to live with other relatives, but these moves are also linked to the escalating risks generally in Chris’ life. I do want to recognise though, the learning points highlighted, because I believe that they are very relevant to the work going on with families experiencing child to parent violence.

There is no one way in which families experience CPV. For some, where the issues are less complex and there is early intervention, the matters can thankfully be resolved quickly and harmony restored. But we know that there are other families where children – and adults – experience multiple vulnerabilities: each piling trauma on trauma, risk onto risk, building a complex story of harm in a long person’s life and making a resolution significantly less straightforward. Each issue will need to be addressed in order to fully understand the family’s experience. In the meantime, a family lives day to day with the fear of what might happen to their young person, what news they might hear, each knock on the door a  moment of dread.

In Chris’ life there were professionals who were able to build supportive, caring, therapeutic relationships with him at various points in time. Within these relationships there could have been opportunities for protective work to take place. Nevertheless, inadequate sharing of information between agencies meant that some workers were unaware of the risks to him. Once he was understood primarily through an ‘offender lens’, people lost sight of Chris’ multiple vulnerabilities, and with this came a less rounded set of responses, and the loss of focus on the way young people can be both victim, and purveyor, of harm. With multiple agencies involved in such a complex case, coordination, lead roles, and transfer of information all become vital. This was seen to be lacking here, not helped by frequent changes of staff. Despite some excellent intervention at certain points, attention is also drawn to a failure to engage fully with this young man, or to ascertain his views and wishes. And finally, one phrase that stuck out over and above the others: “Poor quality assessments and reviews were regularly confused with intervention and activity confused with impact.” I hear this as a complaint from families time and time again. It is an area in which we might all be more vigilant.

These are learning points specific to this review, but they are each important to all the work we undertake with families whatever the circumstances. I believe we can all learn much as we reflect on our own practice, and seek to develop further in the safeguarding and protection we offer.

The full report is available to download here.

The Executive Summary is also available here.

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