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Serious case reviews

Key themes and practice implications

Each case reviewed (see the previous chapter) was unique with individual learning points arising from each report.

There were however some key themes that arose in a number of the cases. The cases reviewed reflect the challenges practitioners face in relation to:

  • Working with large and complex families
  • Recognition of and challenges of working with risk of child sexual abuse including sibling abuse
  • Recognition of and challenges of working with child neglect
  • The risks and impact on a child’s development of non-school attendance
  • Where there are gaps in obtaining, retrieving or sharing information, it remains possible for a dangerous man to join a vulnerable single-parent household without constraint
  • Within a formal CP investigation of child sexual abuse, it is hard for the voice of a learning disabled child to be heard and acted upon 

The cases highlighted the need for the following changes in practice:

  • The need for assessments to focus on the child's experience rather than the adult’s needs or excuses
  • The need for all Child in Need and Child Protection plans to include detailed analysis of risks and protective factors, looking at both short term and long term outcomes if the required change is not evidenced
  • The need for all Professionals to be aware of Norfolk County Council Children Missing Education procedures and the importance of robustly applying these in cases where it is suspected that a child is not accessing an education
  • The NSCB should ensure that the Resolving Professional Differences policy is properly introduced and supported across partner agencies. Its use should be monitored and reviewed

It was also identified that all agencies should develop a culture of ‘challenge and curiosity’ as part of the process of information gathering. This included:

  • Proactively investigating the child's wider circumstances where concerns have been raised, particularly when a male partner joins the family and refuses to engage with, or avoids, professionals and has a negative impact on family dynamics
  • Good practice around challenging families where there is cause to suspect lying, keeping secrets, and/or avoidance which can be evidenced within assessments and recorded on the child's records
  • Challenge and curiosity to be demonstrated to workers by their line managers and recorded in supervision records
  • Where there are gaps in knowledge about a child's home circumstances, there should be evidence of how workers have tried to address the gaps by talking to partners working with the child or family