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Independent Review Published into Serious Case Reviews


Sep 12, 2016

sccAn independent report commissioned to join up the lessons learnt and key themes from serious case reviews into the death of one Sunderland baby and injuries to three others, publishes its findings today (Tuesday 6 September).

Respected academic Dr Mark Peel and his colleague Dr Trish Shorrock were commissioned by Sunderland Safeguarding Children Board to look at the issues emerging from a number of serious case reviews, covering a period from 2013 to 2015 when services were under particular strain.

Their resulting report concludes that the serious case reviews do not evidence ‘endemic or systemic failure’ within the wider safeguarding system in Sunderland, but instead reflect the underlying issues prevalent at the time, namely:

– A multi-agency safeguarding workforce under considerable pressure both in terms of time and resource, with insufficient leadership direction and support – resulting in issues around consistency and the opportunity for human error.

– A multi-agency safeguarding partnership operating at a basic and pragmatic level only, and working in parallel rather than in an integrated cohesive manner.

The report also highlights ‘rapid turnover and poor retention’ of staff at all levels in Children’s Services as posing a ‘serious challenge’ to the effectiveness of the partnership underlying the operation of Sunderland Safeguarding Children Board and safeguarding children and young people more generally.

It also identifies as key themes across the four serious case reviews:

–  Communication within and between agencies
–  Issues regarding assessments and assessing risk
–  Management and supervision issues
–  Records, chronologies and procedures
–  Failure to listen to the voice of the child

Responding to the report, Jane Held, Independent Chair of Sunderland Safeguarding Children Board, said: “Sadly, these babies and their families were not always served well by the professionals and agencies responsible for supporting them. These included the NHS, early years services, education services, the police and children’s social care.

“We let these babies and their families down. This is something we deeply and profoundly regret and we apologise unreservedly to all those involved.

“It is however important to acknowledge that responsibility for the injuries to three of the babies rests with those the court found culpable. Although the cause of death for Baby E was unascertained, the Coroner was clear that no-one was responsible for her death. Also that there is no direct causal link between the poor practice in these cases and what happened to all of these babies in their everyday family life.”

Ms Held said the findings of the reviews and the independent report reflect many of the same issues identified in last summer’s Ofsted’s inspection which found safeguarding services across the board in Sunderland to be inadequate but that much had changed since then.

She also pointed to the ‘significant progress’ noted by Ofsted inspectors after their first monitoring visit to Children’s Services following the inspection, the findings of which were published on Friday 3 September.

She said: “The standard of practice in these cases and more widely in 2013 was not up to the standards we would expect. A significant amount of work has been done since July 2015 to improve safeguarding across the partnership.

“This has resulted in a steady improvement over the last year. Plans are progressing to ensure that all the agencies involved provide the services that children, young people and their families need to live safe, happy and healthy lives.

“These include safeguarding partners working closely with Sunderland’s Commissioner for Children’s Services and a radical rethink by the City Council of the way it delivers services for children which will see it setting up an independent company to deliver these on its behalf.

“Although there are still many improvements to make I am pleased to see that Ofsted have noted  progress is being made in their first monitoring visit to Sunderland since the inspection and that services appear to be heading in the right direction.”

By Emily