To be supported by a PowerPoint Presentation

The Head of Children’s Social Care introduced a report, that provided Committee with information in respect of the most recent Child Practice Review from Bridgend.

Following this introduction, the Group Manager, Safeguarding and Quality Assurance then gave a power point Presentation for the benefit of Members, that covered the following key areas of the covering report.

In 2013, Child Practice Reviews replaced what were known as Serious Case Reviews (SCR).   This new process stems from the Care and Social Services Inspectorate Wales report published in October 2009 - Improving Practice to Protect Children in Wales: An Examination of the Role of SeriousCase Reviews. This work was pivotal to where we are today, and concluded that action was required to replace the SCR process which had become ineffective in improving practice and inter-agency working.

The guidance sets out arrangements for multi-agency Child Practice Reviews when a significant incident has occurred where abuse or neglect of a child is known or suspected.

The overall purpose of reform of the review system is to promote a positive culture of multi-agency child protection learning and reviewing in local areas.  The Regional Safeguarding Children’s Board is responsible for ensuring that reviews are carried out effectively. Future reviews concerning any Bridgend children will come under the Cwm Taff Morgannwg Children’s Safeguarding Board.

Concise Reviews: a ‘concise’ Child Practice Review is carried out in cases where abuse or neglect of a child is known or suspected and the child has:-

•  died; or

•  sustained potentially life threatening injury; or

• sustained serious and permanent impairment of health or development; and 

   the child was neither on the child protection register nor a looked after

   child on any date during the 6 months preceding –

•  the date of the event referred to above.

Extended Reviews: an ‘extended’ Child Practice Review is carried out in cases where abuse or neglect of a child is known or suspected and the child has:-

•  died; or

•  sustained potentially life threatening injury; or

•  sustained serious and permanent impairment of health or development; and

   the child was on the child protection register and/or was a looked after

   child (including a care leaver under the age of 18) on any date during the

   6 months preceding –

•  the date of the event referred to

She further explained that on 17 April 2019 Bridgend County Borough Council published a Child Practice Review.  The review commenced January 2018 and was commissioned by the Western Bay Safeguarding Children’s Board following the identification of concerns where the above criteria for a ‘concise review’ was met. This review relates to a 9 week old child who died during the night whilst co sleeping with his parents.

The subject of this review was a 9 week old child who died in November 2017 whilst co-sleeping with his parents. Following an inconclusive post-mortem examination and a coroner’s inquest concluding an open verdict, the death was viewed as a result of Sudden Infant Death Syndrome (S.I.D.S)  

Between 2008 and 2017 there were 10 referrals received in respect of the child’s mother who was under 18 years of age at the time of the child’s birth due to family instability, homelessness, substance misuse and mental health issues.  The review highlighted that significant information in respect to these issues was not shared between professionals particularly between health professionals.

There were 9 historical referrals received in respect of the child’s father when he was a child. The father was also “Looked After” for short periods due to his mother’s poor mental health and domestic abuse within the family.

Whilst there was nothing to suggest the infant’s death could have been prevented, there was evidence within the timeframe that the young family may have benefited from a pre-birth assessment and targeted support services.

At the time of the infant’s death, the young family were living in private rented accommodation and, their family support structure was unclear. They were not receiving any local authority intervention and home conditions were noted to have deteriorated.

The Group Manager, Safeguarding and Quality Assurance confirmed that the themes highlighted from the review were:-

·               The GP did not share relevant information around the mother’s mental health with health colleagues and the extent of family support available to the parents was also not adequately explored.

·               The mother was not assessed in her own right as a child and the assessment of the child did not consider the wider risk factors about the parent’s experiences e.g. parental domestic abuse, mental health, lack of family support.

·               There was no specific risk assessment undertaken to consider the above matters.

·               Referrals were dealt with in insolation and focused on housing being the dominant factor.

·               There was no report to the Police by agencies about the mother having under age sex.

The implementation of actions recommended within the report will be reported into both the Cwm Taf and the Western Bay Child Practice Review Management group. In addition BCBC will convene team based learning events for practitioners and the findings will also be incorporated into core safeguarding training for employees.

A Member made the point that improved lines of communication between partners may prevent situations such as the above arising.

The Corporate Director – Social Services and Wellbeing and the Leader in turn, advised that key partners were working closely and that improved engagement had taken place between key stakeholders particularly since the different agencies had installed the WCCIS IT System. This had led to a marked improvement to methods of information being shared between organisations who work together to look after the most vulnerable in society, such as the young and elderly, including those who have experienced problems in their lives.

RESOLVED:                      That the Cabinet Committee noted the report and accompanying presentation.