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Greg Williams has 25 years' experience as a social work manager. For 12 years he has been principal officer for strategic child protection arrangements in Staffordshire, including co-ordinating the work of the area child protection committee. He chairs the West Midlands Regional Safeguarding Children Network.   

The old order changes, and area child protection committees are beckoned towards new horizons in the Children Bill. But any enthusiasm for change in children's services should be tempered by a recognition of past achievements. Lord Laming graphically exposed deficits in organisational systems in the Victoria Climbie inquiry, but he may also have inadvertently conferred a disproportionate share of blame on area child protection committees (ACPCs).

Few would deny the benefits that a statutorily reinforced mandate will bring to local child welfare networks. But before local safeguarding children's boards (the successors to ACPCs) throw the baby out with the bathwater, they would do well to remind themselves of ACPCs' positive influences upon modern practice.

Staffordshire ACPC is one of many that can readily identify modest achievements. One of those achievements, not least in terms of deploying staff time, is the priority it gives to conducting serious case reviews. There is a paradox in placing cases that have arguably gone wrong upon a pedestal of achievement, but closer inspection reveals much more telling messages about better-informed practice in safeguarding children's welfare.

Like Victoria Climbie herself, children and families who exceptionally experience tragic episodes are not necessarily those who have attracted concerns shared routinely on an inter-agency basis. They are not children for whom episodes of serious harm have been necessarily regarded as predictable, save for the chilling wisdom of hindsight (1).

The 1991 edition of  Working Together introduced the Part 8 review into the vocabulary of child welfare organisations. The 1999 edition of Working Together to Safeguard Children appreciably expanded the criteria in serious case reviews.

Between 1993 and 2003, Staffordshire ACPC carried out 30 Part 8 reviews. These took account of the deaths of 23 children, including two sibling groups of three, and of life-threatening injuries to 14 others.

The main purpose of the reviews is to examine how agencies worked together and to identify lessons about operational practice. Detailed analysis often reveals previously unknown features of a family's circumstances.

Some themes, such as shortfalls in information-sharing and certain pre-disposing risk factors, inevitably recur. Where domestic violence and substance misuse co-exist, the risk to vulnerable children becomes acute.

These factors only become evident under the searching scrutiny of a case review. Only three of the 37 children had their names on the child protection register at the time of the critical episode that triggered the review.

But less prominent trends were also part of Staffordshire's experience. Thirteen of the 23 children who died were under three months old and so were clearly not cases in which a pattern of maltreatment had emerged over time. As a consequence these cases led to more effective collaboration between local antenatal services, with hospital-based social work services being seen as a key player within local antenatal arrangements.

Concealment of pregnancy also featured prominently, prompting a harmonisation of collaboration between a range of professional disciplines.

If concealment represents one aspect of risk during pregnancy, the advent of a multiple birth may be another. Four of the reviews featured multiple births, well above the incidence of 15 per 10,000 live births nationally. Factors associated with multiple birth - premature birth, neonatal complications and consequent difficulties in bonding - generally coincide with episodes of maltreatment rather than any expressed increase in stress from having to meet the demands of more than one infant (2).

There are compelling messages here about vulnerable children and their families needing timely access to help and support. Pre-disposing stress remains an enduring trigger to those spontaneous episodes in which young children sustain serious harm.


A feature of the cases in question were serious head injuries sustained by very young children, often accompanied by consistent denials by those believed responsible. While the medical profession remains divided on the aetiology of shaken baby syndrome, Staffordshire ACPC is clear about the prospects of an inconsolably crying child suffering the traumatic effects of a serious shaking injury. It has sought to increase awareness among clinicians about aspects of diagnosis, including the association of hypothermia with serious brain injury in young children.

As this ACPCembarks upon its 31st serious case review, it remains confident about the priority it gives to this aspect of its work. It is not just a matter of reflecting upon how things might have been. By revealing the harsh realities of child maltreatment, serious case reviews can help identify more creative ways to support vulnerable children, their families and professional staff in facing these challenges. There is much still to be done. Preparing care leavers for the challenges of parenthood may be a typical example of a legitimate target that is yet to be fully realised.

But the prospects are good. Let us hope that some of the ACPCs' past achievements might be fulfilled in the new order.

PRE-DISPOSING RISK FACTORS:

• Domestic violence identified in 60 per cent of cases reviewed.
• Adult mental health problems identified in 40 per cent of cases.
• Strong correlation between adult mental health problems and substance addiction.

CRITERIA FOR SERIOUS CASE REVIEW:

• Child death (including suicide) when abuse is a known or suspected factor.
• Child suffering potentially life-threatening injury through abuse or neglect.
• Serious sexual abuse or sustained serious and permanent impairment of health or development.
• Particular emphasis where circumstances give rise to concerns about ways in which agencies have worked together.
• Particular consideration given to children suffering harm arising from specific organisational contexts.

OTHER CHARACTERISTICS:

• Six children died on day of their birth.
• Seven other children died before the age of three months.
• Significant number of parents were looked after as children.
• Four cases involved multiple births. 

ABSTRACT:

This overview of 30 serious case reviews in Staffordshire provides an insight into some of the challenges facing professionals in child protection. There are familiar trends, such as domestic violence, and recurring case examples of serious head injuries in young infants, but also less obvious factors, such as multiple births, which warrant closer inspection of how effectively agencies work together.

REFERENCES:

(1) R Sinclair, R Bullock, Learning from Past Experience: A Review of Serious Case Reviews, Department of Health, 2002 .

(2)  J C Becker and colleagues, "Shaken Baby Syndrome: Report on Four Sets of Twins," Child Abuse and Neglect, Vol 22, No 9, 1998.

CONTACT THE AUTHOR:

e-mail: greg.williams@ staffordshire.gov.uk