Summaries of key themes emerging from the 2019 Triennial Analysis of Serious Case Reviews 2014-17, presenting messages for the police. The presentation include links to related Research in Practice resources which will be useful for learning and development activities based on the findings of this report

1. 2019 Triennial Analysis of Serious
Case Reviews
Messages for Police Professionals
1

2. Workshop objectives
› Review main learning from the report in four
key areas:
− Neglect and its relationship to poverty
− Opportunities to intervene
− Vulnerability of adolescents
− Multi-agency working
› Identify implications for the police and
criminal justice system.
› Support staff to develop their knowledge,
skills and practice to keep children and young
people safe.
› See https://seriouscasereviews.rip.org.uk/
for further information.
2

3. Key themes
› Findings based on:
− Quantitative analysis of 368 SCRs notified to DfE 2014-2017
− Detailed analysis of 278 SCR reports that were available for review
− Qualitative analysis of a sample of 63 SCR reports
› Complexity and challenge: complexity of the lives of children and
their families, and challenges faced by practitioners seeking to
support them.
› Service landscape: challenges of working with limited resources,
high caseloads, high levels of staff turnover and fragmented services.
› Poverty: the impact of poverty, which created additional complexity,
stress and anxiety in families.
› Child protection: once a child is known to be in need of protection
the system generally works well.
3

4. Neglect and its relationship to poverty
› Neglect featured in 75% of all
SCRs examined. It is the most
common category of abuse for
children on child protection
plans.
› Poverty leads to additional
complexity, stress and anxiety
and can heighten the risk of
neglect.
› Most children living in poverty
do not experience neglect.
› However the co-existence of
poverty and neglect can
escalate adverse outcomes.
› Pathways to serious harm
through neglect include:
− Severe deprivational
neglect
− Medical neglect
− Accidents
− Physical abuse
− Suicides and self harm
− Vulnerable adolescents
harmed through (i) risk
taking behaviour (ii)
exploitation
− Sudden unexplained death
in infancy (SUDI)
4

5. Adverse family circumstances in
cases of neglect
5
Table 1: Parental and family adversity in SCRs where neglect
was a feature (Rates are likely to be an underestimate as they
depend on whether a factor was recorded in the SCR report; in some
cases the question may not have been asked, in others the SCR
author may not have felt the factor was relevant.)

6. Learning points
› Links between domestic violence, substance misuse and
poverty are complex and often inter-dependent.
› Ensure adequate training for frontline staff on recognising and
responding to signs of vulnerability.
› Frontline officers need to be conscious of the intense shame
and stigma experienced by people living in poverty and
maintain humane practice to entering family homes.
› To describe issues effectively, use clear, straightforward
language that is respectful but does not dilute the severity of
the circumstances.
› Acknowledgement and understanding of cumulative harm and
risk should be embedded in all responses.
6

7. Opportunities to intervene
› Use professional curiosity in every interaction to recognise
when action needs to be taken:
− Understanding and responding to neglect is a partnership
requirement and not just the responsibility of children’s social care.
− The voice of the child/young person should inform effective
responses, and lived experiences should be accurately reflected
avoiding professional jargon.
− Cultural beliefs and expectations can impact on the care and
wellbeing of a child and should be considered and investigated
respectfully.
− Information from relatives, friends and communities can be
invaluable in keeping children safe.
− Adolescents may be considered to be ‘putting themselves at risk’
but this may be because they are vulnerable due to neglect.
7

8. Learning points
› Reflective Supervision should be used to challenge unconscious bias
and assumptions.
› Discussing potential hypotheses and considering vulnerabilities,
uncertainties and potential harms can reduce bias.
› Be conscientious about recording actions.
› Follow up any concerns raised by members of the community and
triangulate this with other sources of evidence.
› Understand the perspective of the child and speak to them on their
own where possible.
8

9. Vulnerable adolescents
› One in three SCRs involved
children aged 11 and over.
› Increased potential for extra-
familial risk and harm during
adolescence – virtual and local
communities were a source of
significant risk.
› Most common causes of serious
harm were (i) risk-taking/violent
behaviour by the young person,
and (ii) child sexual exploitation.
› Young people were often not in
school, going missing and seeking
a sense of belonging outside their
family.
Threats outside home include:
› Going missing
› Criminal exploitation eg,
moving drugs (county lines),
violence, gangs, trafficking
› Child sexual exploitation
(CSE)
› Harmful sexual behaviour
(HSB)
› Radicalisation
› Social media and technology
assisted harm
9

10. Complex and Contextual Safeguarding
(Firmin et al, 2019)
10
› Complex Safeguarding
− This encompasses a range of
safeguarding issues related to
criminal activity involving
vulnerable children or
adolescents, where there is
exploitation and/or a clear or
implied safeguarding concern.
− Includes child criminal
exploitation, county lines,
modern slavery including
trafficking and child sexual
exploitation (CSE).
› Contextual Safeguarding
− This is an approach to
safeguarding children and young
people which responds to their
experience of harm outside the
home – for example, online, in
parks or at school.
− It provides a framework for local
areas to develop an approach that
engages with the extra-familial
dynamics of risk in adolescence.

11. Learning Points
› Police training should cover Contextual and Complex Safeguarding
and have knowledge of criminal activity hotspots in local areas.
› It is important to recognise the relationship between adolescents’
prior experiences and their risk of harm.
› Officers need to be alert to the fact that boys may find it difficult to
disclose CSE.
› Behaviours associated with criminal exploitation should be understood
primarily as indications of vulnerability rather than criminality. There
should be a therapeutic/safeguarding response as well as a criminal
justice response.
› There needs to be:
− clear internal safeguarding processes that are understood by all staff
− adequate training for staff to recognise and respond to vulnerability of all
types
11

12. Multi-agency working
› Police investigations sometimes ‘run in parallel’ with other
agencies’ efforts to protect children, rather than being seen
as an integral part of the process.
› In cases of neglect police often take a ‘back seat role’ if
there are no immediate risks to the child or there was no
criminal investigation.
› Silo working is an ongoing problem within and between
agencies, especially for the police.
› The move away from specialist child protection investigation
teams has had a knock on effect on safeguarding work.
12

13. Learning points
› Police officers should be involved at all stages of an investigation
(including strategy discussions) and have a solid understanding of
their role in sharing information.
› Low-level concerns should be recorded as these help to build a
picture of the child's life.
› Information on previous relationships or offences in other force areas
should be checked and shared with partner agencies.
› Achieving Best Evidence interviews should be a joint agency activity.
› Partnership working should be collaborative and open to ‘professional
challenge’.
› Senior leaders need to:
− ensure staff have the capacity, skills and confidence to be active participants
in strategy discussions
− review their team structures and operations to ensure safeguarding and
investigative processes are child-focused, clear and unambiguous
13

14. Reflective questions – frontline staff
› Do I understand my role and the powers
available to me to safeguard children?
› Do I understand pathways for multi-agency
working, including how to escalate concerns
about practice or decision making in my
area?
› Am I confident in understanding how to share
information in a language that describes the
risks, vulnerability and wider lived
experiences of a child?
14

15. Reflective questions – senior leaders
› Is my workforce equipped and resourced to respond effectively
to safeguarding concerns?
› Is my force/department fostering a culture of learning and
innovation e.g. learning from poor practice, using technological
advances to improve safeguarding?
15

16. Further reading
› Brandon M, Sidebotham P, et al (2019) Complexity
and Challenge: A Triennial Review of Serious Case
Reviews 2014-2017. London: Department for
Education.
› Allnock D (2019) Learning from reviews of death or
serious injury as a result of child abuse or neglect. A
briefing paper. Norfolk: National Police Chiefs
Council, Vulnerability Knowledge and Practice
Programme.
› College of Policing. ‘Authorised Professional Practice,
Major Investigation and Public Protection’.
› Firmin C, Horan J, Holmes D and Hopper G (2019)
Safeguarding during adolescence – the relationship
between Contextual Safeguarding, Complex
Safeguarding and Transitional Safeguarding.
Dartington: Research in Practice.
16

17. Contact details
17
www.rip.org.uk
ask@rip.org.uk
@researchIP