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June 2017: SCR Child A

Learning & Improvement Report: Child A SCR and Child A Serious Case Review Final Report

Published June 2017

The report was commissioned by Brighton & Hove Local Safeguarding Children Board following the tragic death of 17 year old, A, whose body was found on a railway track in early 2016. At the point of publication of this report the Coroner’s Inquest has been initiated and is currently adjourned awaiting further evidence. The review was written by an experienced Independent Author, Fergus Smith, and front line professionals who supported A participated in the review, as well as family members and A’s prospective foster carer. This review was conducted using a systems methodology, and the exploration of the services provided to A and his family over five and half years has identified effective systems and good professional practice, as well as examples of systemic weaknesses and areas for development.

The Independent Chairperson of the Brighton & Hove Local Safeguarding Children Board, Graham Bartlett, said

“The death of A was an absolute tragedy. Those the report author talked with spoke of A’s charm, good looks, sporting prowess and dry sense of humour.  We know that A had been in the council’s care since 2004, under a Care Order, and that he had very complex needs having been subjected to significant levels of physical and emotional abuse and neglect in the context of chronic domestic violence in his early childhood. A had experienced a number of unsuccessful attempts to be placed in foster families, such placements were not able to manage his troubled and troublesome behaviours, so, at the age of 12, A lived in residential therapeutic unit in a neighbouring county and remained there until his death. He benefited from good continuity of support from his social work resource officer and independent reviewing officer. However, this report highlights a number of differing perspectives between Brighton & Hove City Council, as the responsible commissioners, and the  residential therapeutic unit, as providers, and the polarised positions that existed between the two and the absence of negotiated consensus in a number of areas impacting A.

As well asking for assurance from organisations in Brighton & Hove about the changes they have made since the death of A, the role of the Local Safeguarding Children Board is to address multi-agency working; the relationship and cooperation between services that should keep children safe, and to tackle areas where joint working could improve. The Brighton & Hove LSCB accept the Serious Case Review report in its entirety and our Case Review Subcommittee will monitor actions necessitated from this review with progress reported to the Board

Front line staff and managers can read our Professionals Briefing which summarises the key learning from the SCR: Child A – Learning Together from Case Reviews  and the LSCB will be holding two seminars in July 2017 to share the findings and discuss how professionals can implement any changes to improve practice. More information and details of how to book a place available here