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Learning from serious case reviews: What can early years settings do?

Here we look at some recent serious case reviews and the relevant learning that can be taken for early years professionals.

Siblings W and X — Early experiences of racism may have contributed to radicalisation

The first serious case review about radicalisation was recently published. Siblings, W and X, were two brothers who died in Syria in 2014 aged 18 and 17 years old. They had had previous involvement with the local authority before leaving the U.K. but professionals had not identified that the brothers were at risk of radicalisation or at risk of fighting overseas.

An older sibling had travelled to Turkey to deliver aid, a few months before it became known W and X had left the UK. The children went to Syria with a friend to join an elder sibling. The review highlighted the unresolved trauma the siblings had experienced and the subsequent ineffective agency response.

The review also noted that early experiences of racism in nursery and primary schools may have led to children becoming alienated, which in turn led them to have low personal self-esteem and as a consequence they became more vulnerable to searching for ways to feel better about themselves through other means. 

Community members expressed concern that schools were not able to protect Muslim children sufficiently from racism and that there was not awareness of hate incidents in schools.

The full report can be accessed through Brighton and Hove LSCB.


BS (2016) — Nursery didn't question child's black eye or properly record injuries

Child BS was a two years and one month old girl who died in hospital due to multiple injuries. Her mother’s new partner was subsequently sentenced to nine years imprisonment. Her mother had been in a relationship with her new partner for approximately five months. The child was found to have extensive bruising on the body, a laceration to the liver and a severe brain injury.

The review highlighted:

  • Known information about domestic violence was not shared with the nursery (although reported by police to children’s services and health).
  • Nursery accepted without pursuing further or taking any action maternal grandmother’s explanation that she did not know how the child had sustained the black eye she presented with at nursery (eight days before the child was hospitalized).
  • Nursery failed to accurately describe and record the face injury the child presented at nursery with one day prior to being hospitalized, meaning it could not be ascertained whether the injuries the child presented with at hospital were the same as those the nursery had seen. The nursery proprietor recalled the child having an injury to her face that was green/yellow. 

The record maintained by the nursery in relation to the injuries was very limited, no record made for the size or location of the injury and no explanation given for it.

The review highlighted that the nursery’s “injuries in” book system, implied an inherent weakness in recognising the potential for children to be harmed by their caregivers.

The review recommended that the local early years service lead a review and develop common guidance and supporting documentation to be made available to local nursery providers in respect of Safeguarding.

Read more about this case review


Child T — Nursery did not follow up on erratic behaviour and sporadic attendance

The review regarding Child T, a girl, who died, aged 4 years and one month criticised:                                                               

  • A “loose approach to assessing parenting capacity”.
  • Practitioners had not searched for evidence to refute allegations before dismissing their validity.
  •  A local tendency for high threshold cases to be managed under child in need procedures (as opposed to being managed under child protection procedures).
  • “Step down” arrangements for ceasing social work involvement hadn’t been sufficiently informed by up to date assessment and multi-agency input.
  • Areas of risk not fully assessed.
  • Core assessment unfinished due to social worker sickness.

Child T’s bruised body was found in the home of her mother’s new partner, one week after moving in with him. The child had been repeatedly exposed to and ingested heroin, methadone, ketamine and various benzodiazepines over a period of at least 6 months prior to her death.

There was a history of substance misuse, and there had been previous serious domestic abuse from father to mother. Agencies were unaware that mother was in a new relationship with a new partner and had recently moved in with him.  Mother had had a previous child initially removed, then permanently removed four months before child T was born. 

Child T’s nursery had reported that the child appeared well presented but was sometimes withdrawn and unkind to other children and her attendance was sporadic. Child T did not come back to nursery after the summer school holidays, and died one week after she was expected back at nursery.

The review suggested that early years childcare providers should be alert to the safeguarding issues raised by sporadic attendance and patterns of poor pre-school attendance should trigger a response from early intervention services.

Patterns of chaotic parenting and disguised compliance begin in early childhood and have long lasting consequences on children’s life chances.

The full report can be accessed through North East Lincolnshire LSCB website.


Learning for early years professionals

  • Ensure staff are able to ask sufficiently curious and probing questions and not just take things at face value, whether that is asking about the cause of an injury to a child attending early years provision, a possible indication of domestic abuse, or whether a new partner has moved in or become involved in childcare.
  • Ensure absence management procedures identify and respond to unexpected absences quickly. Be aware that ongoing absence may be a safeguarding issue and should trigger an appropriate response, which may be early help.
  • Help staff recognise and understand how to respond to disguised compliance.
  • Ensure staff feel confident about how to escalate any concerns that adequate action isn’t being taken to safeguard children and how to challenge in the event there is disagreement with another organisation or professional, such as a social work assessment not being completed within timescale.
  • Ensure that staff are confident about sharing information.
  • Ensure systems for responding to and recording to presenting child injuries are robust.
  • Ensure childcare provision is welcoming to all and staff can identify and respond to any instances of racism and bullying.
  • Remember the existence of “Claire’s law” (the Domestic Abuse Offender Disclosure Scheme)- this was designed to protect potential victims of domestic abuse by allowing them to request information about their partner’s past, or that of a person of concern to them. Any parent thinking of starting a new relationship could go to the police and request that they are given relevant information about that person’s past. The police will consider the request, the risk and this will inform whether and what they disclose. Local police can give further information.

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