Index Number:
No. 2.02
Document:
Case File Audit Summary
Approved by:
NSCB 2014-15
Latest Review Date: March 2016
Description:
Report and action plan from multiagency practice audits
CASE REVIEW SUB COMMITTEE
Summary of Case File Audits 2014
To update the Board of the outcome of case file audits undertaken in 2014 by
the Case Review Group
Inform the Board how learning from audits link to that of other reviews
including of
SCR.
Purpose
Report:
Background
The Case Review Sub-Committee is responsible for undertaking multi- agency case
file audits, and in 2014, 5 such audits were undertaken.
A sub panel of the Case Review Group, met on 17.02.15 to collate and review the
findings and learning resulting from the five audits. The table below demonstrates the
learning from individual cases and the report concludes with the thematic learning
from all five.
Case
1.
Summary
4 children 6-18
yrs
Adult step sister
CP plan in place
for 3 years
Issues identified
a) Chronic,
pervasive neglect.
and
Maternal
mental
health
issues
b) Poor
understanding of
mothers partner’s
role in family
c) Young person’s
mental
health
/suicidal ideation
d) Use of PLO in
management of
case
e) Information
sharing
GP not involved in
process
f) Lack of focus on
children’s needs
Action/Outcome
Plan made to undertake a
deep dive audit, however this
was not possible due to
capacity issues.
Actions taken:
a) Neglect strategy now in
place, ongoing training
and awareness raising
b) Echoes Eve review;
Learning
and
Development
committee
taking
assessment of fathers
work forward
c) Echoes Matthew IMR;
self harm pathway in
place
and
training
delivered
d) PLO panel to be
developed to ensure
against case drift and
appropriate use of PLO.
e) Alert/reminder sent to
all
GP’s
regarding
information sharing in
Dec
2014
Audits
underway to review the
contribution of GP’s to
ICPC’s and
review
conferences
f) Learning events related
to
IMR’s
included
training on maintaining
a focus on the children
and will be repeated
annually, to ensure
learning
from
ALL
reviews including audit
is taken forward
2
3
4
2 children aged 3
and 4 yrs
Live with mother
and transient
father
4 children
between 1 and 9
years.
Live with mother
and transient
partner (father of
youngest
children)
2 children aged 3
and 11 years
Live with mother.
Father
had
recently resumed
contact
with
family
a) Domestic violence
b) Neglect
c) Severity
of
violence: risks not
well recognised
d) Focus on mothers
needs
e) Lack of focus on
children
f) Poor information
sharing. GP not
involved
in
process
a) Domestic violence
b) Alcohol and drug
abuse
c) Chronic neglect
and
emotional
abuse
d) Lack of focus on
children
a) Domestic violence
b) Alcohol misuse
c) Child had been
injured
in
DV
incident
d) GP
did
not
contribute
to
process
e) ICPC stood down
and
strategy
meeting held.
f) Child in need plan
in place
a) Immediate
action:
referral to MAPPA and
MARAC process for
perpetrator and victims
b) See above
c) See case 1.
d) See case 1
e) See case 1
f) See Case 1
a) Following the audit the
case transferred into the
legal process to safeguard
the children by legal orders
The above actions from
cases I and 2, apply to all
issues identified.
a)–d) Above actions apply
d) ICPC stood down but
strategy meeting held and
comprehensive
and
detailed signs of safety
assessment undertaken.
Good evaluation of risks
and
danger statement
agreed.
Father had moved out and
mother took legal action
(non-molestation order) to
prevent further contact
Child in need plan was
robust and appropriate
5
2 children aged 2
and 3 years
Three
older
siblings removed
from family due to
neglect
Live with mother
and
transient
father
a) Neglect
b) Alcohol and drug
misuse
c) Domestic violence
d) Developmental
delay in one child
e) Avoidable injuries
to both children
f) Disclosure in past
that Dad hit one
of the children
g) Managed under
PLO with no CP
plan in place: very
unusual
to
manage case in
this way.
h) Did
other
professionals
contribute
to
decisions under
PLO and how was
progress
monitored
by
multi-agency
partners
i) PLO remained in
place for several
months
a)
Following
audit
applications
for
legal
orders pursued in respect
of both children
b)
PLO
panel
in
development (see case 1)
Learning
and
actions
above apply to all other
issues identified.
Thematic learning from case file audit.

Pervasive and corrosive impact of chronic neglect: professionals have in some
cases underestimated the impact of neglect on the child.

Lack of focus on the child, and attention redirected towards parent’s needs.

Poor information sharing, this was apparent in all of the cases, particularly, in
relation to the absence of primary care information in the assessment and
decision making process

Domestic violence, substance misuse and parental mental health issues:
professionals did not always appreciate the toxic nature of these issues,
especially in combination, on the wellbeing and safety of the child

Use of PLO did not have the desired effect of moving the case forward and
effecting change. These had been allowed to drift.

There was, in some cases, a focus on compliance with the tasks of the plan,
rather than on outcomes for the children

Poor assessment of fathers / father figures/partners and their role within the
family.
Actions related to thematic learning
NSCB will commission “sand stories” training as part of NSCB annual training
programme, this explores engaging with hostile families and focusing on all the
children in the family.
The neglect strategy has been developed and is being implemented
Domestic violence has been a focus of GP single agency training in 2014
NSCB has arranged a conference on working with substance misuse in families in
February 2015
Learning events will be arranged in relation to the Eve report and the lessons from
these audits will be included in those events
A PLO panel is in development, to oversee and review the use of PLO letter before
proceedings, to ensure they are appropriate and to prevent drift in such cases.
The assessment of fathers, has emerged from these and other reviews, particularly
Eve, and the learning and development group have been requested to address the
training needs of staff with regard to this.
GP contribution to safeguarding children: GP safeguarding toolkit developed and
distributed, and template for report writing introduced. The Named GP is undertaking
an audit of GP submissions of reports to conference.
Good practice
Case 4 is an example of the effective use of the signs of safety model in a strategy
meeting, providing a comprehensive picture of the risks and protective factors for the
children, and producing danger statement and robust child in need plan.
Linda Lincoln
18.02.15