It’s funny how the little things often get in the way of the big picture. It’s like the little puzzles you used to play as a child, where you needed to move tiles on a grid into a certain order, so you could reveal the image. The problem was, the tiles would only move around one at a time. So it could take an age before you could see what all the tiles showed together.
Our programme of work supported by the Department for Education – Information Sharing to Protect Vulnerable Children and Families – looks at the issue of missing the big picture in the context of Serious Case Reviews, which are carried out in cases where a child has died, or has been seriously harmed.
Quite often, all the ‘tiles’ of information about the vulnerable child in question, and their family or peers, are already on the grid. The child’s GP would have noted child protection concerns on their system. The school might have more than one piece of the puzzle, following disclosures from a parent. There is likely to be another tile sitting on the Police’s database, following an anti-social behaviour call-out – perhaps even a domestic abuse flag.
To understand the real risk to that child, the GP needed to share their notes with the child’s Health Visitor, who had a similar concern on a recent visit to the family’s home, but in this instance had accepted the parents’ plausible explanation for a small bruise. The child’s teacher had become worried about her sudden change in behaviour, but due to a breakdown in communication with the Council’s Child Social Care department, this tile wasn’t pushed into the right position either. And the Police did carry out an assessment of the risk of domestic abuse in the household, but downgraded it because the parents weren’t living together.
One way or another, because of cultural or organisational barriers to critical information being shared about that child, no-one saw what it all meant until it was too late to save that child.
But the story needn’t be repeated. Serious Case Reviews have an important role to play in helping local places to learn the lessons from these cases in order to prevent similar tragedies happening in future. This could mean strengthening the governance structures that enable ‘No Further Action’ decisions to be reviewed and challenged. Or improving supervision of front-line staff so that niggling concerns are chased up and triangulated with other agencies. Or it could mean more training and guidance on how to spot early signs of abuse and how to share that information appropriately.
So that in future, everyone involved in protecting vulnerable children and families will be able to see the bigger picture, and prevent these tragedies occurring.
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We have also recently started working with the Department of Health and the national Troubled Families team (based in the Department for Communities and Local Government) to look at how sharing health data can help improve outcomes for families and children. To read an introduction to this area of work please see my colleague Imogen’s blog.