A serious case review (SCR) has been conducted by the Stoke-on-Trent local safeguarding children boards (LSCB), following the death of an unnamed child who died in the winter of 2010, following a "life-threatening event". The child had been the subject of a child protection plan.  

The overview report highlighted various areas of concern. These included:  

  • insufficient detail in record keeping;
  • professionals not always following accepted policies and procedures; and
  • poor inter-agency communication.

It was however noted that that there was no conclusive evidence that the tragedy could have been avoided. The message appears to be how possible gaps in this instance might be filled in future cases, where a difference might be made for a child and their family.

A topical recommendation from the review was that consideration should be given to the possibility of creating a single multi-agency service for children and families. Readers will recall our summary of the Lord Laming report and the contents of Professor Munro's interim report, which also endorse a multi agency approach. This topic will be addressed in our child health seminar in the autumn, which readers are welcome to attend.

Good record keeping and ensuring that appropriate child protection colleagues are kept up to date in relation to the circumstances of vulnerable children and families remain key issues.