Wolverhampton Safeguarding Children Board published the findings of a Serious Case Review into parental neglect on Monday 26th September 2016.


It centres on a case in which the children of a Wolverhampton couple were taken into care in 2014 after an emergency admission to hospital identified significant concerns regarding their supervision and care.

The father was jailed for two years for gross neglect following a subsequent child protection investigation. The mother has passed away.

A Serious Case Review (SCR) was commissioned last year by Wolverhampton Safeguarding Children Board to ascertain the involvement of agencies and determine what could be learned from the case.

The review was led by an independent chair, Donna Ohdedar, with the final report written by independent author Jane Scannell.

The final report makes a number of recommendations, the majority of which Wolverhampton Safeguarding Children Board has already implemented.

These recommendations include ensuring that professionals and agencies are aware of how and when cases should be escalated for more intensive intervention, and effective information sharing.

It also recommends reviewing training around neglect to ensure that it is sufficiently focused on identifying risk, ensuring systems are in place across all agencies to flag children and families of concern, and for professionals to ensure they focus on the whole family unit when they are working with children and parents.

In addition, the 14 agencies involved have identified a total of 60 actions which are being implemented.

Family E report

Alan Coe, Chair of Wolverhampton Safeguarding Children Board, said: “This was a difficult case for all concerned. Parents have a duty to care for, nurture, and love their children, and with this family that simply did not happen.

“The Safeguarding Children Board held this Serious Case Review to ask two questions – was there anything more the agencies involved could have done, and should they do things differently to potentially avoid something similar from happening in the future.

“The report found that there was a wide range of services and practitioners supporting the family, and many displayed considerable commitment to improve the care the children were receiving.

“Indeed, the case illustrates the complexity of the work of professionals working with vulnerable children and families which meant that, despite considerable effort of all concerned, the neglect the children were exposed to was not effectively addressed.

“The review process has identified how some of the systems and procedures which existed at the time were not effective.

“‘The report identified that although much help was offered, coordination was lacking. Had this been better it may have made a difference – but equally it could also have been the case that the parents’ resistance to help would have remained exactly the same.

“What we do know is that there was a lack of information sharing across the system, and that professionals did not consider the whole family unit and the impact that individuals were having on one another when they were working with the parents and children. This was an exceptionally large family group and the report tells us that professionals partly lost sight of the needs of individual children with the family group.

He added: “The agencies and particularly front-line professionals involved in this review have shown real commitment to examine their practice and identify ways to improve the support their offer to children in similar situations, and I am confident that the changes we have put in place will reduce the likelihood of a similar situation happening again in the future.

“But we are going further than that, and further than the recommendations contained in this report. The Board has commissioned a review of multi-agency practice in our current work with families to assure ourselves that the shortcomings identified in this case are not found in others.”

The agencies involved in the review were Wolverhampton Safeguarding Children Board, City of Wolverhampton Council, Wolverhampton Clinical Commissioning Group, the Royal Wolverhampton Hospitals Trust, Black Country Partnership NHS Trust, Recovery Near You, Spurgeons Young Carers and Base 25, the children’s schools and the family’s GPs.

The Serious Case Review utilised the Significant Incident Learning Process (SILP), a recommended model which involves front line staff and their managers in reviewing cases, focusing on why those involved acted in a certain why at the time.

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