Child E

Child E Serious Case Review


  • Divergence of professional views around care plan planning
  • Importance of explaining rationale for decision making
  • Concerns resolution process
  • Dynamic risk analysis of potential significant harm to children


Following a pre-birth assessment of his mother, Billy, at two weeks, became subject to an interim care order to Leeds City Council  (LCC) and was placed with foster carers. LCC undertook a twin track options assessment of adoption and/or placement with Billy’s biological father and partner. Regarding the latter option, only neglect had been identified as a possible risk factor. LCC, notwithstanding some concerns from other professionals, proposed to the Court that Billy be placed for a four week assessment with his father and partner under section 38(6) of the Children Act 1989. Three weeks into the placement it emerged that Billy had suffered serious and extensive non-accidental injury. He was removed by LCC from his father’s care. A police enquiry was undertaken which eventually resulted in the father receiving a non-custodial sentence.

Key learning and practice improvements

Use of the Rethink Formulation Planning Approach:

  • Consider using a ‘ Rethink Formulation’ approach to support  an effective restorative approach to multi-agency working and appropriate planning.
  • When appropriate use the reunification framework to include partner agencies and practitioners in safe parenting assessments and planning for reunification with families.  

Explaining Rationale for Decision Making:

  • Lead practitioner should explain the rationale for decision making, especially in care proceedings, to the rest of the inter-disciplinary team, ensuring everyone is aware, understands decision making and has opportunity to explore further if required.
  • Professionals should ensure that they understand the essentials of the Children Act 1989 and associated children’s law when involved in child care planning decisions.

Use of the LSCP Concerns Resolution Process:

  • Consider use of the concerns resolution process (see LSCP website) where there is professional disagreement about a case.
  • Don’t allow drift in relation to resolving concerns. If the process is delayed for any reason ensure the process is restarted as soon as reasonably possible.

Remember that risk is not static:

  • Think dynamic risk assessment: “The continuous process of identifying hazards, assessing risk, taking action to eliminate or reduce risk, monitoring and reviewing, in the rapidly changing circumstances of an operational incident.”
  • When circumstances change, risks change.
  • Think the unthinkable and consider it as part of assessment and planning.’ The Black Swan Event?’.

Your next steps

Share and discuss the identified good practice and learning points with colleagues, and ensure the following is embedded in your practice:

  1. Make sure you know about Rethink Formulation, when to use it and how to access Rethink Team support if needed.
  2. Explain the rationale for your decisions.
  3. When making decisions (especially involving care proceedings) make sure to involve the entire multi-agency team.
  4. Update your assessments when circumstances change.
  5. Know about the LSCP Concerns Resolution Process and how and when to initiate it.

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