Serious Case Review Report – Dylan Tiffin-Brown – Northamptonshire SCB

A Serious Case Review (SCR) is one of several reviews and audits undertaken within the learning and improvement framework established by a Local Safeguarding Children Board (LSCB). A review provides an opportunity to open a ‘window on the system’ especially at a multi-agency/service level.

Any learning, perhaps especially from a situation with the most tragic of outcomes, needs to continue to strengthen the development of the various strands of a ‘safety net’ (individual practice, its organisation and management, governance and quality assurance arrangements between and within each partner agency) comprising the response with, and for all children, young people and families.

Child Ak died in December 2017 just after his second birthday. Following a 999 call, ambulance crew conveyed Child Ak to the local General Hospital. Basic life support was undertaken throughout but sadly Child Ak died as a result of cardiac arrest. Child Ak was also found to have high levels of several drugs in his body and multiple injuries, bruises and other unexplained injuries of concern. Subsequently, his father was arrested, charged with and convicted of his murder.

The review concentrated in detail on a relatively brief period from 1st October 2017 – 31st December 2017.

• 1st October 2017 is the approximate time from which Child Ak’s parents, who lived separately, established informal care arrangements for Child Ak.
• The end date for the review included a period following Child Ak’s death, included to assist an understanding of initial steps taken to ensure that Child Ak’s siblings were safeguarded.

A panel was appointed to plan and manage the review comprising named and designated representatives from the local authority children’s services, appropriate health services, the police and the LSCB. The panel was chaired by Malcolm Ross and a lead review report author, Phil Heasman (a qualified social worker; previously a Principal Lecturer in Social Worker; an independent training, learning and development consultant) was appointed. Both the chair and report author are independent of the case under review and of the organisations involved. Individual agencies completed Internal Management Reviews (IMR reports) and a comprehensive integrated chronology was compiled from information provided by relevant agencies and services. An event was held for relevant practitioners to identify learning and encourage reflection on their involvement, to examine the actions and decisions taken and to understand their context.

1.5 For the purpose of the report, the child who is the primary focus will be known as Child Ak. The report refers additionally to other family members and other significant people identified by their relationship to Child Ak where possible, although in some places the relationship is described in terms of the link to Child Ak’s mother and father where this assists clarity.

Click here to read our news story or download the full report here.