Keywords: child sexual exploitation, Childline, online grooming, sex offenders> Read the overview report, Death by suicide of a 17-year-old boy in January 2016. Learning includes: need for staff to fully understand the behaviours and presentation that is indicative of sexual abuse; need for staff to understand the factors that have an impact on disclosure; need for professionals and sectors to enhance their confidence and build opportunities to hear the voice of children and young people; importance of professional curiosity and for professionals to respectfully challenge each other.Recommendations: review single agency training on child sexual abuse to ensure sufficient focus on the key indicators and disclosure process; provide clarity on the use of professional meetings as a tool in dealing with difficult and complex cases, highlighting the opportunity they provide for multi-agency reflection.Keywords: child sexual abuse, foster care, disclosure, professional curiosity> Read the overview report, Death of a 5-year-old boy in June 2018. Both parents were homeless and living in separate hostels throughout the pregnancy although Baby J's mother moved to her parents after the birth. - Physical abuse (20%) - Emotional abuse (9%) - Sexual abuse (3%) Senior abuse & neglect. PB went missing several times, returning to FC2 although this was not always reported. Registered charity number 216401. Alex’s health deteriorated from age 6 and hospital admissions increased due to CF. There was evidence that the mother had experienced domestic abuse, coercion and control which continued with a partner who became Alex’s stepfather. A common assessment framework (CAF) and a Child in Need assessment were completed.Learning: keeping the focus on the child at risk when dealing with resistant parents or assessing parental capacity; critical thinking skills are necessary when assessing families with complex dysfunction; remaining attuned to the presence of unknown men.Recommendations: all children assessed as medium to high risk through self-harm or suicide are referred directly to CSC to coordinate multi-agency working.Keywords: alcohol misuse, parenting capacity, self-harm, suicide> Read the overview report, Non-accidental injuries to 6-week-old Child J, sustained on at least two separate occasions. His first long-term foster carer (FC1) requested that the placement be ended, citing ill health. consider opportunities to ensure disguised compliance and focus on children to be examined regularly in staff supervision meetings; develop and implement guidance relating to looked after children who sustain injuries; consider options for ensuring continued and meaningful engagement of GP services throughout safeguarding processes; consider how non-statutory voluntary organisations can be identified and included in safeguarding processes; consider requiring the local authority to complete and share the outcome of an analysis of children placed at home, the circumstances and decisions which led to placements being initiated and how compliance is monitored, to ensure the safety of all children who are subject to home placement agreements. 5 referrals were made to Children’s Social Care, the last 8 days before Nolan’s injuries.Key issues: lack of curiosity about late booked pregnancy; no recognition of the impact of prematurity, unexpected home birth and illness on the parents’ ability to cope and implications of any rejection of help; challenges to parenting capacity should be communicated; the need to follow up referrals with checks and a visit.Recommendations: make the reporting of bruising to non-mobile babies mandatory; ask member agencies to report on how they ensure the role of fathers and wider family members in the household are properly assessed; ask the police to review its internal handover processes; the LSCB should demonstrate the essential value of professional curiosity.Methodology: follows a systems-based methodology which maximised staff involvement and kept the depth of the inquiry proportionate to the complexity of the case.Keywords: infant deaths, non-accidental head injuries, non-attendance, parenting capacity> Read the overview report, Review of the responses of agencies between 1 January 2012 and 31 January 2014 to a young girl who was found to have contracted two sexually transmitted infections whilst in local authority foster care. VIDEO: Toddler died after physical, sexual abuse in 'horrific' case, police say Risk assessments need to be continually updated as circumstances change. Although there were concerns about his emotional wellbeing at home and school in December 2015, a referral to children’s social care was not made.Learning: the challenge for professionals working with families where members have a range of complex needs; need for coordination in provision of services across local authority boundaries; specific practice issues were found which highlight the dilemmas faced by front-line practitioners when exercising professional judgement in their safeguarding practice.Recommendations: to strengthen the sharing of information to ensure a whole family approach when working with children in blended families; to re-launch the CAMHS pathways within the borough; for the London Safeguarding Children Board to work with organisations across London to mitigate the risk to children where there is a lack of clarity associated with localised commissioning arrangements; partner agencies should be asked that contracts with service providers include an expectation that they should fully participate in any serious case review process.Keywords: child deaths, child mental health services, disguised compliance, emotional disorders, parents with a mental health problem, self harm> Read the overview report, Death of a baby girl under 2 months old of white British/Pakistan origin, in October 2015 as a result of fatal injuries received after falling from her car seat. Horrifying record of child sex abuse in Amish communities with more than 50 cases in seven states as victims tell of being shunned or sent to 'mental health' facilities if they complained . Cause of death was not ascertained but there were concerns she had died while co-sleeping with her mother and maternal grandmother who were both believed to have been under the influence of alcohol.Key issues: Child B and her siblings were on a child protection plan under the category of neglect. Help for adults concerned about a child Mother’s partner was convicted of causing grievous bodily harm and was imprisoned. Learning: GPs should take a coordinating role when a child is attending a variety of clinics and hospitals for treatment; practitioners should be wary of relying solely on information provided by parents and ensure that the child's views are sought and listened to; practitioners should be alert to signs of disguised compliance by parents; practitioners need to maintain professional curiosity in cases where concerns emerge over a period of time.Recommendations: request a review of the national Child Protection Procedures regarding FII; share learning from this review with NHS England; request that the Department for Education updates guidance on safeguarding and FII.Keywords: fabricated or induced illness, disguised compliance, general practitioners, professional curiosity> Read the overview report, Death of a teenage girl in spring 2015, by suicide.Learning: the need for a coordinated approach to children and young people who self-harm; sufficiently robust safeguarding responses to self-harm and suicide ideation in teenagers; assessment as a dynamic process that should be updated as circumstances change; guidance around exclusion and vulnerable pupils in school.Recommendations: to launch a campaign to raise awareness of self-harm and suicide ideation in children and young people; that agencies and CAMHS have sufficient tools, education and knowledge to assess risk and implement risk management plans for children and young people who self-harm; to ensure that the TAF/CAF model that supports early help for children is provided for families whose needs do not reach the threshold for statutory services; the LSCB should be assured that NHS England has informed all pharmacies in NHS England regarding selling of medication (Nytol) to children; to review processes for communicating available help to bereaved parents and their families.Keywords: suicide, depression in childhood, exclusion from school, listening, self-harm, sibling relations> Read the overview report, Sexual abuse of a 15-year-old adolescent by her older brother in 2015. 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