Last updated: 04.01.16

'Toxic trio' cases require a multi-agency approach

A serious case review by the Bracknell Forest Local Safeguarding Children Board claims that safeguarding cases involving the 'toxic trio' of domestic abuse, mental ill-health and substance misuse require a multi-agency approach.

The board came to this decision after examining a case where a two-month-old baby, known as Child C, suffered child abuse in 2013.

Research revealed that various agencies involved with Child C?s family did not work together effectively, leading to individual services making decisions without a full picture of the family's history and situation.

Children's social care over-relied on information from health professionals, the review claimed, who believed there were no concerns, despite being aware of the wider family context.

In May 2012, when children?s social care reviewed the family's child in need plan and decided to close the case, it made the decision in error, without input from health professionals who held relevant information.

The report claims the case demonstrates that over-reliance on the opinion of health organisations or on children's social care alone is to be avoided, and all agencies must bring their own expertise to these difficult decisions.

Although the review did find many instances of 'highly effective inter-agency working' when information was shared, the response of the agencies involved was found to be sometimes lacking.

Police, children's social care and health visitors were aware of the incident, yet there is no evidence that the emotional impact of C's sibling witnessing domestic abuse was considered,? the review said.

Further to this, the review also stated that there was no evidence that any agency involved was minded to challenge that lack of action.

In response, Bracknell Forest has proposed to risk assess cases when deciding who carried out core assessments.

Other changes will also include training social workers on the importance of family history, holding regular case file audits and creating regular opportunities for cases to be discussed with adult social care.