This page lists the serious case review executive summaries, that have been published.
Statement from WFSCB independent chair, Laura Eades
On behalf of the Waltham Forest Safeguarding Children’s Board, I would like to express our deep regret and sadness for the death of Diamond.
The death of a child by force feeding is extremely rare. To our knowledge this case is the first of its kind in this country and we are determined to learn from the issues that were central to this tragic loss of life.
The Board has carried out a full serious case review of the practice of all of the professional agencies which came into contact with this family. The purpose of this review is not to determine guilt or blame, but instead to understand what can be learned to prevent any future harm.
The serious case review has found that there were weaknesses and shortcomings in the practice of some of the agencies involved with the family, but the panel and the independent authors of the report have concluded that the death of Diamond was not predictable.
Had best practice been followed, the risk to Diamond of force feeding would have been better recognised and the family would have been offered further support and intervention. This should have reduced the probability of Diamond being subject to behaviour that proved in this case to be fatal.
Our role is to make sure that children are better protected in future. As a result of this review, action is being taken on the areas where practice has been identified as needing improvement. We are also taking steps to ensure that there is better information nationally available about this rare risk to children.
Tragedies like this remind us all of the crucial role we have in ensuring the safety and wellbeing of the children we come into contact with. This case highlights the complexity of work to protect children in this country and the need for constant vigilance.
Serious case review - Child W - October 2011
- Serious Case Review - Executive Summary - Child W (121KB PDF file)
Serious case review - Child Z - March 2010
- Serious Case Review - Executive Summary - Child Z (339KB PDF file)
Serious case review - Child JK - September 2007
A guide to serious case reviews for staff and managers
The death or serious injury of a child is a distressing event for everyone. When this then leads to inquiries being made about the work of staff who were providing services to the child and family it can lead to staff feeling very anxious.
That is why it is important that all staff involved in the process of a serious case review (SCR) into the death or serious injury of a child understand why the review is happening, what it expects to achieve, what it involves, what is expected of them and what is the time frame.
The purpose of the guide to serious case reviews for staff and managers (47KB PDF file) is to go some way to alleviating these concerns.
