Monmouthshire’s Local Safeguarding Children Board has completed a Serious Case Review into the death of “Child A” in Monmouthshire on 20th November 2010. Welsh Assembly guidance requires Safeguarding Boards to undertake a Serious Case Review when a child dies or is seriously injured and abuse or neglect is proven or suspected.
The purpose the review is to establish if any lessons can be learned from what has occurred, what the lessons are and how they can be actioned to ensure, as far as possible, that a similar tragedy does not happen again.
The Overview Report concludes that “Child A”’s death could not have been predicted or prevented. Within the various contacts that the respective agencies had with the family prior to the tragic events of the early hours of the 20th November 2010, there was never evidence to indicate or imply that “A” was a child who was at risk of harm. In the light of this conclusion the Overview report makes no recommendations.
The report has also noted that there are some areas of practice learning that have come out of this process. But they have no bearing on “A”’s death. The organisations involved have produced action plans to address the issues raised. These are being implemented and will be monitored by the Board.
Simon Burch, Chair of the Safeguarding Board, said:
“This has been a tragic case and our thoughts are with the family and the rest of the local community at this difficult time. The independent report is clear that these events could not have been predicted or prevented by any of the services involved. Nonetheless, as Chair of the LSCB my focus has been on ensuring that any lessons, however small, are learnt and that the family’s voice has been heard during the review. We published the report as soon as possible after the end of the court case so that the family can begin to move on.”
