Norfolk Serious Case Review published today

5th August 2020

A serious case review into the death of a Norfolk child has recommended multi-agency work to look at the guidance around the safe use of stairgates.
(scroll down to access the report)

Child AH died in April 2019 after becoming trapped between two stairgates at his home. The stairgates had been stacked two high to prevent children in the family from climbing over them.

Chris Robson, Chairman of the Norfolk Safeguarding Children’s Partnership, said: “This was a tragic accident and the thoughts of the whole partnership are with AH’s family and friends.

“AH’s mother was seeking to protect him by installing these gates and there is no doubt that she loved her children very much.

“The review recommends multi-agency work to review the published risks of using stairgates so that parents and carers know when and how to use them safely. However, despite the absolute tragedy of AH’s death, I would not want to deter anyone from installing a gate to stop small children from accessing the stairs. Used in the right circumstances, there is no doubt that stairgates save lives.”

The then Norfolk Safeguarding Children Board commissioned the review into AH’s death last year to look at how agencies worked together and identify any learning that could lead to improvements in safeguarding practice.

The report has been published today by the Norfolk Safeguarding Children Partnership, which is made up of all of the agencies in Norfolk that work collectively to protect children and young people.

The family first started receiving support in 2012, when the health visitor reported that the home was cluttered. Support was provided by the then Children’s Centre and continued for several years. In addition, the family received an enhanced level of support from the Healthy Child Programme from 2013 until 2018.

Some of the children had additional needs which included, speech and language difficulties, attention deficit hyperactivity disorder, dyslexia, general learning difficulties, autism and developmental delay and one had a genetic condition that can cause a wide range of health difficulties. Their mother came to live in England in her teens and had little contact with her extended family.

The last contact into the Children’s Advice and Duty Service was made shortly before the incident leading to the child’s death. A referral into Early Help services was accepted on 26 March, just days before the tragic accident.

The review found some areas of good practice, including consistent support by health visitor and family support workers, which enabled good relationships. Considerable efforts were also made to support the children’s development and meet their health and education needs and additional practical help with the children was given.

The report also made six recommendations to the partnership including promoting family network training to all frontline professionals. It said that training should also highlight learning from this review, such as assessing the family’s cultural background; issues of isolation linked to depression and the possibility of coercive and controlling relationships. It also said that in cases of neglect, children’s wishes and feelings needed to be evidenced and that young carers’ services should be further promoted across the partnership.

Chris Robson added: “It is clear that the professionals working with AH were able to build a good relationship with his mum and offer a range of support to her. AH’s mum also wanted to work with those who were there to help and wanted to do her best for her children.

“We are grateful to AH’s mum, dad and sibling for their support with this review and their valuable contribution, in what remains a difficult time for the family.

“There are always things we can learn from any tragedy and, in this case, more could have been done to look at the wider family network and to explore the role of the oldest sibling as a young carer. As a partnership we welcome the recommendations of the review, which will help us to further improve practice across the partnership.”

The full report is available here.

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