Protecting Scotland's children and young people: it is still everyone's job

2. Background on Child Protection Structures in Scotland

Child Protection Committees

2.1. Child Protection Committees are not creations of statute. They were first established in Scotland across each local authority in 1991. Since then, they have been subject to reforms and review. The Scottish Executive's Child Protection Reform Programme (2003-2006) resulted in national guidance, Protecting Children and Young People: Child Protection Committees (2005). Child Protection Committees ( CPCs) are current strategic fora for local interagency child protection partnerships. They are locally-based, inter-agency strategic partnerships responsible for the design, development, publication, distribution, dissemination, implementation and evaluation of child protection policy and practice across the public, private and wider third sectors in their local authority locality and in partnership with all those working in child protection across Scotland. Their role, through their respective local structures and memberships, is to provide individual and collective leadership and direction for the management of child protection services within their local remit and to contribute to the provision of effective child protection across Scotland. They work in partnership and are accountable to their respective Chief Officers, comprising of Local Police Commanders and Chief Executives of Health Boards and Local Authorities, and the Scottish Government to take forward child protection policy and practice. Through this structure, they are democratically accountable to local elected members.

Child Protection Registers & Case Conferences

2.2. There is no legal requirement for the use of Child Protection Registers, Child Protection Case Conferences or Child Protection Plans in Scotland; however, these are all core components of the formal child protection processes outlined in the National Guidance for Child Protection in Scotland (Scottish Government, 2014).

2.3. When there is a concern that a child (including an unborn child) or young person is considered to be at risk of significant harm, an inter-agency Child Protection Case Conference is arranged by the relevant local authority social work department. The conference will be informed by an investigation of concern which is usually undertaken on a multi-agency basis. A Child Protection Case Conference involves a range of relevant professionals, family members and the child (if appropriate) and will consider whether a multi-agency Child Protection Plan and/or review of an existing Child's Plan is required to reduce the risk of significant harm to the child. A Lead Professional who is responsible for co-ordinating the work will be identified. The Case Conference will decide whether to place the child's name on a Child Protection Register or where there is a need for Compulsory Measures of Supervision in which case a referral to the Children's Reporter is required (if this has not already been done). In 2014-2015, just over 6000 Child Protection Case Conferences (excluding reviews) were held in Scotland; of these, 73% resulted in a child being placed on the Child Protection Register (Scottish Government, 2016a).

2.4. All local authorities are responsible for maintaining a central register for their authority area of all children - including unborn children - and young people who are the subject of an inter-agency Child Protection Plan. This is called a Child Protection Register. The register is an administrative tool designed to alert practitioners that there is sufficient professional concern about a child to have warranted an inter-agency Child Protection Plan being in place. A child and family are supported by a Core Group of those professionals who are involved in delivering the Child Protection Plan. The Core Group are critical in working directly with the child and family to reduce the risk of harm to that child. The Child Protection Plan will be reviewed at a subsequent multi-agency Case Conference for the professionals to consider evidence of any progress which has reduced the risk and to decide whether there is still a risk of significant harm requiring the child to remain on the Child Protection Register.

2.5. In 2015, around 3 in every 1000 children under 16 were on a Child Protection Register in Scotland; however, there is variation across Scottish local authorities in the rates of registration on the Child Protection Register (Scottish Government, 2016a). Children can be placed on a Child Protection Register before they are born; around 5% of registrations are for unborn children. Just over half of all children on Child Protection Registers are under the age of five (Scottish Government, 2016a).

2.6. Over the last fifteen years there has been an upward trend in Child Protection Registrations; between 2000 and 2015 there was a 34% increase in the number of children on a Child Protection Register (Scottish Government, 2016a). The most common concerns (and there can be multiple concerns with an average of 2.5 concerns per child) identified at Child Protection Case Conferences for children who were subsequently placed on the Child Protection Register were: emotional abuse (39%), neglect (37%) parental substance misuse (36%), domestic abuse (35%), non-engaging family (24%), parental mental health (23%), physical abuse (22%), and sexual abuse (9%). Around one in six children who are on a Child Protection Register had previously been on a Child Protection Register (Scottish Government, 2016a).

2.7. The Children's Hearings System is the legal system in Scotland which plays a key role in the care and protection of children where it is decided that compulsory measures are needed. Around 13,688 children were referred to the Children's Reporter on care and protection grounds in 2015/16; this equates to 1.5% of children and young people in Scotland under the age of 16 ( SCRA, 2016). Lack of parental care was the main reason for a care and protection referral (41%); followed by 1874 referrals due to a child being a victim of a Schedule One offence (14%) ( SCRA, 2016:9) (see Appendix E for a Glossary of terms). In an audit of Child Protection Orders between 1 ^st October and 31 ^st December 2013 conducted by the Scottish Children's Reporter Administration, just over a quarter of Child Protection Orders (27%) were for pre-birth children with the most common established ground being 'lack of parental care' (77%) and the majority of children were consequently looked after away from their birth parents (70%). (Henderson & Hanson, 2015).

Significant and Initial Case Reviews

2.8. A Significant Case Review ( SCR) is instigated when a child dies, or is discovered to have been exposed to or suffered significant harm and the Child Protection Committee considers that a Review is necessary because the undernoted circumstances apply.

2.9. When a child has died and the incident (or accumulation of incidents) gives rise to significant/serious concerns about professional and/or service involvement or lack of involvement, and one or more of the following apply:

• Abuse or neglect is known or suspected to be a factor in the child's death;
• The child is on, or has been on, the Child Protection Register or a sibling is or was on the Child Protection Register. This is regardless of whether or not abuse or neglect is known or suspected to be a factor in the child's death unless it is absolutely clear to the Child Protection Committee that the child having been on the Child Protection Register has no bearing on the case;
• The death is by suicide or accidental death;
• The death is by alleged murder, culpable homicide, reckless conduct, or act of violence;
• At the time of their death the child was looked after by, or was receiving aftercare or continuing care from, the local authority.

When a child has not died but has sustained significant harm or risk of significant harm as defined in the National Guidance for Child Protection in Scotland (Scottish Government, 2014), and in addition to this, the incident (or the accumulation of incidents) gives rise to serious concerns about professional and/or service involvement or lack of involvement, and the relevant Child Protection Committee determines that there may be learning to be gained through conducting a Significant Case Review (Scottish Government, 2015).

2.10. On behalf of the Chief Officers' Group, a Child Protection Committee is responsible for deciding whether a Significant Case Review is warranted and how the review will be undertaken (Scottish Government, 2015). An Initial Case Review ( ICR) is 'an opportunity for the Child Protection Committee to consider relevant information, determine the course of action and recommend whether a Significant Case Review or other response is required' (Scottish Government, 2015:9). Following an ICR, a decision to proceed to a Significant Case Review is taken when SCR criteria are met; where there is potential for significant corporate learning; and where a SCR is in the public interest and in the best interests of the child or young person and their families.

2.11. There can be a range of concurrent or sequential proceedings which occur when a child or young person dies or has experienced significant harm. These may include criminal proceedings, formal Inquiries, professional disciplinary procedures and local reviews. Neo-natal deaths are subject to a Sudden Unexpected Death in Infancy Review ( SUDI), where there is an unexplained death of a child under two years old. The circumstances and agency responsibilities in respect of all children who die while 'looked after' are reviewed by local authorities and the Scottish Government, and are the subject of a statutory report to Ministers.

2.12. Fatal Accident Inquiries ( FAIs) are inquiries conducted in public before a Sheriff when children die in custody or where the Crown Office and Procurator Fiscal decide an Inquiry is in the public interest. Between 2000 and 2015 there were 27 Fatal Accident Inquiries into the deaths of children and young people under eighteen years of age. Of these, four were concerned with deaths of five children or young people known to the authorities because of concerns around their safety as a result of parental behaviour or their own risk taking behaviour. In one case where the young person had committed suicide the Sheriff had no criticism of the professionals involved in the care of the young person. In two cases there had been criminal proceedings against adults in connection with the circumstances which led to the deaths occurring; in the first case a parent and in the second case against a person known to the young person who had supplied them with drugs which caused the death. In the latter case the Sheriff stated that the levels of care that the young person had received from health and social work professionals were of the highest level. In the other case the Sheriff determined that the death might have been avoided if the agencies involved had obtained all the pre and post birth information available across a number of organisations' records and there had been better communication between them allowing better assessment of risk to the child leading to different decisions being taken. In the FAI into the suicide of two children, the Sheriff determined that there were other actions which the professionals involved could have taken by which the deaths might have avoided, including the provision of all information and better communication.

2.13. In 2016, the Care Inspectorate published a triennial review of Significant Case Reviews in Scotland. Between 1 April 2012 and 31 March 2015, twenty Significant Case Reviews concerning twenty-three children and young people were submitted to the Care Inspectorate from fourteen Child Protection Committees (Care Inspectorate, 2016). The profile of children was very similar to the earlier Vincent and Petch study (2012) in relation to gender and age, with limited data on ethnicity, socio-economic circumstances and no recorded disability. Eleven children had died (five infants or pre-school and six young people aged 15-17 years old) and twelve children had been significantly harmed or were at risk of harm. The fatalities included drowning, physical injury, drug overdose, suicide, accident and sudden unexpected infant death. In over half of the cases, parental mental health was a factor, as was a similar rate for domestic abuse. Parental substance misuse was documented in over half of all SCRs and was a feature in all five cases involving the death of an infant or pre-school child. As with the findings of Vincent and Petch (2012), the vast majority of children (87%) had social work involvement; furthermore, three children were on the Child Protection Register and a further two children had their names recently removed from a Register (Care Inspectorate, 2016). The Care Inspectorate concluded that there is a need to improve the consistency and quality of Significant Case Reviews and confirmed that SCRs were not always clear on what needed to improve and how this would be monitored by Child Protection Committees (Care Inspectorate, 2016). There is currently no national data on the number of Initial Case Reviews conducted in Scotland or comparative audit.