Serious Case Review After Child's Death

After a four-month old baby from Wokingham died from cot death after moving to Reading last year - a report says authorities in BOTH towns can learn lessons from what happened.

Wokingham and Reading children's services say they've already made improvements - after a serious case review criticised the way they made referrals and shared information.

Heart's been given these statements from the two councils.

Reading Borough Council :

"In March 2009 a child known to children's services in Wokingham moved to Reading and was referred to Reading children's services. Unfortunately, the child died in April 2009. Any child's death is an appalling tragedy for the parents, and our deepest sympathies are with them and their wider families.

The Coroner's inquest found that this was a case of sudden infant death syndrome - which is known as cot death. However, regulations required the Reading Local Safeguarding Board to carry out a serious case review to see if any lessons could be learnt.

While attaching no responsibility for the death to Reading Borough Council, the serious case review found that there were a number of failings in the support this family received from us at the time. Reading Borough Council and its partners had already taken action on all the recommendations made in the Serious Case Review to remedy these.

These include:

-- revision and improvement of the arrangements for transferring cases from other local authorities to Reading
-- simplification and acceleration of referral routes for other agencies involved in safeguarding and family support
It is important to note that an Unannounced Inspection carried out by Ofsted in August 2009 commented on the speed and effectiveness of the remedial changes implemented and on the improvements in the service over the past year.

We continue to work closely with Reading LSCB to ensure that the interface between children's services across Reading are working effectively."

Wokingham Borough Council:

Andy Couldrick, general manager children’s services, said: 

“The sudden and sad death of four-month old Child A in April 2009 was distressing for everyone involved and I would like to express my sincere condolences to Child A’s parents and their families.

“At the inquest, the Coroner recorded the death of Child A as sudden infant death syndrome – which is known as cot death.  However, regulations required Reading’s Local Safeguarding Board to carry out a serious case review to see if any lessons could be learnt. Wokingham services contributed to the review.

“An independent review of the involvement of all the agencies that came into contact with the family has taken place. While attaching no responsibility for the death to Wokingham Borough Council, a number of shortcomings in services we provided have been highlighted and we accept the recommendations from the independent report, all of which we have already incorporated into our extensive programme of improvements in children’s services. Everyone at the borough council is committed to the continual improvements of safeguarding children within the Wokingham Borough.

“With regard to the recommendations specific to Wokingham Borough Council, we have created strong and clear management structures in children’s services and improvements are already being noted by the Government Office for the South East (GOSE) in respect of recording, planning, decision-making and progressing social care plans.

“In addition, last July the council set up a single referral and assessment team which ensures there is a high level of consistency in services, easier access and seamless communication between the council, partner organisations, children and their families.  Now, over 88 per cent of initial assessments of children referred for services are completed within seven days, which is a vast improvement on last year, and above the target agreed with Government.

“It is clear from the report how essential it is that information is shared between organisations in order that everyone understands where children are likely to be at risk. We are working hard with our partners to improve the quality of the work between agencies to help protect our most vulnerable children and young people.  Not only are we seeing children and young people quicker, we have also improved the quality of our assessments.

“We have come a long way since the death of Child A some 14 months ago but there is still more to be done but we are moving in the right direction. Recent reviews by the Improvement and Development Agency and GOSE show that the enormous amount of hard work by the council has accelerated improvements and this will ensure we are well placed to sustain and improve services further.”


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