Independent investigation: Shaun O’Neill, Modbury (2013)

All services engaged primarily with adults to develop practice tools that will assist staff to identify the risks that adults may pose to their children. All agencies working with adults must make their own assessment of risk to children and should not rely on whether or not the child is known to Children’s Social Care as the basis for this assessment.

Where there is a risk of further illness in the parent that is likely to have an effect on the child/children, a multi-agency meeting should be called. The purpose of this meeting is to jointly assess the potential impact on the child/children and agree a contingency plan should protective factors be removed. The plan must be communicated to other agencies that may have contact with the family.

GP practices need to find ways to receive and respond to indicators of risk to children, including incidents of domestic violence. A nominated Senior person within every GP practice is to ensure that there is a recognised and effective system within their practice to flag up incidents (including domestic violence) and fulfil their safeguarding responsibilities.

A process should be commissioned to enable GP practices to receive police 121A’s.

The findings from this Serious Case Review relating to the MASH should be referred to the current MASH review/MASH Board.

An appropriate representative from all agencies who are signed up to the MARAC operating protocol should ensure regular and effective attendance at all MARAC meetings. Alongside the assessment of risk to the adult victim, the risk to children should be specifically considered in every case. The chair of the MARAC is responsible for ensuring that risks to children are thoroughly considered.

The DSCB will receive an annual report from MARAC with specific reference to the identification of risk to children and the appropriate referral of children to the MASH in incidents where the risk meet the threshold for social care intervention.