Historic review of Oxfordshire child admitted to hospital with severe weight loss

Review results in more effective across-agency working

Oxfordshire Safeguarding Children Board (OSCB) has today published the findings of its historic serious case review – into ‘Child K’, an Oxfordshire child admitted to hospital with severe weight loss in 2016.

Overall, the serious case review found that no professional had responsibility for understanding the child’s needs as a whole.

Derek Benson, Independent Chair of the Oxfordshire Safeguarding Children Board (OSCB), described the events as “serious”, emphasising that “lessons have been learnt and recommendations acted on, ensuring more effective across-agency working.”

The purpose of the review was to identify recommendations to improve safeguarding practice across all agencies. The recommendations for improvement relate to health agencies, public health commissioners, NHS England, and Oxfordshire County Council’s children’s social care services.

Child K was admitted hospital in 2016 weighing 37kg with a BMI (body mass index) of 13.7.

The medical assessment given was that without health services’ intervention there would have been a significant risk to the child’s life.

Child K was known to have been electively home educated from a young age and to have had contact with health services. Following their admission to hospital, home conditions were found to be extremely poor with no hot water or heating.

As a result of the seriousness of Child K’s condition and concerns about the way in which professionals had worked together, the chair of Oxfordshire Safeguarding Children Board decided that the case met the criteria for a serious case review.

Publication of the final review and report was delayed whilst Thames Valley Police investigated circumstances surrounding the case. Due to parallel family court proceedings, it was three years before criminal enquiries concluded and a decision taken by the CPS that no charges should be brought.

Derek Benson, Independent Chair of the Oxfordshire Safeguarding Children Board (OSCB), said:

“This historic case, from 2016, was serious and we did not wish to delay consideration of lessons learnt whilst the police investigation was taking place. We therefore produced a detailed interim report with recommendations, agreed by Oxfordshire Safeguarding Children Board in 2018.

“The recommendations have been accepted and acted upon by all the organisations involved, ensuring more effective across-agency working is now in place.”

The steps taken as a result of the recommendations include:

  • Training is included in all health care updates so that safeguarding concerns of children with health and/or disability needs are identified and communicated to relevant health professionals.
  • A system to notify GPs that a child is being electively home educated is now in place and being used.
  • All electively home educating families are now sent information regarding support available from health professionals, in particular support from school health nurses. There is information regarding immunisations, vision screening and contact details for all the teams.
  • Information about the legislation and guidance underpinning the regulation of elective home education has been disseminated to all professionals working with children. It reminds them that they may be the only professional seeing the child and any safeguarding concerns should be referred to MASH in the usual way.
  • The constipation and urinary continence pathway has been re-designed with all referrals going via a central hub.
  • An audit of strategy meetings for children in hospital across all teams has been undertaken and all appropriate actions have been implemented.

Notes to editors:

  • The child is referred to as ‘Child K’ in the review to preserve their anonymity.
  • Oxfordshire Safeguarding Children Board is made up of the statutory services responsible for children in Oxfordshire, including key safeguarding partners of the county council, the NHS OCCG and Thames Valley Police.
  • Future serious case reviews will be referred to as safeguarding practice reviews.