D was born on 7.10.03 the fourth child of his mother and the third child of her relationship with his father, the couple were separated at the time of D’s death. Their relationship was characterised by domestic violence with several of those incidents being referred to the Police and Social Services. At the time of D’s birth his father was bailed with a condition not to approach his mother, having been charged with a Section 47 assault against her. He met with his Probation Officer 14.10.03 and expressed concern about the welfare of the children and their mother’s capacity to care for them and that she may be depressed and drinking alcohol to excess during the evenings, this was referred to Social Services. Subsequent enquiries undertaken by Social Services resulted in a decision to close the referral on 27.10.03 On 5.11.03 the evening before D’s death his mother and the four children spent the evening at home and in the locality together mother’s friend. They watched fireworks in the garden and at a local pub then brought six cans of lager at an off license before returning home. On returning home the children were put to bed, two in their own beds, the oldest child in mother’s double bed. D was left wrapped up asleep in the living room while mother and her friend stood by the front door drinking lager and some sparkling wine. Sometime around midnight mother went to bed taking D upstairs with her. He did not settle in his Moses Basket so she took him into bed with herself and the oldest child, placing D on her chest. D did not apparently wake during the night to be fed. Sometime later mother awoke and found D lifeless next to her. She called an ambulance and D was taken to Hospital. Attempts to resuscitate him were unsuccessful and he was pronounced dead at 8.43 am. The Coroner was informed and on 7.11.03 a post-mortem examination was carried out. The inquest has yet to be held. Police Officers identified some empty cans of lager plus some other alcohol, together with “Prozac” medication in the house.
Merseyside Police commenced an investigation which, ultimately, resulted in a decision to take no further action this decision was made on 13/12/04. There has been some debate throughout the work of the review group about whether this case met the criteria for a Serious Case Review. When the Serious Review Group was established there was concern that D had ingested Diazepam which significantly influenced the decision. It was not until a later date that further testing showed that this was a false toxicology result. Other features of the case do not fulfil the criteria for a Serious Case Review and could have been reviewed with internal management reviews. 2.
• To review multi-agency involvement with D and his family, commencing
with initial Domestic Violence referral to the police.
• To complete an integrated factual chronology of agency contacts and
• To review agency management reports and any additional documentation,
and to assess whether actions taken have been congruent with individual agency procedures, ACPC procedures and best practice.
• To recommend appropriate actions in respect of any single or multi-
agency issues arising and including time scales for implementation of monitoring.
• To present the final report and recommendations to an independent
person for scrutiny and to the ACPC for endorsement.
3. Membership of ORG The Overview Review Group consisted of representatives of the following agencies. St Helens Social Services Department St Helens Primary Care Trust Merseyside Police St Helens Education and Leisure Services National Probation Service NSPCC 4. Background Information D’s mother was known to the police as a victim of Domestic Violence. This was also known to the school attended by her oldest child. She presented as seeming to care well for her children, she had experienced postnatal depression several
times in the past and had some involvement with psychiatric services but no indication of negative thoughts of harming the children. The GP had some knowledge of her alcohol usage but had no significant discussion with her about this matter. D’s mother was on antidepressant medication throughout the period covered by the chronology April 1999 to November 2003. D’s father was known to the police as an offender and for Domestic Violence incidents. He was subject to a Community Rehabilitation Order. The family’s contact with Health Services did not identify any concern other than some missed appointments. D’s brother attended nursery and school no concerns were identified about him. Staff did however note concerns for his mother around Domestic Violence issues and offered support. In Jan 2003 the NSPCC project received a Health Visitor referral requesting support in helping D’s mother apply strategies to help her cope with the children’s behaviour. She was visited by workers but failed to engage with the service despite several attempts to visit. Social Services received information about Domestic Violence incidents, advice was given about available support, the case was then closed on each occasion. 5. Agency Involvement Compliance with child health monitoring was reduced with the birth of each child. Health records make no reference to issues of domestic violence or alcohol until 23.10.04. The Health Visitor at the time of D’s death had not identified any concerns regarding alcohol. There is no record that she was made aware of any domestic violence concerns The involvement of NSPCC January – March 2003 was unsuccessful as D’s mother did not engage with the services offered. No contact was made by the project with the school or any other professionals because the difficulties in engaging meant that the usual assessment process for the referral did not take place. The voluntary nature of the project meant that contact with other agencies would not be made without the consent of the service user unless child protection issues were involved, and her consent was not obtained. There was a lack of recorded information on the file about identified concerns. Education staff had no concerns regarding the oldest child’s safety or welfare during this period and they maintained good levels of monitoring in relation to his progress and well-being. At the time of D’s death his father was subject to a Community Rehabilitation Order. During a routine appointment with his probation officer he discussed his concerns about D’s mother’s use of alcohol and her capacity to care for D and the other children. His Probation Officer referred the concerns expressed by D’s father; there was liaison with other agencies after which Social Services closed the case. There
was an expectation that further monitoring would be carried out by the Health Visitor who had a visit planned. The Police attended incidents of domestic violence on seven occasions between May 2001 and February 2003; five of the incidents were also referred to Social Services. The officer attending the scene of the violent domestic incident on 25.3.02 did not take positive action in line with the Merseyside Police Policy on Domestic Violence. There was evidence of an assault and an arrest should have been made. Information was not passed to the Police family Support Unit about breach of bail conditions. The Social Services casework file contained information about four of the five domestic violence incident referrals noted on Police records but not about the incident on 25.3.02 which was clearly an incident of significant concern. This was later traced elsewhere in the Social Services filing system. However, it had not been collated with the main family casework records. Given this it is difficult to identify the extent to which the information was considered in context at the time. Following the referral on 14.10.03 the case was allocated appropriately for screening. However there was a delay in this process due to internal issues of staffing and capacity. There was a failed attempt to contact the GP and the records do not contain an exploration of the possible effects of depression and prescribed medication and concerns about alcohol use. No checks were made with the relevant school. There was a lack of clarity about the monitoring arrangements made with Social Worker and Health Visitor D’s mother was not made aware at any stage of the referral by any professional. Key information was not shared concerning all the instances of Domestic Violence. The Police failed to share a significant incident. The NSPCC did not record concerns about Domestic Violence so this did not form part of the assessment. Social Services did not share information about Domestic Violence with the health Visitor on 23.10.03 when requesting information and support for the family and health records make no reference to issues of domestic violence or alcohol until 23.10.04. There was a lack of clarity between Health, SSD and NSPCC about the levels of concern and information sharing was based was based only on verbal communication. Within Social Services there were resource issues. The management of the Assessment Team was under pressure due to holiday cover, the two managers were unable to pass information directly to one another and made assumptions about work having been completed as instructed. There was also only one senior practitioner post 6.
There were no breaches of the ACPC Child Protection Procedures
The sharing of information by the Probation Service was appropriate and complied with local and national guidance.
In their respective reports, where relevant, agency internal management reviews have identified recommendations which are endorsed by the Overview Review Group. The Overview Review Group has made the following recommendations: - 1
Professionals need to ensure they pass information on in a way that is
clearly understood. A clear record should be made. 2
When there are concerns about a child all professionals known to be
involved with the family should be consulted. The concerns about the child and family should be shared in full. 3
Where there is an expectation that monitoring is appropriate this will be
explicitly agreed between the agencies, including identifying what is meant by monitoring and how feedback should be managed. The agreement should be recorded and confirmed in writing by each professional. 4
Professionals should not underestimate the effects of Domestic Violence.
Procedures for decisions about when to conduct a Serious Case Review
should be reviewed. 9.
Professionals were offering support to the family and although there were some communication difficulties this did not significantly affect any outcomes. No cause of death has been defined for D. The inquest has yet to take place but no action is planned against any individual including his mother. The review was started a year ago and has been delayed due the unavoidable long-term absence of the Chairperson of the Overview Review Group. During this year there have been changes in practice which address some of the issues raised in the report.
DIREITO PROCESSUAL PENAL PROF. LUIZ FLÁVIO GOMES AULAS 1 E 2 (GABARITO ABAIXO – CONFIRA) 1) Assinale a alternativa incorreta : a) Segundo clássica lição de v.Liszt/Schmidt o ius puniendi possui três momentos: a) direito de ameaçar com penas; b) direito de impor tais penas e c) direito de executá-las. b) O princípio do devido processo legal tem duas acepções, uma delas cons
COMPLETE PRICE LIST FOR GENEKAM PRODUCTS 2014 Ready to use PCR Kits (conventional PCR; gel agarose based) BACTERIA & PARASITES NAME OF PRODUCT REACTIONS Borrelia burgdorferi CE Brucel a abortus CE Brucel a genus (incl. 2 genesequencings) Campylobacter genus (incl. 2 genesequencings) Clostridium genus (incl. 2 genesequencings) Clostridium perfringens ε (epsilon)