Today, Cambridgeshire and Peterborough Safeguarding Children Partnership will publish a Child Safeguarding Practice Review into the death of a young lady called Nadia who tragically took her own life in 2019, when she was 16 years of age. Our deepest sympathy continues to be extended to the family and friends of Nadia.
Nadia was a child who experienced bereavement, sexual assault and difficult family relationships. She spent the last 12 months of her life as an inpatient in mental health establishments and during this time there was a powerful sense that Nadia felt she had no place to call home. This review examines Nadia’s life story, and the services that were provided, from the age of 12 until she sadly died.
The purpose of the CSPR was to learn from Nadia’s experience of the multi-agency service that she received and determine what changes needed to be made to improve how children are safeguarded.
Within the course of the CSPR there were examples of highly committed practitioners who showed care and compassion and did their very best to provide Nadia with what she needed. It is almost inevitable that any case that is the subject of a CSPR will identify a need to improve service provision. This review does not conclude that, had these things been in place, Nadia would be with us today.
As part of the review process, we had the opportunity to speak with Nadia’s family. We recognise that this will have been extremely difficult for them and we extend our gratitude to all that shared their stories and experiences of Nadia and helped ensure her voice was heard through the report.
Nadia’s mother and father’s view was that it would be important to Nadia for her real name to be used in the report. Father said: Nadia wanted to be a social worker, she wanted to help other children. Publishing this report in her real name honours her wish to help others.
The involvement of multiple agencies in the lives of Nadia and her family has been detailed and appraised within the CSPR. Recommendations based on the review findings have been made for agencies and work has already begun to address the recommendations.
The partnership remains deeply committed to ensuring that agencies make the changes needed to take forward the learning from this Child Safeguarding Practice Review and Nadia’s tragic death.
Notes for editors:
Cambridgeshire & Peterborough Safeguarding Partnership – 3 statutory partners
Working Together to Safeguard Children 2018 confirms that the three statutory safeguarding partners in relation to a local authority area are defined in the Children and Social Work Act 2017 as
- Local Authority
- Integrated Care System
- Chief Officer of Police
The three statutory partners have a shared and equal duty to make arrangements to work together to safeguard and promote the welfare of all children in a local area.
The Executive Safeguarding Partnership Board is made up of senior directors from the three statutory partners and other agencies and is the overarching countywide governance board for both the children’s safeguarding agenda and adults safeguarding agenda. The Executive Safeguarding Partnership Board is a high level, strategic board that has a primary focus on safeguarding systems performance and resourcing. This Board has the statutory accountability for safeguarding in both local authority areas. In addition, the three statutory partners are responsible for the governance of the Child Safeguarding Practice Review process.
Sitting below the Executive Safeguarding Partnership Boards are a series of Boards and sub groups.
What is a Child Safeguarding Practice Review?
A Child Safeguarding Practice Review, formerly known as Serious Case Reviews looks at how local professionals and organisations worked together to safeguard the child or young person at the centre of the review.
The review considers what was done, what lessons can be learned for the future and what changes may need to be made. It is not a criminal investigation or public enquiry and its aim is not to blame but to learn.
Why are you carrying out a CSPR?
Regulations state that Safeguarding Partnership Boards must carry out a CSPR when a child dies (including death by suspected suicide) and abuse or neglect may be a factor.
What is the purpose of a CSPR?
The purpose of CSPRs is to establish what lessons are to be learned about the way in which professionals and organisations worked together to safeguard and promote the welfare of children.
What it is not
CSPR’s are NOT inquiries into how a child died or was seriously injured, OR who is to blame. That is for the coroner and criminal court. CSPR’s are not part of disciplinary procedures relating to an individual. If information comes to light which indicates action should be taken, this is for the relevant agency to consider.
What happens with the recommendations from a CSPR
Once a case review has been signed off at the Safeguarding Children Partnership Board the recommendations are actioned to the relevant agency/ board/ government department for them to complete the recommendation. It is the responsibility of the relevant agency/ board/ government department to progress and complete the recommendations. Oversight of completion of the actions is undertaken through the Child Safeguarding Practice sub group. This group is chaired by an independent person who does not have any links with local agencies.