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Learning Briefing: Thematic review – Non-Accidental Injury to infants 0-2

1. Learning Journey: What did we do?

  • We reviewed the experiences of children who had suffered suspected Non-Accidental Injury (NAI) and the multi-agency partnership response to these cases of concerns.
  • We interviewed partnership senior leaders to explore their oversight and undertook table top audits with a lens on pre-birth assessments.
  • We undertook 2 sessions modelling the Appreciative Inquiry methodology where NAI was suspected. We conducted a survey of the partnership workforce.

2. What good practice did we find?

  • Assurances that vulnerable children who suffer injury receive the right help and that there is systemic “curiosity” when a concern is raised.
  • Professionals were generally confident in their knowledge of NAI through updated training.
  • Even within current Covid-19 risks these children were admitted to hospital to allow for follow-up investigation
  • Children continued to receive oversight through a variety of live and virtual interactions
  • Key frontline agencies in social care and health maintained face to face contact with vulnerable parents.
  • Children’s Centres increased and expanded their virtual offers alongside face to face.

3. What else did we find?

  • The authentic voice of fathers/significant males was missing in assessment processes.
  • The impact of developmental trauma on the lived experience of children today may not be fully understood and incorporated as a dynamic risk into assessments.
  • Professionals lack confidence in the case resolution protocol when trying to resolve disagreements about service thresholds.
  • The South West Child Protection Procedures resource is not used as the intended “go to” reference across all agencies.

4. What can we learn?

  • When undertaking assessments do we pay particular attention to the impact of domestic violence as a feature in parental family history and as a reality in their relationships now? How does this relate to parental capacity to change?
  • Hesitancy around escalating/using dispute resolution processes remains, particularly where there is a perceived challenge to “expertise” . How can we support practitioners to feel more confident in asking for resolution when there are professional disagreements?
  • How we record opinions can influence how others determine risk. E.g. a record of “no concerns” in one area could lead to an overly optimistic view of vulnerability within another? Does language in our recording demonstrate an understanding that risk is not fixed?
  • Consistency in pan-partnership training and information is needed to ensure temporary, new and long-standing practitioners in all settings receive correct and updated information.

5. What are the recommendations?

  • Task & Finish group to fully implement the ICON programme.
  • Exploration and collation of individual agency quality assurance activity that identifies emerging themes and patterns across the Partnership to enable future shared learning.
  • Views of biological fathers and males within the home should always be sought directly so that full assessments of involvement, support offered, additional vulnerability or risk can be made.
  • Issues concerning need for increased visibility of South West Child Protection Procedures to be progressed via the relevant partnership representative.
  • Referrers to MASH should routinely be provided with feedback on the status of their referral and details of a manager/clinician with whom any disagreement can be discussed with, particularly if there is no further action envisaged.
  • Ways to support practitioners to be confident and courageous when challenging other professionals need to be explored further.
  • Recognising the use of locum and temporary staff across the Partnership, explore how these staff access timely and relevant safeguarding training, and that any information provided is current.
  • Review the effectiveness of Multi Agency Impact Chronologies following training to partners in 2020 and the North Locality pilot 2020-2021.

6. What can you do?

  • Read and share the Review and briefing with colleagues and discuss the learning in team meetings, supervision and 1-2-1s.
  • Consider how to ensure men in families are always included in assessments. Might more flexible approaches be needed to enable their views to be heard? How can you reach out to them?
  • Reflect on your recording – is it objective and set within a clear moment-in-time framework?
  • Read the Case resolution protocol and ask for support from your line managers to use it.
  • Identify areas for your learning and improvement actions you can take.

If you are worried about the safety or wellbeing of a child or young person in Devon,
please complete the request for support online form.


If you think that the child is at risk of significant harm,
contact our Front Door directly by calling 0345 155 1071.


In an emergency call 999.