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Learning briefing: Jan

The Incident

Jan, a young child, was involved in a critical incident where they sustained serious injuries and were airlifted to hospital. Their parent was subsequently arrested, and the child was subject to an Interim Care Order and, following discharge from hospital, was placed in foster care with supervised contact with their parents.

The Background

Jan and their family are non-British nationals who arrived in the UK several years ago. Jan briefly attended a local primary school before the school were informed that the family were moving back to their country of birth. Authorities from that country alerted Devon County Council to concerns about their welfare; domestic abuse, parental alcohol misuse and child abduction. A S47 Investigation was completed. Jan later enrolled into another school.

Missed Opportunities – Health and Social Care

  • A timely response from Childrens Social Care (CSC) following concerns raised by the authorities, and a robust Social Care Single Assessment would have identified Jan as a child in need of services.
  • The Child Protection Medical did not alert the school nurse to the concerns by copying them into the report.
  • Missing information within health records in relation to Jan’s school and delay in allocating an NHS number, impacted on their visibility to health colleagues and appropriate information being readily shared across health services.

Missed Opportunities – Schools

  • Errors in the school admission and leavers process impacted on the wider education system being aware of Jan and being alerted to their subsequent removal from school roll. The school had minimal face to face contact with the family, limiting their ability to assess the quality of their relationship. Jan took sporadic days off school. This pattern was not identified and there was no involvement from the Educational Welfare Officer. It was disclosed to the school that a parent had recent issues with alcohol. This was not considered as a concern and passed onto the Safeguarding Lead.

Next Steps

  • CSC will develop a protocol for managing information received from out of county/international agencies who are concerned about a child’s welfare.
  • Schools to ensure that they complete appropriate paperwork when children join and leave schools.
  • Public Health Nursing Service will improve the process for assigning NHS numbers to children.
  • Staff working with children need to consider the impact of the risks and protective factors that exist for them.
  • Staff to notice patterns of attendance or issues in order to understand a child’s lived experiences. Chronologies should be routinely used.
  • Children should be spoken to alone and with an interpreter (where required) during all assessments.
  • Professionals to talk to families about their heritage and focus on the universal needs of children.


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.