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Training and resources for professionals

Appreciative Inquiry Report Following the death of T

This Appreciative Inquiry was carried out by DCI Ali Lander and Head of Service Daniel Crampton in February 2019.


T (born 2nd March 2003), aged almost 16, died of a drugs overdose on 3rd February 2019. A Rapid Review, completed 20th February 2019, noted that T’s life was characterised by early trauma and a cluster of adverse childhood experiences; domestic abuse, parental drug use and sexual abuse from a young age. T had been the subject of Child in Need plans, two periods of child protection planning and care proceedings which resulted in a Supervision Order. These did not sufficiently reduce risk/build protection over time. At the time of his death, T was subject to a Child in Need plan to Devon Children’s Services.

Professionals’ responses to T’s needs had features that we commonly see in serious case reviews; professionals’ assessment of seriousness, the quality and consistency of the formulation of interventions, consistent attention to history and the lived experience of the child.

Since the publication of the seminal Paul, Death through Neglect in 1995, there have been numerous serious case reviews, local and national, examining the challenges of working with neglect that is serious, chronic and global. The complexity of embedding the learning from reviews underpins the reforms enacted in Working Together 2018.

The DCFP decided to examine the conditions for learning to practice effectively with neglect, to explore the ways in which our current conditions are conducive to learning to practice effectively with neglect and the ways in which are they non-conducive. We hoped that this would give us insights to further build on strengths and grow better conditions while ameliorating or mitigating the conditions that are not conducive. The DCFP had been allocated DfE resource to develop an Appreciative Inquiry (AI) approach and decided to trial that methodology for this review. The DCFP elected to engage with three multi-agency groups, the staff and managers involved with T, staff and managers working on a neglect case that has the hallmarks of good practice and senior leaders responsible for practice in the locality. The hope was that this approach might enable a deeper, systemic understanding to emerge, leading to a more compelling mandate for learning and change.

Session 1: Focus on T

Overview of Session

A pen picture of T (including a photo) provided by his friends brought him into the room in a very powerful way. There were plenty of loving and warm descriptions of T shared by those who had known him; his humour, fierce loyalty and how good being in his company could be.

The group of participants was small which, alongside the approach of the AI facilitators, created an emotionally permissive space, which allowed participants to voice very difficult and deeply charged thoughts and feelings about T’s death and working together. This was a compelling reminder that child protection work is deeply emotional and relational and much of our complicated review processes neutralise the difficult feelings that are evoked in the work and in the untimely death of a child as a result of abuse.

The emotional permission facilitated a depth of honesty about the perception of agencies’ involvement, sharing of frustration, good practice, and professional challenge. A context was created which enabled discussion about how we could improve ways of working as well as recognising and reinforcing good practice.

The shock of T’s death, the impact on him of his parents’ parenting patterns and lifestyle, his own drug and alcohol use and relationship with his girlfriend were all considered. The complex questions of taking teenagers into care was explored. The team involved with T recognised that taking T into care was unlikely to have made the difference to the recklessness and lack of self-care that underpinned T’s behaviour. All professionals felt that latterly, good progress had been made with T. CAMHS had built a strong and positive relationship, resulting in T stopping drug use and all agencies reported they wouldn’t and couldn’t have predicted this tragic event occurring.

Devon has recognised that an intensive, responsive service offer for teenagers and their families is a very real service gap. The planned implementation of the Edge of Care service in Devon is intended to close this gap and is likely to be the most eloquent way to respond positively to T’s untimely death.

Key Learnings

  • Child protection work is emotional and relational; unexpressed angers, frustrations and worries can become toxic and undermine effectiveness. High quality supervision and strengths-based approaches to problem solving will reduce the likelihood of this and help to create the conditions for more effective practice
  • When lead professionals fully occupy the space of their authority, the impact is profound; anxiety is contained, information flow happens easily, different perspectives and views are encouraged, cooperation increases and depth and accuracy of risk analysis is made more likely. A safe space to practice is created by effective lead professionals. The reluctance of some agencies to occupy the lead professional space (partly because of resource pressures, partly because of anxiety) when a complex case is not open to social work is a significant barrier.
  • Linked to this is the risk of defining complex cases in ways designed to assign professional responsibility or access resource/service. We need to find better ways of surfacing these underpinning drivers rather than arguing about the superficial manifestations of the drivers and/or blaming each other for not stepping up.

AI allowed all practitioners to fully understand the case from everyone’s perspective, identify and overcome barriers and identify how we can improve practice and embed learning in a timely manner.


  • DCC CSW Assistant Team Manager – South
  • DCC Disabled Childrens Service Family Practitioner – South
  • Police DS
  • GP
  • CAMHS Practitioner


  • School Pastoral Worker

Session 2: Focus on Good Practice

Overview of Session

The team working on a case identified as good practice could hardly wait to get together to talk about their practice. They were excited and pleased to have been identified as an example of good practice.

The family had complex needs, with three children, one of whom is disabled. There was a history of domestic abuse between parents. Intervention initially focused on the disabled child, however, the events at home had a detrimental impact on the wellbeing of all. The collective passion and ownership of responsibility was apparent throughout the meeting.

Key Learnings

  • Strong multi agency networks and excellent involvement from the schools were crucial factors. The school played a key part in communication for the disabled child. The continuity of staff working with the family led to a consistent approach. All agencies knew the plan and stuck to it.
  • The Social Worker fully occupied the role of lead professional; co-ordinating all activity and planning meetings to include all agencies, thereby developing a clear, jointly owned plan which all partners were bought into it and contributed to. Risk was reviewed dynamically because the Social Worker responded promptly to calls/information from other agencies. Statutory intervention was used to good effect.
  • An holistic approach to the whole family, including both parents was a strength. This captured the needs and issues of everyone. Both parents were helped separately with their issues and kept on board with the plan. Positive support and clear expectations built resilience within the family to manage their own environment and challenges. The voice of everyone within the family was heard and listened to. Practical strategies were put into place.

The case confirmed that good quality, early intervention works.

This AI ensured the practitioners involved knew their work was recognised as good practice which is affirming and self-reinforcing. They were clearly proud to have been asked to share their knowledge and expertise.


  • Education Welfare Officer
  • Learning Disability Nurse
  • IRO
  • Head Teacher
  • Head Teacher
  • DCC Disabled Childrens Services Team Manager – South
  • Social Worker – South


  • Childrens Centre Worker

Session 3: South Senior Leaders

Overview of Session

Senior managers demonstrated that they knew T’s case and had spent time reflecting, exploring what they need to do to strengthen practice in their locality and had already taken action to implement learning. The senior team recognised that staffing and demand pressures in the South of the County risks undermining the conditions conducive to good practice in neglect. However, the good practice case was from the same Locality, demonstrating that a risk is not an inevitability

Strategic level partnership in Devon is now a strength and multi-agency working in Early Help has also significantly strengthened and is now a strength. Senior managers are mindful that the retrenchment in public services over the last decade, has created gaps, which, in a county the size of Devon, manifests in different ways in different localities. The South Locality intends to build upon the success of its Early Help Partnership to bring together the senior leaders in the Locality to respond to changing and emerging needs by jointly considering need and risk and the most effective deployment of existing capacity.

The vision and intention that underpins the role of the Locality Director, to bring together the system in each Locality has not yet been realised and the Local Authority and partnership will want to consider this further in 2020.


  • CSW Team Manger – South
  • DCC Locality Director -South
  • Health
  • CSW Area Manager – South
  • Early Help Area Manager – South


  • CAMHS Manager
  • Head Teacher

If you are concerned that a child is being abused please call

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Professionals should complete the MASH contact form.

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