G290(P) 12 years on from the Laming Report: From recommendation to practice

Abstract

BackgroundThe Laming Inquiry investigated the death of Victoria Climbie, a nine year old girl, at the hands of her great-aunt and partner. The Laming Report (2003) found a series of shortcomings within organisations involved and their ability to work together. 108 recommendations were made, 27 specifically directed to health. Our trust was one of the organisations highlighted in the report and we have audited the report’s recommendations since 2005.AimsTo review all audits since the Laming Report to ensure that safeguarding procedures are compliant with its recommendations.To examine whether audit recommendations were acted upon or whether the same common themes emerged at each audit cycle.MethodBetween 2007 and 2015, 6 audits of the Laming recommendations have been performed. Each audit examined 30 sets of notes in which safeguarding concerns were raised. The subsequent results and recommendations of each audit were examined for evidence of both good practice and areas where recommendations were not met.ResultsThe overall trend was an improvement in the number of recommendations that were fully met. The recommendation was regarded as fully met if it was documented in 100% of cases. Only 2 recommendations were fully met in 2007 and 7 in 2015. Where a recommendation was not met, there was a significant improvement between 2007 and 2015. Concerns were clearly documented in 58% of notes in 2007 and in 99% in 2015. Action plans were documented clearly in 67% of notes in 2007 and in 90% in 2015. Each year’s recommendations were acted upon with new documentation being introduced for example a discharge planning meeting proforma. One common theme raised was the need to improve of documentation of GPs, hospital number and school.ConclusionMeta-analysis of 8 years of audit of the Laming recommendations has shown some recommendations have become common practice with no child being discharged without discussion with a senior and documentation of consultant. Good documentation has a crucial role in all aspects of a patient’s care particularly in safeguarding and we still seek to improve documentation and communication within our trust and with other agencies.