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Serious Case Review: Safeguarding a child with disabilities

The serious case review into Charlotte Avenall, an eight-year-old with severe learning difficulties, provides plenty of lessons.

In September 2009, Charlotte Avenall, an eight-year-old girl with severe learning difficulties, was found dead in her bedroom in Mansfield. She had accidentally hanged herself.

Her room was in squalid condition, with faeces smeared over the walls. She was locked in for 12 hours each night and forced to use a chest of drawers as a toilet.

In April this year, her mother and step-father were both jailed for 12 months for wilful neglect.

A serious case review undertaken by the Nottinghamshire Safeguarding Children Board established that a number of agencies had been involved with Charlotte and her parents since her birth. But despite the intention to provide a good service, there were lessons to be learnt in the way different agencies co-ordinated their approach and identified safeguarding issues.

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