Serious case reviews: policy and practice


Title: Analysing Child Deaths and Serious Injury through Abuse and Neglect: What can we learn? A Biennial Analysis of Serious Case Reviews 2003-2005

Authors: Marion Brandon, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black

Institutions: All the authors apart from Jane Black are members of the Centre for Research on the Child and Family in the School of Social Work at the University of East Anglia. Dr Ruth Gardner is also employed by the NSPCC. Jane Black is a designated nurse with Norwich PCT

Available: The study is available from the DCFS


When a child dies and abuse or neglect is known or suspected to be a factor in the death or injury, government guidance requires that local safeguarding children’s boards (LSCB) carry out a serious case review. Also, when children are seriously injured, consideration must be given to carrying out a serious case review.

The aim of the serious case review is to consider any lessons that could be learned about interagency working to safeguard and promote the welfare of children. Every two years, the government commissions an analysis of all the serious case reviews undertaken. This study by Brandon and colleagues is the third overview analysis and examines serious case reviews notified between April 2003 and March 2005.

The aim of the study is to explore lessons to be learned from the serious case reviews in order to improve multi-agency practice to safeguard children at all levels of state intervention, from universal services through to child protection and looked-after children. The specific objectives of the study are to:

Provide descriptive data from the sample.

Scrutinise a sub-sample of cases to chart thresholds of multi-agency intervention.

Identify and analyse some interacting risk factors within the sub-sample.

Identify lessons for policy and practice.

This study examined 161 cases and an “intensive sample” of a sub-group of 47 cases. There were examples of inaccuracies and inconsistencies in the information available and the authors acknowledge this may not have been a complete sample of reviews.

The report provides an analysis of data on the characteristics of the children in the full sample. Two-thirds of the children had died and one-third had been seriously injured. As with other similar analyses, almost half were under the age of one, with all but seven of the 76 babies being under six months. But one-quarter of children were over 11 and, unlike similar studies, a number (9%) of children over 16 were included. This is a reminder that older children are also at risk of death or serious harm from abuse or neglect. Most children in the full sample lived with at least one parent, but some lived with relatives, in foster care, residential homes or other accommodation.

Information from the intensive sample formed the basis of the analysis of parental characteristics and care-giving environments. There was evidence of house moves in about one-third of the cases, and a similar proportion of children were living in poor conditions.

A lack of supportive family networks characterised the lives of many of the families. As with other studies on child maltreatment, domestic violence was a feature in many of the families. More than half of the parents had mental health or substance misuse problems, with all three factors were evident in one-third of the families.


The types of injury or harm varied and included physical assault, neglect, sexual abuse and suicide. Most of the families were previously known to children’s social care. Just over half were receiving services at the time of the incident leading to the serious case review. Only 12% of the children were on the child protection register.

The authors remind us of the importance of all professionals working with children being aware of factors that can interact to increase risk of maltreatment, because most children who die or are serious injured are not within the formal safeguarding procedures. As in all other studies of serious case reviews, interagency communication problems were present. There was some evidence of verbal communication being more effective, which is important to note in the current climate of increasing reliance on electronic methods of information-sharing.

From the detailed analysis of the intensive sample, Brandon and colleagues developed a useful characterisation of the cases. They were divided into three categories:


Physical assault.

Older children.

Families of the children in the neglect group had long-standing involvement with children’s social care. Family histories tended to be complex, confusing and overwhelming for professionals. The families’ problems were frequently compounded by poverty and poor living conditions. The difficulties in deciding when “enough is enough” in cases of neglect is well documented, and in this study there was evidence of workers feeling helpless and at times fearful of families, which led to avoidance and drift in decision-making. The authors identified the “start-again syndrome” as one way practitioners managed these dynamics. In these situations, little consideration is given to the parents’ past histories and the focus is on present circumstances, leading to a lack of systematic analysis of parental capacity and the children’s experience of harm.

Although sharing some characteristics with neglect cases, the key difference in the physical assault cases was the presence of “volatility”, which frequently erupted into violence. Almost half of these cases involved head injuries to young babies. Involvement with children’s social care services tended to be less, but there was often a history of a previous injury, illness or admission to A&E. Universal services, such as police and health professionals, were more frequently involved with these families, often not recognising the impact of domestic violence on children.

The third group were the “hard to help” older children. Almost all of these had a long history of involvement with children’s social care, some with periods of being looked after. Many had presented with very challenging behaviours after traumatic histories. Agencies often appeared to run out of helping strategies and “give up” on the young people. Arguments about which agency was responsible, including between adult and children’s services, and thresholds for interventions often led to neglect of these extremely vulnerable young people’s needs.

As with other similar studies, assessments of the children and families were frequently deficient. There was some evidence of an accumulation of facts based on the assessment framework. But there was little evidence of a dynamic analysis of the interaction of protective and risk factors, including a hypothesis of the nature, origin and cause of the concerns that can be reviewed and evaluated in the light of new information. I suggest this could be influenced by performance indicators that evaluate practice in terms of quantitative measures, such as time taken to complete the assessment, rather than the quality of the analysis and outcomes of the intervention.

The authors suggest the need for an “ecological transactional” perspective – which focuses on interactive risk factors. A key message is the need for practitioners to undertake detailed, analytical and theoretically informed assessments that include the relationship and developmental histories and processes that have shaped people’s lives. Reflection on the emotional impact of the work on professionals is also essential.

The study contributes to the discourse on how we safeguard the welfare of our most vulnerable children. Effective interventions require professionals to understand the importance of relationships to engage with the complexities of the work in a systematic and analytical way to be curious and sceptical, but also to act compassionately.

Anna Gupta is senior lecturer in social work at Royal Holloway College, University of London


A study conducted by Rose and Barnes analysing serious case reviews undertaken from 2001-3 is available from the DCFS

The latest guidance from the Department for Children, Schools and Families on interagency roles and responsibilities in relation to safeguarding, including guidance on serious case reviews 

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