Proposals for Lord Laming’s serious case review inquiry

Community Care offers Lord Laming some recommendations to make serious case reviews more effective as his inquiry into child protection procedures nears its conclusion


1. Independent reviews that focus on learning not recrimination

Ofsted’s Learning lessons, taking action evaluation found that serious case review panels often lacked sufficient independence. Community Care has heard evidence of report authors being prohibited from accessing relevant interviewees. We recommend that: authors be independent and free to pursue all avenues and reviews focus constructively on how and why the case happened, rather than what happened. Other industries have successfully made this change.

2. Reports distributed to all relevant practitioners

In order to properly learn the lessons from tragic cases in which a child or vulnerable adult has been failed, information about those cases must reach all relevant practitioners in the UK.

At present this does not happen: in several recent cases, councillors and the General Social Care Council did not see the serious case review until late in the process or until the media revealed details. Seldom are reports seen by all practitioners in the authority, let alone those in other authorities.

No single organisation has a complete list of all the SCRs conducted. The government’s existing biennial review, which considers only cases involving children, is not sufficient.

Community Care recommends that a single body should collate all reviews and circulate them to practitioners – frontline and managers, social workers and other professionals, wherever they are based in the UK. The system must include both reviews on cases involving children and those on adults.

The nominated body should also monitor trends, report on areas for practice improvement and recommend how training should be developed. This could be taken on by a body such as the Care Quality Commission or the General Social Care Council, or a new organisation could be created.

3. Publication of reviews in full

Serious case reviews are usually published only in summary. This limits learning. Community Care recommends that reviews be published in full so that practitioners can use specific details to inform their practice according to their experiences and roles. There is some resistance but it is possible to publish without harming anonymity (see box below, right). Names can be removed and reviews could be collated and distributed centrally, thereby disassociating them from specific local authorities, teams and known cases. It would help if reviews focused on learning not recrimination.



The aim of any serious case review should be to find out what went wrong and find ways to stop it happening again. Yet if you compare the summaries of such cases you see the same conclusions and patterns repeated.

To escape this cycle, social work needs to adopt serious incident review practices from other professions and sectors, including medicine and, more surprisingly, the airline industry.

In the past, adverse incidents in medicine and aviation have been put down to human error. However, concluding that a person made a mistake does not necessarily address the fundamental problem – it doesn’t tell us whether there were any ­contributing factors. By focusing on blame or avoiding blame, the actions needed to make a real difference to practice are missed.

One example of this comes from the airlines industry and was highlighted by Malcolm Gladwell in his book Outliers. He cites air crashes where there was an element of pilot error because the crews failed to communicate the nature of the emergency to air traffic control (ATC).

Poor communication

Gladwell says contributory factors were that the air crews did not have English as a first language and that they came from cultures where authority is heavily respected. Instead of cutting off ATC will an urgent “we need to land now” they failed to interrupt or contradict ATC, delaying emergency action. Poor communication rather than technical skills were to blame.

As a result, changes were made in pilot training, leading in turn to a reduction in similar incidents.

This approach of looking at how and why the system failed is a method of serious case review advocated in the Social Care Institute for Excellence’s “systems approach”. It looks for the underlying cultural, habitual or technological issues that could have caused a failure of practice.

The Scie model is intended to be used in any circumstance where practice needs to be reviewed, not just in the cases of serious harm or death. By bringing rigour to the process and making case reviews more common, it is hoped that approaches like this could make serious case reviews more open and useful in the future.

More on the Scie model


Serious case reviews are simply not fulfilling their aim. They are designed to explain how and why mistakes were made, but many believe that the executive summaries are little more than a chronology of events, without analysis.

The answer is to publish reviews in full. But opponents argue this would compromise anonymity and discourage individual workers from being open. Such arguments don’t stand up to close inspection.

It is already common practice to remove names from reports. But at the moment it is sometimes possible to identify those involved in the case because executive summaries are published by the relevant local safeguarding children board. This is usually done in the immediate aftermath of a court case.


If a single body collated and disseminated full serious case reviews, perhaps once a quarter, it would be more difficult, not easier, to identify those involved.

Disciplinary procedures could be used to ensure practitioners comply with the process. However, this would not compel frankness, so the approach to SCRs is key.

If they focused constructively on why and how mistakes occurred rather than what went wrong and who made the errors, the blame culture would be reduced, and practitioners reassured.

This approach must be extended to all parts of the serious case review, including executive summaries, which currently vary in the quantity and quality of the information disclosed.


‘My report was changed’

“I was commissioned by the then director of social services to write the part 8 review. It later turned out that it was actually on behalf of the area child protection committee (ACPC). But the local authority nobbled it before it reached the ACPC.

“I wrote the final draft of the report, sent it to the local authority to distribute to the ACPC members as agreed, then went on holiday. I came back for the meeting scheduled to finalise and endorse the report.

“When I looked through it, it was clear that it had been changed ­significantly. Whole paragraphs had been rewritten. The original report had not only criticised social services but had implications for the health authority.

“The excuse made by the social services department was that it was trying to do more joint working with health and didn’t want to offend anyone. The chair of the ACPC went ballistic when she found out the report had been changed. The director and assistant director would not discuss the matter until I threatened to make their conduct public. They couldn’t see they had done anything wrong. They thought I was being difficult.

“It was like being in a Kafkaesque world.”

Anonymous author commissioned to write a report on one of the most high-profile child death cases in the past 10 years

‘Rewrites unacceptable’

“I have been horrified to hear from fellow report writers of overview reports being edited after submission without consultation or agreement. I regard this as totally unacceptable and I would not allow such a report to go out in my name.

“My personal experience has been a wholly positive one. But, in view of the worrying accounts that I have received from others, I feel there is an urgent requirement that local safeguarding children boards should agree a proforma contract outlining the terms of engagement of overview writers and enshrining their independence.”

Patrick Ayre, author of serious case reviews

This report is published in the 19 February edition of Community Care under the headline “Our blueprint for serious case reviews”

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