Serious case reviews

A serious case review (SCR) must be carried out in the event of the death of or reported serious harm to a child in England. Since the creation of SCRs, only the executive summaries were made public, but the coalition government promised to publish all SCRs commissioned after June 2010 in full.

Opinion across the sector has been divided over whether SCRs should be published in full, and people have continued to talk about different possible forms the reviews could take.

Some of those who supported full publication were disappointed at this government time-frame.

A government report published in October 2010 made the argument that serious harm cases should not merit a SCR. Others have gone so far as to question whether SCRs are necessary at all.

Prior to publication, SCRs are evaluated by education and social care inspectorate Ofsted. In July 2010, Ofsted gave its first outstanding mark to a SCR.

SCRs published in full by the English government so far:

Baby P in Haringey:

The first and second SCRs into the death of Peter Connelly were published in full on 26 October 2010. The first review, written in part by Sharon Shoesmith, Haringey DCS at that time, was rated inadequate by Ofsted and a second was commissioned.

The conclusions of the second review panel, chaired by Haringey safeguarding children board’s independent chair Graham Badman, were in stark contrast to those of the first SCR. The first SCR found “numerous examples of good practice within all agencies” and that, “with the possible exception” of a paediatric assessment conducted two days before Peter’s death, no single factor on its own would have led to him being saved.

The second review drew a number of negative conclusions about services’ treatment of the case, including the statement that placing Peter with a family friend when his mother’s treatment of him was in question “sent the wrong message”, as well as a statement from Peter’s father saying his role as a possible carer was overlooked by social services.

Take Community Care’s quiz based on the Baby P SCR: what would you have done?

Khyra Ishaq in Birmingham:

The SCR into the death of Khyra Ishaq, the seven-year-old who starved to death in May 2008 due to the neglect of her mother and stepfather, was published in full on 27 July 2010. It concluded that Khyra’s death was preventable and due in part to a lack of information sharing.

The full review also revealed that the social worker overseeing Khyra’s case had 550 cases on the go at the time of the child’s death.

The government has also promised to publish, retrospectively and in full, the SCRs into the Shannon Matthews case and the Edlington attacks. The Edlington SCR was criticised by the sector when its executive summary was published in January 2010.

Take Community Care’s quiz based on the executive summary of the Shannon Matthews SCR: what would you have done?

Children’s minister Tim Loughton has, however, said one of these two reports might not be published in full due to the possibility of putting surviving siblings at risk. He would not specify which one.

In spring 2010, three serious case reviews were carried out in Swansea, Wales about the suicides of three teenagers. Swansea safeguarding children board was accused of watering down these reviews, removing criticisms of social workers, but the board denied this.

Wales is currently negotiating a new system of SCRs.

Northern Irish case management reviews (CMRs) are very similar to their serious case review counterparts in England in terms of criteria and the way in which they are carried out. The current system was introduced in Northern Ireland in 2003 and approximately 30 reviews have been undertaken to date. One main difference between the English and Northern Irish systems is that at the moment, CMRs are not on a statutory footing. This is set to change at some point in 2011, however, when the Northern Ireland Assembly passes legislation establishing a regional Safeguarding Board for Northern Ireland. This board will replace the current Regional Child Protection Committee and will be sited within the Public Health Agency.

Despite these changes, the process of CMRs is not set to change in the immediate future.

Scotland’s significant review system is also undergoing some change, following the publication of recommendations by a short life working group of multi-agency professionals. The group was commissioned by the Scottish government in November 2009 to consider the SCR process in the light of recent research and practice. The group presented its report at the end of July 2010, recommending the reports be audited. The group also recommended the government commission an analysis of all SCRs undertaken since their implementation, as well as a template for SCR full reports and executive summaries.

The Scottish government has accepted these recommendations. An analysis of past SCRs is due out this spring.


NSPCC page on serious case reviews

SCIE’s systems model for serious case reviews

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