Case review model aims to end social work blame culture

The traditional approach to serious case reviews (SCRs), carried out by local safeguarding children boards (LSCBs) after the death or serious injury of a child, has been widely criticised for inhibiting learning by focusing on mistakes and blame.

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In her review of child protection, Eileen Munro recommended a systems approach to serious case reviews. Eight pilots of the systems model developed by the Social Care Institute for Excellence are now well under way. Louise Hunt reports on progess so far.

“You don’t feel you are being blamed,” says social worker Josie Boughton, reflecting on the new approach to serious case reviews her local authority is piloting: the Social Care Institute for Excellence ‘Learning Together’ model.

“You are really able to dissect the decisions you have made, which helps you to reflect not just on that case, but also on current cases,” Boughton adds.

It is a salient point. The traditional approach to serious case reviews (SCRs), carried out by local safeguarding children boards (LSCBs) after the death or serious injury of a child, has been widely criticised for inhibiting learning by focusing on mistakes and blame. But the SCIE model is all together different, Boughton says.

Endorsed by Eileen Munro, the ‘systems’ model began with six pilot case reviews in the North West and West Midlands. Since then, a further 20 have been carried out as part of SCIE’s Learning Together training and accreditation programme.

Supporting good practice

Adapted from the systems approach used in other high risk industries, including aviation and health, the model has been designed to identify factors that support good safeguarding practice and those which make poor practice more likely.

Rather than simply identifying what happened, SCIE says the approach helps professionals to explain why things happened, understanding their actions or decisions will probably have seemed sensible at the time.

The overriding feedback from the pilots is that Learning Together enables social workers to engage with cases in a much more constructive way than the current approach, which is frequently branded time consuming, costly and not conducive to real learning or change.

“The current system can feel like a very negative and punitive approach,” says Joanna Nicolas, an independent child protection consultant and lead reviewer on one of the pilots. She also found the model to be “much more effective”.

How does it work? A team of local senior managers brings together all the professionals involved with the child to openly, and in detail, discuss their experiences of the case. Two lead reviewers, one internal and one independent, oversee the process.

The case group has the chance to give feedback on the reviewers’ first report before it is presented to the LSCB. The board then decides what action to take, unlike the current system where the board must produce an action plan even if it disagrees with the recommendations.

“Everyone on the case group was nervous at first, but they realised the process is about looking at systems and not individual mistakes,” Nicolas says. “It is about trying to understand what the situation was like for those workers at that time.”

She describes Learning Together as “a really constructive way of learning and reflecting on practice and working with other professionals – the more time you spend with other professionals the more the barriers come down”.

Doing things differently

So has the model significantly changed practice at the pilot sites? Nicolas thinks so. “Frontline workers say they are doing things differently now. They say they feel more empowered to challenge other professionals about how to do things.”

Boughton, one of 30 social workers involved in the pilot at Gloucestershire council, has learnt the importance of being able to escalate concerns, not only within her organisation, but also to other agencies involved in the case.

“Before if I was worried about something another professional did I would normally only discuss this with my line manager, but now if I had concerns about what other agencies are doing I would share my concerns with them,” she says.

The model will soon be tested on three live SCRs, the results of which will inform the government’s revision of the Working Together guidance, due to be published in the summer. After this, the model could be adopted nationally.

Sheila Fish, a senior research analyst at SCIE who is leading on the Learning Together model, says the evaluations from the three live sites – Coventry, Devon and Lancashire – will be “really useful in seeing what extra challenges come up when the model is applied to real SCRs, when emotions are running much higher and there are added complications such as parallel civil or criminal proceedings”.

The challenges

The model does have its challenges, Fish concedes. “The process itself doesn’t take any more time than undertaking single agency reports, but under this system everyone’s time has to be accounted for, rather than it being work that gets done at home late into the evening,” she says. But in the long term, if it helps practitioners in all agencies to learn lessons, “it is much more likely to be cost effective,” she adds.

The model could also be applied to more typical cases to improve learning in particular practice areas, Fish believes. This proactive approach would fit with Munro’s recommendation for supporting the development of professional judgement, she says, as well as ensuring feedback between all parts of the system about what is working well and emerging problems.

“If we are trying to move from a compliance driven model involving people blindly following policies and procedure then you need a different method of learning and, as we have seen from the pilots, Learning Together has the potential for initiating the kind of real cultural change this requires,” Fish adds.

LSCBs have raised concerns about the resources required to implement Learning Together, but Boughton believes the approach can genuinely change practice. “It has really made me challenge my thinking about how I manage cases,” she says.

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