It was announced last week that the case of six children who all died in a house fire, deliberately started by their parents, would be the subject of a serious case review.
In the Philpott case none of the children were on child protection plans nor has the criminal trial revealed any details indicating the children’s deaths could have been predicted or prevented by professionals.
A serious case review will cost Derby Safeguarding Children Board at least £50,000 but more likely in the region of £150,000 to £200,000 given there are six children involved.
Any recommendations are likely to be distributed by the media, interested in getting another bite at the story, not by professional or government channels.
And this, according to Ray Jones, independent chair of Bristol’s Safeguarding Children Board and professor of social work at Kingston University, is the problem with serious case reviews (SCRs).
“At the moment serious case reviews are heavily bureaucratic, very expensive and prove to be a serious distraction for front line social workers and managers involved. And I’m not sure we get that much benefit out of them in terms of learning.”
Yet the government has spent some concentrated time thinking about SCRs – announcing wide ranging changes, not only in the new and revised Working Together to Safeguard Children guidance, but also in its response to the Carlile Report on the Edlington case.
Government’s proposed changes to SCRs
• A national panel of independent experts to advise and monitor LSCBs about when to initiate a serious case review, when to publish them in full and to monitor that lessons are being learnt. The panel will also report to Government their views on how the SCR system is working.
• A freeing up of how SCRs are conducted to allow for different learning models to be used.
• A set of principles that all SCRs must adhere to including – recognising the complex circumstances in which professionals work, understanding the underlying reasons why people acted as they did, avoiding hindsight bias, transparency about research methods and making use of research as well as case evidence to inform findings
• A support programme contracted for SCR authors.
• A two-stage study to look at the barriers for organisations learning from SCRs and how to breakdown those barriers.
• Discussions on if a designated family judge should advise and oversee every serious case review.
• Discussions on the idea of creating a central repository of SCR reports which would be available online.
One of the biggest changes is the creation of a national, independent panel of experts to “advise and monitor” local safeguarding children boards (LSCBs).
Appointments to the panel will be made by ministers and Community Care understands they will not be experts in SCRs but sourced from other fields which ministers feel can contribute to the SCR process.
It has attracted criticism from the sector. The Association of Directors of Children’s Services described it as an “unnecessary bureaucratic intervention on the part of central government”. They pointed out it was likely to interfere with the independence of the LSCB chair.
Jones agrees. “Already there are three tiers of independence in the system- the chair of the LSCB needs to be independent, the SCR author needs to be independent again and the management reports that are submitted have to be authored by someone independent of the case and its management. Why do we need a fourth layer of independence which will prove to add yet more bureaucracy and expense?”
The newly formed Association of Independent LSCB Chairs is also less than enthusiastic. Chair Sue Woolmore says they recognise the introduction of the new panel as a government led initiative.
“Alongside this we already have a sector-led improvement scheme which we as an association are very committed too and we see it as a key vehicle to strengthening the role SCRs have to play while ensuring SCRs do not monopolise the agendas of LSCBs.”
She adds the independence of LSCB chairs is paramount if they are to maintain their contribution to improving child protection.
The panel will also “observe and reflect” on the national learning from SCRs, instead of the biannual analysis of SCRs traditionally commissioned by the DfE from the University of East Anglia (UEA).
Less research and increased costs
However, a Department for Education spokesperson denied they were ditching evidence based research in favour of “views” from an expert panel.
“We have commissioned analysis at two year intervals and, while well received, lessons are not being learnt. That is why we are reviewing the situation to see why things are not improving before commissioning further research.
“We have provided set-up funding for the Association of Independent LSCB Chairs which is looking at how to improve learning from SCRs, and the new national panel of independent experts on SCRs will have a role in advising the government on how the system is working more widely.”
Yet cynics within the sector wonder if it does not also provide a convenient “breather period” for the government- the impact of cuts could be a common issue that would feature in any future national analysis of SCRs.
Marion Brandon, who co-ordinated the biennial analysis for UEA, says it is a pity to lose the database that has been built up.
“There’s more than 800 cases and there is no other dataset like it in the world. There is interest from some of the smaller countries, such as Wales, in keeping it going but unfortunately you do need quite a big number of SCRs to be able to see the patterns and trends.”
It was the last biennial analysis which highlighted the trend that the number of SCRs being commissioned was dropping- particularly those that relate to serious injury and where there is more scope for LSCBs to decide if a SCR is necessary.
The drop was largely attributed to the government’s push to publish reviews in full instead of just an executive summary and former minister Tim Loughton believes ministers should have the right to order LSCBs to undertake an SCR to stop such avoidance.
Certainly many view the new panel as a subtle attempt by central government to put more pressure on LSCBs to commission and publish SCRs.
Yet, Jones argues that the dropping numbers of SCRs is also a response to the escalating cost of SCRs in an era of massive cuts. He points out such costs are only likely to increase with the addition of a national panel and fewer but better trained SCR authors.
The government’s promise to examine Lord Carlile’s recommendation to have a judge oversee every SCR is also likely to be an expensive move, and given the massive delays that already beset the family justice system, unlikely to be a popular use of a precious resource.
However, most in the sector welcomed the government’s move to free up Working Together to allow LSCBs to consider other models for SCRs.
Brandon says this might be the opportunity to explore the option of longer and shorter reviews, depending on the case, as is the case in Wales. She says she has anecdotal evidence that LSCBs find it easier to get lessons out if there is not a SCR.
“Just gathering everyone together and doing learning in small groups appears to be more effective. Because often by the time a SCR is completed it is a long time down the track and everyone feels removed from it.”
David Tucker associate director of policy at the NSPCC, agrees that for those cases where a child has not died a full SCR can be both cumbersome and expensive.
“It would be good to see LSCB’s designing processes that would allow some kind of a review of a case that is quicker and better at distributing learning. But it does rely on LSCBs being open and it will be a difficult balance to achieve.”
For those cases where a bigger review is needed, Tucker is surprised the government did not promote the Social Care Institute of Excellence’s “Learning Together” model more.
While “Learning Together” is no less expensive or time intensive, it has been proven to have better success at embedding learning into systems than the current process.
“One of the biggest issues with SCRs is there is a substantial gap between the big picture issue identified by a review and how that gets filleted down into what are often very process driven recommendations. That was something identified by Munro and why she felt systems learning models would be more useful,” Tucker says.
The NSPCC has also begun sifting through all the SCRs it holds links to in order to create themed reports. The first two will centre on domestic abuse and substance abuse respectively.
Tucker says it was initially an internal learning tool but the reports will soon be available for public consumption.
“Our intention is to release a themed report every three months so there is some wider dissemination of learning.”
However, he points out that the NSPCC can only hold links to SCRs and some LSCBs have already taken down the reports- although the new Working Together guidance does stipulate reports must be published for at least 12 months.
“There was also the recent case of a council who removed a SCR after five days, claiming they were trying to protect the children. That is just nonsensical. You either publish a report or you don’t.”