The world of serious case reviews is changing. In the year following Peter Connelly’s death there were 173 serious case reviews (SCRs). In the following two years, so up until 2011, there were 184. Then everything changed.
Following a recommendation from Professor Eileen Munro in her review in 2011, the government piloted the methodology she recommended: the Social Care Institute for Excellence (SCIE) Learning Together model. This was a systems approach to reviewing cases. The argument for it was that our model for SCRs – set out in the original Working Together – had no proven methodology behind it. The lessons were always the same, they were expensive, resource-intensive and we clearly were not ‘learning the lessons’.
Then in March 2013 we had the latest revision of Working Together. It states local safeguarding children boards (LSCBs) “may use any learning model which is consistent with the principles in this guidance, including the systems methodology recommended by Professor Munro”. Those principles apply to all case reviews, not just the cases that meet the criteria for a SCR.
Why should we keep doing SCRs?
Until 2011 we had the bi-annual reports of Brandon et al, an invaluable data analysis of all the SCRs. But now, because LSCBs can use any methodology they choose as long as it fits with the guiding principles, we’ve lost that rich source of data analysis. The NSPCC will publish all SCRs on their website, but no one is bringing that data together (I understand the Department for Education is looking to redress this).
What we do know for sure, however, is that between 2008 and 2011 there were 357 SCRs. Munro is right: they are costly, time-consuming and the lessons are almost always the same. So why, as the current argument goes, should we carry on doing them?
The reason is simple: when you do a systems review you find out very different things. But we do need to be careful as ‘systems methodology’ is a term that’s bandied about, with all sorts of individuals professing to know how to do them and what they look like.
The starting point for systems reviews is accepting that very few people go to work intending to do a bad job. Our society seems to want to blame people when a terrible tragedy happens. I’ve heard opponents say ‘yes, but the systems model does not address individual failings’. It absolutely does, but they would be dealt with in the same way as the old style of SCRs – by the individual agencies.
Since 2011 I have lead four systems reviews. In each one, I could give you many, many examples of professionals going way beyond what is in their job description. Workers going out on a limb and working all hours, to do the best they can, often in overwhelming circumstances.
Listening to those on the frontline
The terrible thing is that children will always die as a result of maltreatment. We will never be able to stop that, but if we really mean it when we say we want to learn, the best place to start is by listening to those on the frontline and that is what systems reviews do.
None of this is about covering poor practice; it asks why and how it happened. What you almost always find is that the reason why a worker did not do something that, with hindsight, should have been a priority, was due to everything else that seemed a priority on that day.
Doing systems reviews we find things that we would never have found before, and I have done both. For example, in a chronic neglect case one of the things we looked at was how we, typically, work with neglect. Think about the neglect cases you are involved in, what do we do? We have concerns about the child, so we bring another agency in, things do not seem to be getting better, so we bring another agency in. The situation does not seem to be improving, so we bring another agency in and another and another.
At one point, the mother in this case had eight different professionals, all offering her some level of parenting advice and yet research is clear that the most effective way of working with chronic neglect is as few professionals as possible, doing intensive work with the family. We would never have found that using the old methodology.
Multi-agency working and capacity to change
Another finding from a systems review I’ve been involved in is multi-agency working. We know we need to get better at it, but it revealed what good multi-agency working is. To most professionals it seems to be when there is good multi-agency involvement, meetings are well attended and professionals feel they can challenge each other. All those are important components, but the real evidence of good multi-agency working is that things improve for the child.
We talk a lot about whether a parent has the capacity to change, but the systems review found that what we seem to mean by that is the mental capacity. But capacity has two components, the mental capacity and the motivation. We need to get much better at looking at the motivation a parent/carer has to change.
And finally, instead of workers who feel battered and bruised and scape-goated by the process itself, you see workers gradually feeling listened to, empowered and reflective, not defensive, who have learnt so much by going through the process.
So, for those who ask why we are still doing serious case reviews, just wait a while. Let’s see what we find now that we do them so differently and review it again in a few years’ time.
Joanna Nicolas is a child protection consultant and trainer