Ethos of ‘blame’ in serious case reviews acts as a barrier to learning, report finds

Government report calls for a re-think on how serious case reviews are conducted, and more training to embed learning and practice

Credit: Image Source/Rex Features

10 recommendations

The report recommended key changes to the SCR process.

1: To review the appropriateness of SCRs as a process for embedding learning across disciplines.

2: To develop an ongoing and accessible database of national and regional learning – to identify emerging key themes.

3: Design and develop evidence-based learning ‘tools’, applicable nationally, to facilitate collective, targeted and tiered learning.

4: Develop national database for all practitioners to access SCR executive summaries with on-going key themes identified.

5: Ensure clear guidelines to enable confidence across disciplines in information sharing, thresholds, recording systems and measuring impact.

6: Develop a CPD programme for all practitioners to enable deeper learning to overcome obstacles to good practice.

7: Cross-disciplinary course development from initial training for all practitioners in the future.

8: Develop national learning and auditing tools that can be used to increase local awareness of key themes from SCRs.

9: Capture, within local and national reporting, the recording of how learning and practice changes from SCRs are taken forward.

10: Integrate, within existing and planned inspection processes, the assessment of the impact of the key themes identified by SCRs.

Inaccessible language, an ethos of ‘blame’ and a lack of local attention are all hampering social work learning from serious case reviews, a government report has found.

The report, commissioned by the Department for Education and carried out by Kingston University, examined the roadblocks that social workers face when trying to learn from serious case reviews (SCRs).

It recommended that SCR models should “reset the process to promote learning rather than blame” and have more focus on reflection and analysis, rather than primarily description and judgments based on hindsight.

Researchers found policy and procedure development and implementation is “not proportionate or sensitive to the scale, locality and context of the case” when analysing SCRs, while this is exacerbated by the selectivity of media coverage.

Similarly, it found rapid policy change in the wake of SCRs impacts significantly on frontline staff and creates confusion.

“Recently serious case reviews seem to have become more of a process of allocating accountability and blame,” said Professor Ray Jones, who worked on the report.

“What the government needs to do is make the process more practical and less onerous.”

The level of regular and appropriate training across disciplines is insufficient, the report also found, while frontline staff have limited involvement in the generation of learning, and ensuring its relevance and applicability.

Communication systems were also criticised for being ineffectual in ensuring learning informs practitioners across disciplines.

The findings were informed by social care professionals across England with “considerable consistency of views across all four geographical areas of England”, the report stated.

There was also agreement about the barriers from frontline practitioners and managers, senior and strategic managers and across all agencies working in safeguarding.

The report also called for a continuing programme of training to embed learning and practice change, and for changes in policy to be discussed and tested with frontline practitioners.

The findings are, “a job for the new education secretary [Nicky Morgan MP] if serious case reviews are going to have a positive rather than a negative impact”, Jones said.

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2 Responses to Ethos of ‘blame’ in serious case reviews acts as a barrier to learning, report finds

  1. Edna July 21, 2014 at 2:58 pm #

    This report and its focus / ‘findings’ are not surprising as Prof Ray Jones’ views on the ‘expertise and skills’ of social work are well known. I would not call this impartial research findings.

  2. Geoffrey Cox MSc. LLb. July 25, 2014 at 7:55 pm #

    Learning (or lack thereof) from Serious Care reviews

    Safeguarding is ostensibly about protecting vulnerable people from abuse or neglect. Serious Case reviews aim to see that all agencies learn lessons about the way they safeguard vulnerable people at risk and prevent tragedies from happening in the future. Protection, learning and prevention.

    A quick reading of many SCR’s however generate some familiar repetition ‘that failings occurred’ and that ‘lessons have been learned’. But have they?

    The sadly repetitive experiences and rising numbers of safeguarding cases, (the vast majority of which rarely get publicised) might suggest that learning is neither disseminated, implemented, nor it would seem desired. Either way, reading of the most serious cases suggests little has changed. Mid Staffs over the failings from 2005 – 2009 has been the biggest case in our history, but several things stand out.

    Firstly, the principle cause of failure was short staffing in pursuit of a cost cutting agenda. So what has been learnt? If anything, the position has since deteriorated, as finance is diminishing in austerity measures, cost cutting is still prioritised over care, and the current plan still ambitiously refers to ‘efficiency measures’ to save another £20bn from Health and £8bn from Social Care as if practitioners were frivolous, careless and wasteful and as if more can be delivered for less. We all know better, but such pervasive language used towards our Health and social care system continues to be the unfortunate choice of our political leaders.

    Secondly, the scandal of the lack of care and poor management at Mid Staffs raised important questions not just about that hospital and the NHS, but also about how large organisations are managed and the culture that is created, largely as a result of the above.

    Performance measures and targets may well communicate to an organisation what the leadership is trying to achieve, but they must be used in the right way. If used as they are to terrorise people, people become intimidated and act accordingly. If used to learn and improve they will help to get and keep an organisation on track.

    So where are we on that? Jeremy Hunt’s new safety league table might vilify the most honest whilst obscuring the deeper questions about how to create a safety culture throughout the NHS. They certainly do nothing to address the fear culture which appears to be prevalent.

    That Sir Robert Francis QC will be leading yet another inquiry, this time into the culture of fear that surrounds whistle blowing in the NHS, to make recommendations on how to create an open culture, is both welcome but overdue, but wasn’t that covered in his original report, along with the Berwick and Keogh reports? The fact that those who speak out currently still expect to suffer at the hands of the NHS shows an abject failure of vision, leadership or effective action.

    Berwick advocated we must abandon the use of blame as a tool, and instead “trust the goodwill and good intentions of the staff”, and build a culture of learning, and put this more succinctly that Francis. But what has changed? Sadly little.

    This leads on to the third aspect, the voracious appetite we have for blame. A review into safeguarding processes in 2011 described a negative and at times traumatic experience of the safeguarding process itself. Managers consulted felt that a safeguarding alert triggered a response that was often disproportionate to the issues raised, traumatic for staff and destabilising to the future of the (organisation). Yet, there has been little change in 3 years which suggest we are quite vested in a system that is oppressive, pervasive and destructive.

    The fourth part, which is the opposite, is about learning. The lessons to be learnt have been very much ignored, the reasons for which seem clear; that learning means action and action means cost, and cost is out of the question. This will not be tolerated by our politicians who have and continue to make claims about the economy, and whose success may depend upon a toxic mix of austerity, ideology, and spin.

    The only route to progress is one that starts with a policy of honesty of where we are right now, a clear vision where we seek to be, and an effective plan of how we are going to get there, not one that rubbishes the views of all professionals and practitioners, one that rubbishes the strong values of right and wrong we used to prioritise as a nation, but addresses what value we place on health, and care of the elderly, disabled and vulnerable. The second part is in building a nationwide consensus upon how we could all do better, developing a system for sustained recruitment, retention and learning. The third part, is to finance that plan, not pretend that we can do more for less as with Mid Staffs irrespective of the personal and Human cost.

    Geoffrey Cox MSc. LLb.
    Friday, 25 July 2014