What serious case reviews say about social work practice

Analysis of almost 300 serious case reviews highlights importance of professional judgment and hearing the voice of the family

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The latest triennial analysis of serious case reviews was published this week and, while generally positive about the role played by services in protecting children, it also identified several “pressure points” on the system.

It looked at 293 serious case reviews relating to incidents from 2011 to 2014, and these were also considered in the context of learning from SCRs over the 10-year period since the first triennial analysis of incidents in 2003-2005.

Here, we highlight some of the main messages from the report:

Cases are being closed too soon

  • The report identified how, while less than half of children involved in serious case reviews were involved with children’s social care at the time of the incident or abuse, almost two-thirds had at some point been involved with children’s social care.
  • “It is apparent that many of these children’s cases had either been closed too soon or lacked the ongoing support services and monitoring that the children and families needed.”
  • It said this showed the need for long-term planning and support where children have known risks or vulnerabilities. (pg 11 & 179)

Social workers should be more authoritative

  • The report highlighted using authoritative practice as an appropriate response to complex issues.
  • “Principles of authoritative practice include allowing professionals to exercise their professional judgement in light of the circumstances of particular cases.”
  • The style of practice also encourages professional curiosity and taking responsibility for their own role in the safeguarding process, the review said. (pg 17/18 & 200)

Uncertainty about thresholds

  • Difference in perceived thresholds could lead to frustration, or even a breakdown in effective working, the report said.
  • “Assessments may be needed at the point of early help, not just once child protection risks have been identified,” it said.
  • It added that where the threshold for social work involvement is not met, there could be “little analysis of risks of harm”.
  • As a result of this, “support plans may be unclear and easily drift”. (pg 15 & 242)

The voice of the family can become lost

  • The report stresses that “hearing the voice of the immediate and wider family” is as crucial as hearing the voice of the child. Hearing children is dependent on “safe and trusting environments” so children can be seen individually and speak freely.
  • Adolescent voices are equally important to younger children’s, the report said, “but they may struggle to express their needs or feelings”. It also added that there is a risk of adolescents being lost between child and adult services. (pg 14 & 68 & 131)

Professionals can have a “narrow view of their responsibility”

  • Often professionals involved in cases “hung back expecting others to act”, the report said.
  • Sometimes people involved in case would pass on information and consider their responsibility ended. (pg 16 & 177)

Workloads are challenging services

  • “High and unmanageable” workloads had resulted in delays to services, high thresholds or lower quality, the report found.
  • It said it was important for leaders to “think creatively about how their systems and structures can effectively support front-line workers”. (pg 17 & 190)
SCRs to be replaced
The government has recently announced that it will scrap serious case reviews and replace them with a centralised framework based on a mixture of national and local reviews, which it believes will bring greater consistency.

8 Responses to What serious case reviews say about social work practice

  1. Peter Endersby July 7, 2016 at 2:18 pm #

    Just a shame that these lessons to be learnt which aren’t new in social work were on the backs of at least 300 children dying or getting seriously injured. Will these same mistakes appear in the next 300 and if yes then what is the point of SCRs?

    • Hilary Searing July 8, 2016 at 7:11 am #

      The point of SCRs is that they make fascinating reading if you’re interested in the details of what went wrong. What they do not address is failures of accountability in children’s services – which are a critical factor contributing to the continuing failure of services. My article titled ‘Watching the Watchers’ offers a radical critique of the child protection system http://www.radical.org.uk/barefoot/watchers.htm

      • Sarah July 10, 2016 at 10:05 pm #

        Hilary I have read your article and find it extremely lacking in insight if not entirely contradictory. The case example of Ellie Butler and social work “failings” is appalling. There is absolutely no reference to the fact that social workers do not have the authority to remove children even when risk is identified. Only the courts and police can enforce such power. Also you fail completely to acknowledge that the Local Authority was pushed out in favour of an Independent Social Worker and were ordered by the courts to apologise for having asserted they felt Ellie’s father posed risk.

        The comment “One idea for improving practice is to give all social workers a working knowledge of risk assessment. In my experience, the situations putting children at greatest risk are relatively easy to spot. These include the following: a male partner in the home with a history of violence, incidents of domestic violence, parents who are addicted to drugs or alcohol and are socially isolated, a baby who is failing to thrive or frequently presented for medical attention, teenagers who repeatedly go missing from home. All social workers should be trained to look for indicators of risk”

        On what planet is greatest risk “easy to spot”?? This leads me to suspect you do not in fact have direct experience of frontline child protection work – 99% of referrals for the criteria you allude to.

        It is exactly this dangerous mindset which chooses to over simplify the assessment process and think risk can be determined easily which leaves so many children at risk. You also fail to acknowledge social workers do not kill children, it is their carers/abusers who do so.

        In addition, your article and viewpoints may be more persuasive if you acknowledged the role of all professionals in working together – and that any case that reaches Child Protection/statutory thresholds, cannot do so in the absence of a multi-agency decision. Social workers alone cannot enforce statutory powers.

        • Hilary Searing July 17, 2016 at 8:43 am #

          Sarah, I accept that in the case of Ellie Butler the Local Authority was dis-empowered by the judge’s decisions. But it was not powerless. Power comes from its statutory duty under section 47 and in the ability to think creatively about how to keep children at risk under social work surveillance. I have personal experience of a child protection case where parents refused to let me into their home and to see their children. However, concerns about the children made it necessary to put a Child Protection Plan in place, have regular Core Group meetings and keep a watchful eye on the family.

          In other words, there are important social work tools that could have been used in the Ellie Butler case – though I recognise there would have been a huge backlash from the parents and they might have gone to the media again! This was obviously an extremely difficult situation for professionals involved in this case and I am certainly not blaming individuals.

          • Sarah July 22, 2016 at 7:11 pm #

            Hilary, can you please explain what you feel Child Protection actually does in terms of getting through the door to see children? If parents refuse, social workers cannot enforce access to a property – and certainly in my experience, families tend to become far less engaged when Child Protection is enforced and often feel extreme anger.

            In Ellie’s case, and in many others in similar circumstances, parents put in complaints against workers and repeat that cycle to deflect and keep workers at arms length.

            From that point all a worker can do is escalate to PLO and go down the care proceedings route. This is only effective if the courts respect the social work judgements.

            All the steps the Local Authority could reasonably take in terms of care proceedings had been done with Ellie and the courts turned against the Local Authority and refused to acknowledge evidence of risk – ordered Local Authority to apologise and dismissed all historical evidence of significant harm.

            I really do not understand what more a social worker can do in those circumstances. Surely the role of courts and systemic failures are far more pertinent in the case of Ellie Butler and 99% of all other SCRs. If you explored these aspects instead of demonising social work practice then perhaps your statement of “not wanting to blame” would be more convincing.

      • Manda J July 10, 2016 at 11:55 pm #

        I am a Mum, fairly newly qualified 46yr old sw in a mental health multidisciplinary team, have a depth of life experience in a wide range of difficulties. I gained a first class honours aged 45.
        Most of my colleagues and university cohort in different settings ALL have too much to do with never enough time. In uni we’re all well aware of the need for all that’s recommended from SCR’s, no one passes without an in depth awareness of what has is required for a good assessment, how to plan and intervene, to analyse, reflect and review. To have “respectful uncertainty” use evidence from research understand a wealth of theories and models work withon a legal and ethical framework and so on. We all not only have to learn a systems approach for our service users, we have to work within a government system. This system appears to me to be setting every public service up to fail so it can privatise them easily. It runs it by fear, risk and blame. Systems theory for business is how we can manage others and profit most efficiently. The social worker learned role is to support and empower people, to always put children at the centre listening to their wishes and feelings. Of course there are poor workers but why?
        Most of us don’t have time to be all what we know we can be because beaurocracy and targets put pressure on everyone to rush!! More workers quite obviously would solve this yet nooòo more funding cuts. Charities funding cut and so much more from austerity measures…panels have no money to give so they have to say no to requests relating to often desperate situations. It’s lucky to get half what’s assessed as being needed.
        I applaud anyone brave enough to join children’s services, for their blame and vilification means “they’re dammed if they do and damned if they don’t”. But my main reason for not considering ever working with children is to know I would have to prioritise between children in need not who meet a set thredhold….that’s a lot of emotional turmoil I imagine. Inevitably a tolerance would need to build hence the need for what we learn Reflection but where is the time??. This is what the government has caused….Not enough time!!
        The amount of administration and lack of funding is what causes training to be crushed by risk of blame. In mental health there’s a greater risk of suicide. So whilst we need to make notes of everything and identify risks – it’s for fear of blame that someone we work closely with has died or has been harmed or harmed others. I for one would prefer more time for the people and families I work with than writing about it. I understand why it’s occurred and needed, but it needs time much more time than what is available. The answer is more workers more support services. As social workers I’d like to believe we all know who’s caused this awful situation in what seems to be all public services.
        Please be aware who really causes many children and families to be let down! And please remember social workers do not kill anyone and are all only human – budgets don’t allow for a toy wand let alone a magic one. Nqsw go into fast paced teams….all stories are about hard work not enough hours… but we all love what we do!
        I’m amazed we as social workers accept what we know is happening. Though we just could not strike as those hours are needed for many others who need us!! Courts, hospitals, benefits, schools, police, housing, Doctors, fostering and adoption, charities, social enterprises, groups, councills, commissioners, law, policy you name it social workers have to liaise within all disciplines and agencies’ frameworks. We liaise trying to di the best we can in the limited time available. We do not only work with one family at a time bit te ns of families. Guess we wait for another framework, supposed to support what we all recognise as the issues in current services which can place all those vulnerable at a high risk of being let down.

        Bit of a rant, but hopefully you get where I’m coming from.

        • Sarah July 11, 2016 at 6:32 pm #

          I completely agree with you Mandy. This is what I find concerning when comments are made around “making social workers more accountable”.

          Social workers cannot sneeze without being made accountable – and there appears to be very little acknowledgement or understanding of the role. In this sense I do think Hilary makes some valid points within her critique around tensions within the role; however there appears limited insight into the powers a social worker can currently exercise nor understanding around the impact of he current climate in terms of resources and time.

          The inescapable truth is exactly what you describe – too much work and not enough resources or workers. Too much emphasis appears to be made around “social work failings” and not on the key issues. This keeps on occurring. We need to look at the bigger picture instead of talking about more training and accountability. None of this can be implemented until the more pressing issues are addressed.

          If Hilary truly believes that in every case where there is a male in the home with a history of violence, any concerns around substance misuse, children with the presentation in health/health concerns etc and adolescents going missing regularly are enough to warrant an escalation/statutory input through Child Protection and further escalation, 100% of Children’s Social Work referrals would warrant escalation.

          As it stands many cases do not proceed past referral, and many close earlier due to being less concerning where actual harm (and not simply un-evidenced potential for harm based on “risk factors”), remain open alongside at least 30 other cases on a social worker’s caseload. Hence focussing on “risk assessment” and trying to suggest social workers lack knowledge is not helpful at any level I can see.

          If we kept every case open on those risk factors, the current number of practitioners would need to have 200+ cases on their caseload. Hence it goes back to resources again.

          Pease people, acknowledge the current concerns and stop scapegoating an entire profession.

          Anyone who does not accept these truths clearly does no have frontline child protection experience – or at least very minimal experience within the last two decades.

  2. Tom J July 12, 2016 at 11:59 am #

    Its astounding that Tony Blair’s clearly flawed assessment (Chilcot Inquiry) leads to the deaths of literally millions of people, yet he will not be prosecuted, as he made an ‘honest mistake’.

    Yet social workers from the Climbie and Baby P cases are literally hung out to dry and no ‘honest mistake’ defence is accepted.

    Blair is now swanning around earning millions from JP Morgan and giving speeces at £100k a pop. And the demonised social worker’s?