Serious case reviews: why aren’t lessons being learnt?

Last month, the mother of Victoria Climbié, the eight-year-old girl who was killed in 2000, said she was shocked that lessons from the case had still not been learned.

Berthe Climbié said the deaths of other children in similar circumstances since then showed nothing had changed. Lord Laming, who headed the independent inquiry into her daughter’s death, said he shared her concerns.

The death of Khyra Ishaq, from Hands­worth in Birmingham, who was allegedly starved to death, and the case of Child B in Westminster, whose parents were jailed for torturing their four-year-old daughter who has cerebral palsy, are examples of the suffering children continue to experience.

What these and other cases of neglect have in common is that a serious case review has to be launched to find out what went wrong. But, in an echo of Berthe Climbié’s comments, some independent review authors and child protection experts say lessons are not being learned.

Although the government publishes a biennial review of cases (see panel, below right), and the themes from these are disseminated, experts say there are major failings in the way councils publish and disseminate the findings of individual reviews.

Patrick Ayre, a lecturer at the University of Bedfordshire who writes serious case reviews, says: “I have spoken to workers who are unaware of where a review has taken place in their own authority and are unaware of the recommendations.

Ineffective systems

“Most authorities have ineffective systems for dissemination. You would think there would be a series of events where the ­lessons would be shared.”

Independent trainer and consultant Jane Wonnacott, who has written more than 30 reviews, agrees: “It is not uncommon for staff who have been involved in cases to not know the outcomes.

“So much effort goes into the review, it is almost like doing the review becomes the end itself. The lessons that are not learned are about how people talk together, relationships between professionals and the information they take on board.”

The government’s guidance on serious case reviews, in Every Child Matters, states that local safeguarding children boards, which set up the reviews, should “clarify to whom the report, or any part of it, should be made available”.

Full reports are seldom released externally and an executive summary, which includes recommendations for action, is usually all that is available to those outside the local authority concerned. This has led to calls for full reports to be released.

Child protection specialist Perdeep Gill says the main problem is a lack of detail. “The problem is there is not enough on how we change practice. The summaries nearly always have the same themes. You need to look at the analysis of how they went wrong rather than that they have gone wrong.”

Gill says many councils believe they are protecting themselves by keeping ­information to a minimum. She believes all full reviews should be released and perhaps anonymised.

Wonnacott agrees that councils are defensive, but says the media play a part because they are not always fair in their reporting.

Unlike Gill, she doesn’t think that full reports should be generally issued, but that an anonymised full report for training purposes can be effective.

“You have to find a way to look at the details of the lessons,” she says. “For example, it is easy to say people don’t communicate, but understanding why the relationships were such that the communications were not right is important.”

In terms of how local authorities are failing to disseminate findings properly, there are many criticisms, including managers believing they can sort out the problems themselves, and a lack of understanding about what causes people to change practice.

Wonnacott says: “Training departments in some places are not integrated with ­operational policies. I know one LSCB ­training manager who doesn’t see the full report, so how can you develop training? I would hope that isn’t terribly common.”

Ray Jones, who conducted the management review into the death of 39-year-old Steven Hoskin in Cornwall in 2006, following horrific abuse, argues that full reports must remain confidential because it is not right to make some details public. For ­example, he cites the identification of individual workers.


However, Jones says there are problems in implementing recommendations from the reviews. Too often, he says, the reviews lead to a change in procedures rather than practice, “creating organisations that are procedure-bound”.

But Colin Green, safeguarding spokesperson for the Association of Directors of Children’s Services, says suggestions that lessons are not being learned from serious case reviews are “sweeping generalisations” and that having an experienced, stable workforce is crucial.

For its part, the Department for Children, Schools and Families says it is spending millions to improve the training, recruitment and professional development of social workers. But it is not complacent about serious case reviews.

A spokesperson says: “Ofsted evaluates all serious case reviews and every two years we commission an overview of all serious case reviews undertaken nationally to ensure we learn lessons for policy and practice.

“Government offices are advising on the implementation of serious case review action plans to ensure lessons are learned.”

The evidence from those involved with undertaking serious case reviews would suggest that, despite these assurances, children will continue to die unnecessarily unless the expression “lessons are learned” becomes a reality rather than a repetitive, but ultimately meaningless, phrase.

More on serious case reviews

Lessons learned in Norfolk

Norfolk Council tries to ensure lessons from serious case reviews are learned by producing an action plan from the recommendations of the executive summary. It then designs training exercises based on issues arising from more than one case, such as recent neglect cases.

Local safeguarding children board chair Caroline Ball says: “The combination of these two ensures that the messages do get out.”

She adds that review authors can be brought back to train key people across the county, using anonymised case studies, altering factors such as age and gender.

In terms of neglect cases, she adds: “We organised a county-wide conference on neglect, and have produced our own guidance which will be disseminated across Norfolk.”

Ofsted slams serious case reviews

A quarter of serious case reviews are being conducted inadequately, according to Ofsted. It found that 25% of local safeguarding children boards in England did not file a single review between April 2006 and October 2007 and there were also “considerable” variations in the quality of 36 reviews.

Also between April 2007 and March 2008, councils in the North West recorded 38 deaths and other serious incidents involving children, compared with just 10 in the South West. This variation was largely due to “inconsistent reporting practices”, the report said.

Full report

This article is published in the 17 July issue of Community Care magazine under the heading “Little-known facts”

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