Ofsted and fellow inspectorates reveal serious case review failings

Inspectors have uncovered failings and wide variations in agencies’ responses to child deaths caused by abuse or neglect.

A quarter of the 36 serious case reviews received by Ofsted since April 2007 were inadequate, according to the third joint chief inspectors’ report into safeguarding children in England, which measured performance from 2005-8.

Reasons included insufficient focus on the child, lack of rigour in challenging practice shortcomings and failure to identify or address information gaps. In three cases, reviews failed to secure the co-operation of key partner agencies.

Since taking over the inspection of children’s social care in April 2007, Ofsted has introduced a new process for evaluating serious case reviews, including capacity for ensuring lessons are learned.

The inspectorates – also including the Commission for Social Care Inspection – revealed a quarter of local safeguarding children boards did not file a single SCR from April 2006 to October 2007, and local variations in the number of SCRs were not fully explained by the number of deaths in each area.

Under the Working Together to Safeguard Children guidance, boards must carry out SCRs when a child dies through suspected abuse or neglect and consider them when children sustain life-threatening injuries through abuse.

The report said LSCBs were interpreting the guidance inconsistently, with some using case file audits instead of serious case reviews.

There were also regional variations in deaths and serious incidents involving children in 2007-8, ranging from 56 (38 deaths) in the North West to 17 (11 deaths) in the East Midlands, mainly owing to “inconsistent reporting practices”.

Sue Dunstall, policy adviser to the NSPCC on child deaths, said a national picture was needed “so government policy can be adapted accordingly, but it seems we’re not getting this.”

She said LSCBs ought to explain why they were not carrying out SCRs in relevant cases.

Colin Green, the safeguarding lead at the Association of Directors of Children’s Services, said a minimum level of competence should be expected of SCR authors and that they should come from different backgrounds.

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