What’s wrong with serious case reviews?

Ofsted has found that nearly half of serious case reviews are inadequate. Maria Ahmed investigates what needs to change

An overhaul of serious case reviews was one of a raft of child protection reforms announced by children’s secretary Ed Balls last week, in the wake of the Baby P case.

Ofsted not only found that the review into Baby P’s death was inadequate (see panel below) but its national evaluation of SCRs, published alongside Balls’ announcement, gave the same rating to 40% of reviews from 2007-8.

Ofsted chief inspector Christine Gilbert said: “We know that serious case reviews are generally successful at identifying what has happened to the children concerned – but are less effective at addressing why.”

In future, every SCR judged by Ofsted to be inadequate must be reconsidered by a panel chaired by an independent person, Balls said. Ofsted will then assess the panel’s report to see if it addresses the issues. Further action could be considered in areas that have more than one inadequate SCR.

At the heart of Ofsted’s concerns about SCRs is the lack of independence of the panel conducting the review from the agencies involved in a case. The issue is also raised by Lord Laming in an interim report to Balls from his current child protection review.

The Baby P SCR illustrates the problem. Like all local safeguarding children boards Haringey is required to have a serious case review panel to oversee SCRs. However, Ofsted found it was “insufficiently independent” because director of children’s services Sharon Shoesmith chaired both the panel and the LSCB.

Independent oversight

The inspectorate’s national evaluation of 50 SCRs conducted in 2007-8, Learning Lessons Taking Action, also identified concerns about the lack of independent oversight in other locations. It found that people from agencies involved in the case often sat on serious case review panels.

Most panels consisted “solely or mainly” of people who were also responsible for preparing reports on their own agencies’ involvement, known as individual management reviews. This made it “less likely” that SCRs would “critically examine” the practice of individual managers and staff, Ofsted concluded.

The evaluation also revealed that poor reviews occurred where agencies took a “defensive stance rather than an open and critical approach to learning lessons”.

Ofsted also found that some local safeguarding children board members wrote overview reports, which draw together all the evidence submitted to the SCR. This breached the requirement on boards to commission reports from people independent of all the agencies involved, set out in the 2006 Working Together to Safeguard Children guidance.

The inspectorate also questioned whether children’s directors should chair LSCBs, as Shoesmith did in Haringey, saying this made it difficult to hold local services to account when things went wrong.

Among its recommendations, Ofsted called for a “greater element of independence” in serious case review panels by including a wider range of professionals from outside agencies.

It called on the government to clarify the degree of independence required of chairs of LSCBs and SCRs, under Working Together to Safeguard Children (see guidance panel).

Laming, whose review was commissioned by the government after the Baby P trial, recommended that serious case reviews should be chaired by people “independent of each of the reporting agencies”, who could be “objective”. This is not specified by Working Together.

Balls has accepted Ofsted’s and Laming’s recommendations, although the government has not yet published details of what it will do. But as the sector awaits Laming’s full report, expected in February, the reaction to the proposals on SCRs has been mixed.

Suspicion of bias

Patrick Ayre, senior lecturer in social work at Bedfordshire University, supports the view that review panels should be chaired by an independent person, to avoid “any suspicion of bias”.

Ayre, who has written many overview reports, also backs the idea of making chairs of local safeguarding children boards independent. “Where the chair is a senior manager in any of the key participating agencies, there is an obvious risk of distortion of the LSCB’s agenda and priorities,” he says.

However, Colin Green, the lead on safeguarding for the Association of Directors of Children’s Services, warns against a “prescriptive” approach to who should chair boards.

There is “no evidence to show that one model of chairing is more effective than the other”, he says. “We understand the concerns about independence, but the remit of local safeguarding children boards goes beyond serious case reviews. There are real advantages to having directors chairing as they are right at the heart of other networks.”

Green, director of children’s services at Coventry Council, also believes there is no need to revise Working Together, arguing that authorities should focus on implementing it more effectively.

But he agrees that overview reports should be written by independent people, although he says there are problems with finding experts. “It is difficult to develop the right pool of people, and parachuting people in from outside of the main agencies is not always effective,” he says.

Ayres also points to a shortfall of experts, typically barristers, academics, private consultants and social care professionals from neighbouring councils. “They also need the full support of their managers and must be allocated appropriate resources, particularly with respect to time,” he says. He predicts this could cause difficulties for councils with “inadequate” SCRs who must now appoint independent people to review them.

Overview report authors

Liz Davies, senior lecturer in children and families social work at London Metropolitan University, calls for national guidance on the selection of overview report authors. Davies, who has chaired three serious case reviews, proposes the creation of a list of approved professionals in each region.

She also recommends more training on serious case reviews, and suggests this should be a requirement for authors of overview reports. Davies describes a recent training session on SCRs she attended as a good example of how to support staff: “The chair of the LSCB made it very clear it was a learning, no-blame environment and gave permission for full debate and analysis. This was an excellent and impressive example of how the process can be well managed.”

Ayre says that authorities need to ensure a “culture of frankness” when carrying out serious case reviews, including giving local safeguarding children boards the ability to challenge poor reports from agencies.

In the wake of the Baby P case, such good practice would seem more necessary than ever.

Guidance on independence in safeguarding

● Local authorities, following consultation with partners, appoint local safeguarding children board chairs.

● The chair can be an employee of one of the partner agencies, including the children’s services director.

● However, he or she must act “objectively” and distinguish their role as chair from their other roles.

● There is no requirement for SCR panel chairs to be independent, which would require revised guidance.

Source: Working Together to Safeguard Children, DCSF

Baby P serious case review

Inspectors deemed the serious case review of Baby P inadequate. Individual management reviews by Haringey children’s services and primary care trust “lacked rigour” and were found to “undermine the integrity” of the SCR. Crucially, the review failed to properly consider why agencies failed to discover that Baby P’s abusers were living in his home. Ed Balls has ordered Haringey to carry out a fresh serious case review of the Baby P case, and appointed former Kent children’s director Graham Badman as the new independent chair of the borough’s local safeguarding children board, replacing Sharon Shoesmith.

Related articles

 Ofsted report on SCRs

 More on Baby P

 Working Together to Safeguard Children

Ofsted: Professionals failing to learn from worst abuse cases

Ed Balls allows five MPs access to Baby P serious case review

Expert guide to child protection