Does the revised guidance on serious case reviews go far enough?

Changes to the serious case review system are welcome but until the reports are published in full there will be limited opportunities for learning from mistakes, writes Amy Taylor

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Opinion is divided on publishing serious care reviews in their entirety, even anonymously. The revised guidance reinforces the current position where only executive summaries are published.

Sue Woolmore, the NSPCC’s local safeguarding children board adviser, believes this is the correct decision, given that many full reports hold confidential information on people other than the child. She says it would be impossible to anonymise them enough to prevent possible identification, making professionals less open out of fear that the media might work out who they are.

However, child protection consultant and trainer Perdeep Gill questions how much can be learned from executive summaries and wants reviews to be published in full. “When I look at the executive summary of the second baby Peter SCR, it is good but there are still lots of questions,” she says.

Community Care shares Gill’s concerns. In its submission to the Laming review, Community Care called for SCRs to be published anonymously in full to maximise learning, and for copies of the full report to be made freely available.

We believe that anything less than this will severely limit the potential for learning from others’ mistakes – and make it more likely that these mistakes will be repeated.

Read why shadow children’s minister Tim Loughton believes SCRs should be published in full

The issue:

Serious case reviews (SCRs) are supposed to identify lessons to safeguard children in a no-blame environment. Yet these good intentions often remain just that as many fail to adequately analyse practice and are feared by the very people and agencies they ought to help.

The media spotlight turned to SCRs in November 2008, when Ofsted found the first serious case review into the case of Baby Peter to be inadequate and children’s secretary Ed Balls ordered a second.

However, concerns were publicly raised months before this in July 2008 in Ofsted’s first evaluation of the SCR process. This found that a quarter of the 36 SCR reports received by the inspectorate after it took over responsibility for inspecting children’s social care in April 2007 were inadequate. A second evaluation, published in December 2008, found 11 of a further 14 reviews carried out between April 2007 and March 2008 were also inadequate.

When a child dies or is seriously injured through suspected abuse or neglect, professionals need to understand not only what has occurred but to analyse mistakes made by agencies or individuals to ascertain the why and how.

Yet Ofsted’s evaluations found many reviews shy away from rigorously challenging practice shortcomings, and fail to examine the reasons behind people’s actions. In the first review into the death of baby Peter, for example, the process crucially failed to properly consider why agencies had failed to discover that baby Peter’s abusers – the mother’s boyfriend and his brother – were living in his home.

The failure of some reviews to address why incidents occur has been acknowledged by many, including Ofsted and Lord Laming.

Revise Working Together guidance

In March 2008, in his progress report on child protection services, Laming called on the government to revise chapter 8 of the Working Together to Safeguard Children guidance to improve the SCR process. The government accepted all of Laming’s recommendations and, at the end of July, put revised SCR guidance out to consultation.

Responses to the revised chapter 8 guidance vary across the sector. Some are optimistic that the proposals will succeed in making reviews the open, positive experience they are meant to be, while others feel the plans fall short and will not bring about fundamental change.

In his report, Laming called for the remit of serious case reviews to be widened and made more explicit.

In response, the revised guidance proposes a new requirement for staff to be interviewed if policies and procedures have not been followed. It emphasises the importance of SCR overview reports by independent authors being clear on where systems can improve.

It also says reviews should consider the impact of organisational difficulties experienced in or between agencies at the time, such as whether there were enough staff, whether people were off sick and whether the resources were adequate.

Praise for the changes

Sue Woolmore, local safeguarding children board adviser to the NSPCC, is positive about the changes and says there is a good chance they will lead to more analysis and less box-ticking. She also praises an extension of the timeframe in which reviews must be completed from four to six months.

“I’m optimistic that, by reviewing the chapter at this stage, we can move away from serious case reviews being procedure-driven,” she says.

“There has been so much focus on ­ensuring that the right boxes have been ticked and that deadlines are met that the quality has been compromised. And nobody wants that.”

Woolmore adds that the inclusion of agencies’ organisational problems in analysis is an important change because these factors often influence practitioners’ decisions.

However, child protection trainer and consultant Perdeep Gill warns that the changes fall short and do not create a review process sensitive enough to understand the reasons behind professionals’ actions.

“I don’t think there’s enough about why,” Gill says. “We need to know why it is that competent social workers make mistakes. It’s only with that kind of information that we can help them.

“In terms of the baby Peter case, the crucial question was how did [the mistakes made by his social worker] come about? And I don’t think [the reforms] they are suggesting would give us that.”

Learn the lessons

The revised guidance emphasises that the prime purpose of SCRs is to learn lessons to improve both individual and interagency working. It says the process should take account of findings of the local safeguarding children board’s (LSCB) previous reviews and research, and that executive summaries should be shared with all relevant parties, including partner inspectorates and monitoring organisations as well as Ofsted. Staff would also be more involved in the process, with the guidance creating a requirement for feedback sessions to be held with professionals involved once the overview report has been completed.

Roger Thompson (right), chair of Doncaster’s LSCB, acknowledges a fear of SCRs in some areas, where the process is seen as a way for individuals and agencies to be held to account and blamed by the media and the public. He is optimistic that the revised guidance will restore professionals’ confidence.

“It’s what we need,” he says. “What we don’t want is [for people] to avoid doing serious case reviews. We want them to be a positive experience.”

Four-month deadline

Faced with the pressure of meeting the existing four-month deadline and the prospect of Ofsted perhaps ruling their report inadequate, independent overview report authors find the current process stressful. This is exacerbating the shortage of report authors, with people unwilling to put their reputation on the line.

Woolmore says the pressure felt by authors, coupled with the fear of those discussed in the review, means some reviews are “hijacked due to there being such high anxiety around them”, resulting in the ethos of learning lessons being lost.

“There’s been so much interest from the media, the public and sometimes politicians about what the judgements mean that people have become concerned about the potential of receiving a negative judgement that could be interpreted in different ways,” Woolmore adds.

A criticism shared by Ofsted and Laming is the lack of independence between the SCR panel that conducts the review and the agencies involved in the case.

Genuine scrutiny

The new guidance, in line with a ­recommendation from Laming, states that, to ensure genuine scrutiny, an SCR panel chair should not be a member of their LSCB unless they are its independent chair. This problem was highlighted in the baby Peter case, in which Ofsted found the SCR panel to be “insufficiently independent” because ­children’s services director Sharon Shoesmith also chaired the panel and the LSCB.

Ofsted’s evaluations also raise concerns that SCR panel members are often from agencies involved in the case, and carry out the independent management reviews into their own agencies which then feed into the SCR. It highlights a lack of honesty in some reviews as a result.

However, the revised guidance will not eliminate this potential for dishonesty, allowing members of agencies who are also panel members to continue to carry out independent management reviews into their own agencies – providing not all panel members are in that position.

Gill says that, even if different people from those on the SCR panel carry out the management reviews, the potential for compromise is still too high.

“The individual reviews are powerful and it doesn’t matter how good the individuals doing them are, the pressures around wanting to protect [their colleagues or their agency] is a temptation,” Gill says. “I would like SCRs to be taken out of the hands of local authorities altogether.”

The SCR process has the potential to provide unparalleled insight into how to prevent harm to children. It is now up to everyone in children’s services to respond to the SCR guidance consultation before it closes on 23 October to ensure this unique opportunity to create a truly learning-centred SCR system is not missed.

Proposed changes to serious case reviews

● Reviews to be more focused on learning lessons to improve individual and interagency working, and for learning to be included in local training programmes.

● More emphasis on acting on lessons as well as learning them.

● More account to be taken of previous SCRs carried out by the local safeguarding children board (LSCB) and relevant research.

● Staff to be given feedback after the overview report is completed.

● A greater emphasis on the need for objective and open analysis of where systems can be improved, and the reasons why procedures and policies may not have been followed.

● A new requirement for executive summaries to be shared with all relevant interested parties. This includes partner inspectorates and monitoring organisations as well as Ofsted.

● A greater focus on considering the impact of organisational difficulties on a situation, such as staff sickness or a lack of resources.

● Extending the timeframe for completing SCR reports from four to six months.

● A new rule that an SCR panel chair must not be a member of their LSCB unless they are its independent chair.

● A greater focus on anonymity for everyone involved in the case.

● More consideration of ethnic, cultural or other equality issues.

● A new system under which Ofsted will publish six-monthly reports evaluating reviews carried out during this period. Every second report will include an in-depth analysis of a particular issue.

Free SCR reference mail

E-mail us to get a copy of an expert-written reference manual on serious case reviews from Community Care Inform, Community Care’s online information service for professionals working with families and children.

Further information

Current Working Together to Safeguard Children guidance

Proposed new version of chapter 8

Ofsted’s national evaluation of serious case reviews covering April 2007-March 2008

Ofsted’s first set of SCR evaluations is in the Third Joint Chief Inspectors report into safeguarding children in England

Laming’s review of child protection

Community Care‘s coverage of the baby Peter case

Published in 3 September 2009 Community Care under heading ‘It’s the Why that’s Missing’

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