Improving the standard of serious case reviews

 Downham: “As a social worker I’m determined to ensure that the people who are at the receiving end of services are treated fairly”

Gillian Downham is leading a bid to improve the chairing of serious case reviews and other inquiries, and to improve lesson learning from them. Vern Pitt reports

In order to improve any process you have to start by asking the right questions, says former social worker Gillian Downham, who has launched a training programme for chairs of serious case reviews and other serious incident inquiries.

Downham, who has chaired five inquiries into killings involving mental health patients, saw the importance of the right questions being asked when following up the recommendations from a recent inquiry.

She was presenting the progress on implementing the recommendations to the son of the deceased. “He asked, ‘how long does it usually take to implement these recommendations?’. Now that was a question,” she recalls. “How would we know? No one had ever tried to measure it before.”

Downham, a barrister and mental health tribunal judge, realised that improving the implementation of her reviews’ recommendations meant that the reviews themselves needed to change. But there was a problem, she says: “It became evident to me that there was nothing in the way of guidance for those chairing these investigations.”

At the same time, conversations with other chairs conducting SCRs in children’s or adults’ services showed her that the skills required across the board were the same.

“They were all making similar recommendations to similar bodies and you were often investigating similar services,” she says.

Downham realised a common training programme and framework for conducting reviews was needed.

She teamed up with social work academics Wendy Rose and Roger Bullock, both SCR experts, and produced a document outlining core competences they identified as necessary to carrying out reviews. The document outlines the experience, knowledge, skills and responsibilities that will make for a successful review chair.

The next step takes place in June and July when Downham has organised three seminars aimed at developing a better understanding of how to conduct reviews.

There is one common mistake that she feels good training can remedy straight away. “It is not good enough to say communication should be better, communication should always be better,” she says. “It’s too easy to be drawn in to recommending things because they seem like a good idea. It has to be based on the circumstances.”

Downham says she always sends recommendations in draft form to heads of services before they are published in the report to ensure that they are workable and realistic. She says this doesn’t compromise public accountability because, contrary to media portrayal, much of the time those conducting reviews and the services they are examining acknowledge they are all working towards a common end.

Another core need to be addressed is increasing the involvement of families and service users. However, this presents challenges. “The difficult bit is being fair with your hearing and being sure that you hear objectively. Don’t get caught up with hearing from groups of people [rather than individuals], which is very tempting,” she says.

She attributes her approach to her own social work background and social work values. “As a social worker I’m determined to ensure that the people who are at the receiving end of services are treated fairly and their views are understood,” she says.

It’s important to be clear, however, that the review itself is just one part of the process, says Downham. She says the rampant media attention that accompanies the publication of a review gives it an artificial level of importance when, at that point, the key job of implementation is yet to begin.

Downham has had discussions with universities about developing a qualification for people chairing reviews. She argues this would help commissioners feel more comfortable about hiring people to carry out reviews and it may lend chairs the confidence to step outside of their comfort zone – usually their previous line of work. Hopefully, it will also improve outcomes for families and the public too.

Downham has set up a social enterprise with professor Roger Bullock and Wendy Rose aimed at improving SCRs and implementing their lessons.


● Involve the family at all points in the process.

● Don’t be generic; base all recommendations on evidence.

● Consult service chiefs on how workable your recommendations are and ensure progress is measurable.

● Return for further reviews one year and two years after the initial report.

Source: Gillian Downham

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This article is published in the 3 February 2011 edition of Community Care under the headline “The secrets of a good chair”

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