Why do we not learn from serious case reviews?

Children’s services need to ask the question “why” more in serious case reviews and learn from the good as well as the bad, say Barry Raynes and Phil Green of children’s services consultancy Reconstruct 

(Picture caption: The importance accorded child safety is reflected in the reluctance to lower the road speed limit)

The fact the government does not reduce the national speed limit to 20mph to prevent more than 2,000 children being killed or seriously injured each year shows that child safety is only one desired outcome for society, government and politicians.

A similar logic can be applied to learning from serious case reviews (SCRs). Since 2007, our consultancy, Reconstruct, has undertaken serious case reviews involving 32 children in England and Wales. Not surprisingly, we found that the same errors and omissions were contributing time and again to agency failures to recognise and react adequately to the risks posed to a child. They have also been cropping up in SCRs and inquiries for years.

Why have lessons still not been learned?

One reason is that we look only at cases where things have gone wrong and, with hindsight, identify what probably contributed to the death or serious injury. We fail to discover, in all the other cases, what actions have helped prevent an incident.

And although the lessons apply to all professionals, to a greater or lesser extent, more professionals view SCRs as applying only to child protection staff. Yet, of the 32 children we reviewed – 15 of whom died, 13 of whom were sexually abused (one murdered her abuser) and four with sustained serious injuries – none was on a child protection plan or register at the time of the incident which led to the review. Only three had ever been.

Case complexity ignored

We often found that the complexity of a case was not acknowledged, and instead a single simplified issue was focused on. Allied to this was a reluctance to change the initial view of the family (either positive or negative), despite the continual drip of further information.

Assessments were often a record of questions and answers and previous information regurgitated. Information was collected but not properly analysed. There were also failures to consider what else needed to be discovered to complete the assessment.

It is easy to check whether staff complete forms within timescales but difficult to check the rigour of the analytic processing of a group of professionals.

In fact, we found a lack of analysis in many individual management reviews produced for SCRs. If senior managers have difficulty writing analytical reports, it is unlikely the staff they supervise will bring the necessary analysis to their own work. Narrative and descriptive case recording is evidence of work being done; it is more difficult to provide evidence to a case audit of the time spent pondering and speculating in an attempt to answer the question “why?”.

Deeply embedded problems

We estimate that our reviews have involved about 750 professionals and we believe that only one of them should have been sacked for incompetence. Rather, problems were deeply embedded in organisations. There is a concern that authorities, in trying to implement change after an inquiry or review, focus on avoiding blame should a child die, rather than preventing the death. They may establish a set of (often more elaborate) procedures to be followed, or provide a training event. Either way, individuals can be blamed next time, for not following processes or carrying out the right practice.

The Munro report criticises the present review process as being too focused on individual failings, and argues for a more systemic approach. Eileen Munro recognises that professionals fail, but believes that the focus should be on why they fail.

We agree with this approach and have, as far as possible, avoided recommending training or procedural rewrites, preferring instead a deeper consideration of problems. Any SCR panel is hampered in this regard by Ofsted’s emphasis on SMART recommendations (Specific, Measurable, Achievable, Realistic, Timely), which are appropriate for something simple but useless for something complex.

NHS guidance

The NHS guidance on learning from adverse events, An Organisation with a Memory, states that “There is a distinction between passive learning (where lessons are identified but not put into practice) and active learning (where those lessons are embedded into an organisational culture).”

If we look at the experiences of children in care, children’s services are not good at active learning. As our colleague, Jason Williams, says ” I am constantly surprised that children bother to continue telling people about their experiences of being in care, as the only logical conclusions are that those asking either don’t care, don’t believe, don’t listen or are powerless to do anything to help.”

Which begs the question, will organisations ever learn from systemic serious case reviews if they don’t yet listen to the voices of the children in their care?

● Barry Raynes and Phil Green worked on 32 SCRs through Reconstruct

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This article is published in the 21 July 2011 edition of Community Care under the headline “Let’s stop repeating the same mistakes”