Serious case reviews ‘disturbingly variable’ in quality, finds expert panel

Report 'feeds the blame culture' hampering serious case reviews, says professor of social work at Kingston University

Local Safeguarding Children Boards have been criticised for producing serious case reviews of ‘disturbingly variable’ quality.

Key SCR problems

Irrelevant detail, jargon and acronyms make it difficult to discern the key events. These SCRs will not be widely read or understood.
SCRs that don’t ask ‘why’.
SCRs that fail to look at human motivation and at the crucial roles played by fear, exhaustion, overwork, timidity, willful blindness and over-optimism are unlikely to determine the root causes of critical decisions.
SCRs that fail to focus on the child or even address the child’s perspective.
Recommendations that are unclear, lack focus or are not addressed to specific individuals or organisations.

The first annual report of the national panel of independent experts on serious case reviews (SCRs) listed “irrelevant detail, jargon and acronyms” and “recommendations which are not clear, focused or addressed to specific individuals or organisations” as serious problems.

The panel’s report stated: “The fundamental aims of a SCR should be to find out what went wrong in the care of a child, when and why it did so, and what can be done to minimise the chance of the same mistakes being repeated.

“The panel’s view is that far too many SCRs fail to do this effectively.”

The panel consisted of barrister Elizabeth Clarke, head of international development at the air accidents investigation branch Nicholas Dann, The Times columnist Jenni Russell and NSPCC chief executive Peter Wanless.

They criticised the quality of SCRs, made recommendations (see box) for improving SCRs and raised serious questions over the non-initiation of SCRs, citing concern with the decisions into what constitutes ‘serious harm’ and is worthy of review.

However Ray Jones, professor of social work at Kingston University, hit back at the findings, saying the report “feeds the blame culture” hampering effective reviews.

“There is nothing in this report which would give reassurance to practitioners that SCRs are not a process for allocating blame,” Jones said. “The report speaks over and over again that SCRs are about identifying failure, mistakes and what went wrong.”

Jones also questioned the panel’s credibility as experts on SCRs and their knowledged and experience of frontline child protection work.

“The panel’s assumption that there must have been mistakes by practitioners and their agencies denies the complexity of working in child protection and possibly reflects that the four ‘expert’ panel members have no experience themselves of frontline child protection practice or its direct management,” he said.

He continued: “Recent research commissioned by the DfE suggests how our learning from terrible events might be better facilitated. It includes greater participation by practitioners, a less costly and lengthy review process and emphasis on reflection and understanding rather than assuming failure and poor practice. This report is all about blame and what went wrong.”

The panel highlighted common problems with SCRs (see box), including practitioners who fail to question why key mistakes occurred, such as why critical observations were missed or simply ignored.

The national panel of independent experts was established in 2013 to help safeguarding children boards ensure action is taken to learn from serious incidents and ensure those lessons are shared through the publication of final SCR reports.

Recommendations for improving SCR quality and enhancing learning

The Department for Education (DfE) should instigate in the next 12 months a review of SCRs produced under 2013 Working Together guidance, to judge how well they are measuring up and publish the findings. In the light of these, it must consider the efficacy of training it funded for SCR authors.
DfE should seek to demonstrate what a good SCR looks like and make this available.
DfE and Ofsted should ensure those local areas which have not submitted a serious incident notification in the last twelve months, or longer, have had no cause to do so.
The panel believes that the issue of cost should not be a factor in the decision as to whether or not to initiate an SCR. DfE should consider the resourcing implications of carrying out SCRs and discuss ways of mitigating this with the Association of Independent LSCB chairs.
DfE should seek to determine what negative effects, if any, the full publication of SCRs has caused.
DfE should take responsibility for considering how a repository of past reports could become a more active resource for learning.
DfE should consider reinstating the SCR biennial reviews, including a review of recommendations made and their implementation, as a useful facility for reviewing national trends in SCRs.
LSCB Chairs should ensure SCR authors appointed understand the need for any recommendations or findings made to be clearly defined and addressed.
LSCB Chairs should each ensure they have a mechanism in place to monitor the implementation of SCR recommendations.

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