Serious case reviews should ‘shed light’ on constraints facing practitioners

Serious case reviews should better reflect the context in which poor decisions were taken by practitioners, according to a report.

The NSPCC and Social Care Institute for Excellence guide set out 18 ‘quality markers’ for safeguarding children boards to consider when commissioning serious case reviews (SCRs).

The report was commissioned by the Department for Education as part of a suite of resources on learning from serious case reviews.

The guide said serious case review findings needed to better reflect the explanations behind professional practice if organisations were to improve. Simply describing practice problems in cases was “not sufficient”.

Need to ‘shed light’ on challenges

The report advised those leading serious case reviews to “minimise the influence of hindsight and outcome bias” when evaluating practice. Reviews should also provide an explanation of why decisions were made as well as “shedding light on routine challenges and constraints to practitioner efforts to safeguard children”.

The report said: “The purpose of SCRs is to support improvements in safeguarding practice. This means it is not sufficient to describe professional activity in a case or to identify elements of practice that were problematic, without explaining why they occurred.

“The analysis needs to identify what has led to and sustained the kind of practice problems that the case reveals, so as to focus improvement efforts.”

Family and practitioner engagement

The report stressed the value of ensuring good levels of involvement from families in influencing the focus of reviews and set out ways to overcome common barriers to family involvement.

“Clarity about confidentiality and how their input will be represented can support participation in the SCR where family members are fearful of repercussions from wider family or community,” the report said.

“Additional support can also enable family members to be involved where there are issues such as domestic abuse. Specialist organisations, such as the Victoria Climbié Foundation of Advocacy After Fatal Domestic Abuse (AFFDA), provide something akin to mediation services that help to facilitate a constructive dialogue between families and agencies.”

Enabling practitioners to take part “constructively” in the SCR process also improved the quality of reviews, the report said.

“Their input is critical to understanding why individuals acted as they did and what was influencing their practice, including routine ways of doing things. How they experience being involved is important. SCRs can be frightening and threatening and employers have a duty of care to all staff, which requires them to provide adequate support.”

Safeguarding children’s boards needed to ensure processes were in place to review the impact of each Serious Case Review, the report added.

“These should judge not only whether actions have been achieved but also whether they have made a difference to safeguarding practice.”