How effective are case reviews in improving safeguarding practice?

Following the review into the death of Finley Boden, we asked social workers whether such inquiries really are helpful in learning lessons from serious cases to inform future practice

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Social work opinion is divided on how effective case reviews are in improving safeguarding practice, a Community Care poll has found.

In late March, the local child safeguarding practice review into the murder of 10-month-old Finley Boden by his parents, 39 days after his return to their care, was published. 

Though the inquiry acknowledged that practitioners’ jobs had been made harder by workforce pressures and lockdown restrictions, it found that a series of safeguarding failures ultimately led to Finley’s return to his parents, Stephen Boden and Shannon Marsden, and to his death.

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These included practitioners’ over-optimism about Marsden and Boden’s capacity to care for Finley and his elder sister, ineffective use of pre-proceedings and “very limited” multi-agency work.

Safeguarding reviews similar to Finley’s case have been conducted for decades to examine the factors behind the deaths of children and adults involved with social services. 

But while their aim is to learn lessons and, consequently, improve safeguarding practice, is this what they typically achieve?


A recent Community Care poll found that respondents’ views were divided on whether or not case reviews improved the quality of safeguarding.

Of 540 votes, 52% viewed such reviews as effective, with 37% saying they were “somewhat” effective and 15% opting for “very”.

However, 48% reported them being either “somewhat” (26%) or “very” (22%) ineffective.

One social worker in the comments of the related article questioned whether the review on Finley’s case delved deep enough into the wider systemic issues that contributed to his death.

“The review looks at the face value issues and missed opportunities, but how much of this could have been prevented if there were adequate staffing levels, lower caseloads and less pressure?” said Anna B.

“Don’t get me wrong, if an individual is neglectful in their practice this should be highlighted, but at what point does all the failings point to a failure in the system and funding rather than the failings of individual practitioners every time?”

What are your thoughts on the effectiveness of child and adult safeguarding practice reviews?

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5 Responses to How effective are case reviews in improving safeguarding practice?

  1. David May 11, 2024 at 5:31 am #

    Utterly agree with Anna B. There are insufficient bodies at the “front line”. This leaves those that remain there overburdened, and with pressures from managers for Social Workers to work excessive hours so to try to cover unrealistic targets and timescales for completion of work tasks. This in turn leads to SWs becoming tired/exhausted and as a result perhaps understandably so less attentive and sensitive to the circumstances that are being assessed. So yes it is the system that is failing SWs and those vulnerable children and adults they have become involved with. Some SWs have been saying this for many years

  2. Sue May 11, 2024 at 7:50 am #

    I completely agree with the individual practitioner. When cases are high, pressures from managers are poor and slow, these impact on the decision making of the social worker who are always the first ones to mentioned in such situations. In these reviews maybe they should start to question the hierarchy of management and consider effective and ineffective decisions they equally have an impact on workers.

  3. David May 12, 2024 at 1:11 pm #

    The reviews need to consider whether or not Children’s Services are sufficiently resourced to provide effective support to children and families and within a Social Worker’s contracted hours of work. There has been long-standing reliance on unpaid goodwill working by Social Workers. This has been and remains unjustified and exploitative. Can senior managers justify exploitation of its frontline staff when exploitation of others is contrary to the values of the social work profession?

  4. Helen May 13, 2024 at 1:06 pm #

    I have been a SW for 30years and the same things come up every time in the reviews – poor communication and missed opportunities.
    it seems that not much has changed.

  5. Paul May 13, 2024 at 3:55 pm #

    Every review outcomes seem to be cut/pasted from every one since year dot. More accountability needed and fresh thinking, maybe have couple of active practioners (social workers) on the panel so we move away from corporate senior manager speak?

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