Faculty of Health & Social Care

Improving Safeguarding Practice:Study of Serious Case Reviews

2001-2003

Wendy Rose and Julie Barnes

Aims and methods of second biennial study

• To explore the value and impact of serious case reviews in improving safeguarding practice

• Focus on emerging themes and on conduct of reviews, recommendations, action plans, implementation and impact on practice

• From study of 40 case reviews which were completed in 2001-3, followed up by interviews and national stakeholder seminar

• Published January 2008

Children in the study: n=45

• Half under 2 years, two thirds less than one year; 9% were 3-4 years; 24% were 5-10 years; 20% were 11 years or older, 5 over 15 years

• Only 8 children currently on local child protection registers, 1 on interim care order; further 3 on interim care orders; 1 child adopted, living with adoptive parents

• Most children died (2 suicides); a quarter seriously injured &/or neglected

Key features and themes

• Disabled children - multiple family pressures • Older children – an important group, different

circumstances, needing more attention• Children growing up in families experiencing

neglect – a challenge for health, education and others in identification and intervention

• Significance of domestic abuse, co-morbidity with other problems (parental substance misuse, mental health) and the threat to children in the family

Implications for policy and practice• Keeping a child or children in focus when

attention is on adult family member needs• Gathering knowledge about family history• Ensuring children are seen by practitioners• Recognising the emotional impact of working with

children and families, when there is violence• Training practitioners on assessment framework• Addressing risk of harm in terms of evidence

from systematic reviews and family information• Focusing on analysis, decision making, planning• Improving interagency communication

Conduct of serious case reviews • Decision to hold a review not easy; rates varied• Very resource intensive: some complex and

difficult to complete, including inter-agency tensions and issues of confidentiality

• Varied enormously in length, style, presentation and time taken to produce, not necessarily related to complexity of case

• 14 overviews by internal author; 11 by external author; not recorded for 40%

• In 20% (8) evidence of family members contributing

Serious case reviews reports • Most contained overview of information,

genogram, chronology, analysis and summary of lessons

• Good practice highlighted in two thirds of reviews• Key issues about recommendations, number and

formulation - most up to 20 recommendations, 12 up to 40, one up to 60 and one had 80

• Issues about confidentiality in writing the report• Executive summary often hard to prepare• Frequently confusing, busy period at conclusion

of review – requiring careful management

Focus of recommendations• Generally not SMART nor strategic• Most frequently need for new or revision of

existing procedures (total of 198 in 40 reports)• Improved communication often cited (81 times)• Also frequently cited, need to improve

information sharing and recording• Assessment practice, including developing risk

assessments (74); training needs identified (72)• Management issues (44), supervision (20), roles

of staff (16) and decision making (15)• Staffing issues rarely figured (total of 12)

Action plans• Most actions directly linked to recommendations• Most were not strategic in approach• Half were single action plans for individual

agencies• Half specified lead officers and had dates for

completion of actions• Number of action points varied – 24% had 10 or

less; 71% had 40 or less; l had over 100• Most clear about intended action, less about

outputs, not about outcomes, what would be different? No costs included.

Mixed picture about impact of serious case reviews (interviews)

• New initiatives and procedures reported • Uncertainty about extent to which

recommendations were implemented fully • Concern that impact was limited • Concern that impact was not sustained • Need for more follow-up and review to establish

influence on policy and practice

Reflections and conclusions• Challenge is to make use of lessons from serious

case reviews and turn them into sustainable improvements in practice – need for commitment, leadership, investment across agencies

• Importance of using themes from reviews to address practice and management issues – locally, regionally and nationally

• Using ‘near misses’ for generating cross agency learning but requires trust

• Learning from success is important but under- developed –what do we do well and how can we do more of it?