Overhaul of serious case reviews under way

Improvements in serious case reviews when children die or are seriously harmed are a crucial part of government plans to overhaul child protection guidance.

Proposals out for consultation this month suggest that all serious case reviews will have to adopt the “systems methodology” approach in future, as recommended by Professor Eileen Munro in her child protection review (see "Systems methodology", below).

The approach, developed by the Social Care Institute for Excellence (Scie) from a method rooted in the aviation industry, tries to uncover how the management and culture of an organisation have an effect on the judgments and actions of professionals.

The NSPCC is a strong advocate for the revised system, which it believes can more effectively uncover any problems agencies might be having, thus leading to the prevention of future tragedies.

Dave Tucker, the charity’s head of policy, says: “It is very good because it gets away from the current model, which looks to blame individuals and produce reams of guidance to prevent problems happening, but fails to consider the environment in which those decisions were made.”

The systems approach is designed to overcome the problem of recurring safeguarding errors, such as those identified in Ofsted’s analysis of serious case reviews published in October. Prominent among these are poor information sharing between different agencies and the lack of focus on the child’s voice.

Despite the absence of any formal evaluation, Scie argues that early findings from a series of pilots and training events on the systems approach, carried out among local safeguarding children boards (LSCBs), have been positive.

The institute’s analysis of its serious case review training in London found that children’s professionals welcomed the fact that the approach focuses on gathering views of frontline staff and “deeper level of analysis” of cases. 

Improved partnerships
Professionals also reported that partnerships across health, social care, police and other organisations involved in child protection improved, says Scie senior research analyst Dr Sheila Fish, who believes a shift to the systems approach is “long overdue”.

Fish says that under the current approach, individual management reviews are carried out separately across each agency and then fed into a final report, which fails to reveal any overarching problems.

“Across every high risk sector from aviation to patient safety to running a power station, this systems-based methodology is being used because it effectively improves safety,” she says.

The government and Scie do, however, acknowledge that it will take time for all LSCBs and professionals involved in child protection to adopt the approach.

Tucker says one barrier is the “simple logistics of unpicking the case, finding out who needs to be involved and getting everyone together”. “It’s an enormous challenge that cannot be underestimated,” he says.

Tim Beach, independent chair of Barnet LSCB, whose reviewers were among those involved in the Scie systems methodology training, says a cultural change is also needed.

“We are very positive about what this approach can achieve, but there are still people that are cynical or have concerns, particularly at a senior level,” he explains.

“Those involved have to ask themselves if they really want to change things for the better or not.”

One concern is that totally overhauling the way in which serious case reviews are conducted could be expensive, in terms of administering new procedures, training staff and bringing agencies together.

But Scie argues that adopting the systems approach need not have a high cost attached. Fish cites the example of one social worker involved in Scie’s training who used the systems approach to improve the way in which parents are challenged when abuse is suspected.

“This social worker looked at training across a number of professions,” Fish explains. “She realised that challenging parents was not something that many nurses, teachers and others were very comfortable doing. So at core group meetings, she paired up those who were comfortable challenging parents,with those who weren’t. This was a simple and effective way of addressing a problem using the systems approach.”



Systems methodology