The first annual report of the National Panel of Independent Experts on Serious Case Reviews said the number of good serious case review reports are outnumbered by the number of reports that fail on key points.
It said problems included reports containing “irrelevant detail, jargon and acronyms that make it difficult to distinguish the key events”.
It also criticised reports for repeatedly listing what happened rather than why it happened.
The report said some SCRs also fail to look at human motivation and the role of “fear, exhaustion, overwork, timidity, wilful blindness and over-optimism” in decisions.
“The fundamental aims of an 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 reports states.
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