DfE urged to consider SCRs for deaths of unborn babies

The National Panel of Independent Experts on Serious Case Reviews said that over the past year it has considered a small number of cases of stillbirth involving potential abuse to an unborn child.

The board's second annual report reveals that the nature of abuse in these cases was such that had the child been born alive but subsequently died, an SCR would have been required.

In 2013, there were around 3,300 stillbirths, where a baby born was dead after 24 completed weeks of pregnancy. If the baby dies before 24 completed weeks, it is known as a miscarriage or late foetal loss.

The panel has recommended that ministers consider whether a future review of Working Together 2015 guidance should extend the definition of "serious harm" to include serious harm to a child in utero where the child is stillborn.

The panel also said it has discussed whether cases where harm – but not serious harm to any one individual – had been caused to a considerable number of young people should be considered to be "serious harm" sufficient to trigger an SCR.

It decided that this falls outside the scope of "serious harm" as currently defined in Working Together and recommends that ministers also consider whether a future review of the criteria should extend the definition of "serious harm" to include such cases.

The report reveals that during the period July 2014 to June 2015, the panel was informed of decisions to initiate 168 SCRs. It also considered a further 107 notifiable incidents reported to it where a decision was taken not to initiate an SCR. The panel agreed that, in 86 (80 per cent) of these cases, an appropriate decision had been made.

During the same period in 2013/14, the panel was informed of the initiation of 184 SCRs. It considered a further 66 notifiable incidents reported to it where there had been a decision not to initiate an SCR, with the panel agreeing in 35 (53 per cent) of these cases that an appropriate decision had been made.

The panel's first annual report, published in August 2014, criticised the quality of SCRs, claiming they were "disturbingly variable", with many including "irrelevant detail, jargon and acronyms, that make it difficult to distinguish the key events".

The latest report reveals that there are still concerns about quality.

"Too many are still burdened with detail, whether relevant or not, whilst failing to present clear findings," the report states.

"These findings should include recommendations addressed to senior managers and national bodies as well as those to frontline practitioners.

The panel is also concerned about delays. It said many SCRs seem to take a very long time to progress to conclusion and publication, with figures from DfE suggesting that only 23 per cent of SCRs initiated in 2013/14 have so far been published.

"The panel remains of the view that there are many cases in which a proportionate, focused SCR can and should be capable of being conducted more rapidly and at less cost, with learning thereby disseminated at a point in time more proximate to the events under consideration.

"There still appears to be too great an emphasis on the methodology of report writing rather than on the production of a report which succinctly and clearly encapsulates what happened, why and what should be done to prevent a recurrence."