Quality of serious case reviews blasted by independent panel

Neil Puffett
Friday, August 1, 2014

The quality of child death reviews are "disturbingly variable" with far too many failing to find out what went wrong, a damning report by a government appointed panel has found.

The independent panel said that there were more poor serious case reviews than good ones. Picture: Phil Adams
The independent panel said that there were more poor serious case reviews than good ones. Picture: Phil Adams

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.

“The panel’s view is that far too many SCRs fail to do this effectively.”

The panel also expressed concern about decisions taken over whether or not to initiate a serious case review.

Under current guidance an SCR must be carried out by a local safeguarding children board (LSCB) if abuse or neglect of a child is known or suspected, and either the child has died, or the child has been seriously harmed and there is cause for concern as to the way in which the authority, or other relevant agencies have worked together to safeguard them.

An LSCB can still choose to initiate an SCR if the criteria are not met.

Since it became operational in July 2013, the panel has been informed of 184 SCRs being initiated, but it said that 49 LSCBs – representing more than a third (34 per cent) of the total in England – were yet to get in touch with the panel.

“Although some of these may legitimately have had nothing to report, the panel takes the view that this is unlikely to be the position with all,” the report states.

It adds that, of the LSCBs that have been in contact with the panel, there is “clearly a deep reluctance in some instances” to initiate an SCR.

“The panel has, on occasions, found the logic tortuous and considerable effort expended on finding reasons why an SCR is not required.”

The panel said some LSCBs are failing to make rational decisions on what constitutes “serious harm” – deciding that serious harm has not been suffered if the victim subsequently recovers from injury, regardless of the severity of the original injury, or the circumstances.

It suggests that the “financial and workload implications” of SCRs could be behind the reluctance to initiate them.

“The panel’s view is that opportunities to learn from mistakes are being overlooked in the argument over where the SCR initiation line is drawn,” the report states.

“It is essential that everyone sees lessons for children’s protection (looking backwards and forwards) as the central issue, not the need to abide only by the letter of the law,” the report states.

The report calls for the Department for Education (DfE) to carry out a review of SCRs initiated since the most recent guidance – Working Together to Safeguard Childrenwas published in March 2013 to decide whether training it has funded for SCR authors is effective.

It also calls on the DfE and Ofsted to investigate whether those authorities that have not initiated an SCR in the past 12 months have genuinely had no cause to do so, and says the DfE should consider reinstating biennial reviews of SCRs so national trends can be spotted.

An NSPCC spokesman said many SCRs don’t seem to be answering fundamental questions about why key decisions were made.

“It’s very concerning that good reports are outnumbered by those failing on key points," the spokesman said.

“All SCRs must get to the heart of why something has happened and what should be done to prevent it happening again. Reports all too often fail to determine the underlying causes when mistakes are made, whether these are due to individual error, organisational failure or overstretched professionals.

“All too often we hear that ‘lessons must be learned’ without any real confidence that the same mistakes won’t be made in future.”

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