Serious case review analysis identifies recurring safeguarding errors

Ages of Concern: Learning Lessons from Serious Case Reviews focuses on lessons learnt over the past four years from reviews of serious incidents involving babies under the age of one and children over 14.

Of the 482 serious case reviews evaluated between 2007 and 2011, which involved 602 children, 35 per cent were babies aged under 12 months and 18 per cent were children aged 14 and over.

Shortcomings in timeliness and quality of pre-birth assessment, which is aimed at identifying risks early, were found in many of the cases involving babies.

There were also repeated examples of agencies underestimating the risks for children arising from their parents’ background and lifestyle, whether they related to drug or alcohol misuse or domestic violence.

Some reviews were found to focus too much on the mother’s needs at the expense of the baby. There was also inadequate support for teenage parents who should be considered as children in need themselves.

Health agencies were singled out for failing to consistently ensure coordination between services such as midwifery, health visitors and GPs.

For children aged 14 and above, cases reviewed showed the complexity and range of risks teenagers face including alienation from their families, school difficulties, accommodation problems, abuse by adults, unemployment, substance abuse, and mental health problems.

Problems identified in case reviews included agencies failing to understand the causes of challenging behaviour and some young people being treated as adults because of confusion about their legal status or availability of age-appropriate facilities.

Chief inspector Miriam Rosen said: "Our analysis of the lessons to be learned from the serious case reviews we have evaluated over the past four years reveals recurring themes which contribute to failures to protect children within these age groups. I hope the reports will help local safeguarding children boards and practitioners alike to review their own practice and be alert to the potential gaps in protecting children of all ages."

Hilton Dawson, chief executive of the British Association of Social Workers, said early identification, which is needed in these cases, is costly and timely.

"Early identification work and intervening to support older children can be costly and time consuming and few social workers are currently able to point to an excess of either," he said. "Ofsted's leaders would serve children better if they were to instead highlight the many challenges facing service providers in trying to safeguard the lives of so many vulnerable children and young people."

A further report published by Ofsted examined 11 local authorities who have focused on ensuring young people do not enter the care system.

Edging Away from Care found that young people and families found the involvement of a key worker as crucial in avoiding the path to care.