Serious case reviews need reform, say academics

A Department for Education-commissioned report by academics into barriers to learning from serious case reviews (SCRs) has called on government to review their appropriateness as a process for disseminating lessons to frontline professionals.

It also calls for the creation of an ongoing database of national and regional learning from child deaths over time to identify key themes.

And it recommends that evidence-based learning tools are developed nationally to enable collective and also targeted learning.

The research team from Kingston University found that one of the principal barriers to learning from SCRs was that their “length, time and content” create an “ethos of blame, avoidance, apathy, defensiveness and increased workload”.

The report added that “the number and dispersal of SCRs nationally means it is difficult to give them all local attention, and what gets attention is then skewed and determined by national media selectivity and coverage”.

The team also found that:

• The numbers of recommendations that generate new policies and procedures is “overwhelming”.
• SCR reports are not accessible in terms of length and common language to make them meaningful and manageable to all users across different sectors.
• The SCR process is costly in terms of finance and capacity and may not generate the most useable or interpretable learning for local practice.
• The learning from SCRs is repetitive and can lead to lack of attention and engagement.

The report calls for the SCR process to be made “less resource demanding, more timely, and more engaging of frontline practitioners”.

It also suggests that SCR reports should be more succinct and shorter.

Most recent government statistics show that between April 2013 and March 2014 there were 114 serious case reviews commissioned and 71 published, compared with 2012/13, when 81 were commissioned and 31 published.