Latest child protection tragedy puts spotlight on new-style case reviews
Neil Puffett
Tuesday, August 20, 2013
Safeguarding experts hope that the Daniel Pelka serious case review will consider the conditions professionals were working under when it reports its findings into the circumstances surrounding the four-year-old's death.
Amid the media comment, heart-rending photos and public horror at the cruelty two adults subjected upon a boy for whom they were responsible, coverage of the death of four-year-old Daniel Pelka has had a sadly familiar air to it.
As in previous high-profile cases, questions have been asked about the actions of the agencies and professionals who had regular contact with him.
While there is no national inquiry in the pipeline, in common with the deaths of Victoria Climbie and Peter Connelly before him, a review of Daniel's case is likely to lead to a raft of recommendations about how to avoid similar tragedies in the future.
But as well as the focus being on establishing the chain of events, the process used in this serious case review (SCR) - due for publication within the next month - will also be closely scrutinised, as it will be the first high-profile case to use updated investigatory methods.
Systems approach
Coventry's Local Safeguarding Children Board (LSCB) has confirmed that it will be using elements of the new "systems approach" model alongside more traditional SCR techniques.
The approach was recommended following Professor Eileen Munro's review of child protection in the wake of the Peter Connelly case.
She had criticised the traditional system as being too focused on errors rather than "looking at good practice and continually reflecting on what could be done better".
Instead, she recommended the use of the systems approach, which tries to uncover how the management and culture of an organisation have an effect on the judgments and actions of professionals.
Sue Woolmore, chair of the Association of Independent LSCB Chairs, says the systems approach should allow the decisions that were taken in relation to Daniel to be placed in context.
"We know from our practice that these things sometimes do happen," she says. "It is the human element that goes wrong. You can't proceduralise the human element out of child protection, and any SCR method needs to recognise that.
"None of us are working in a vacuum and child protection at the moment is in a huge state of change - with the changes to the NHS, policing and probation, and local authority access to resources.
"These seismic changes will have an impact on frontline ability to respond to families. We need to be able to discern how we can exercise the best possible professional judgment in those circumstances.
"The old SCR methodology had become a blunt instrument and no longer fit for purpose. LSCBs can now be more creative and find ways of carrying out a review that makes more sense in the local context."
Full potential
However, Woolmore admits it will take time before the systems approach is utilised to its full potential. "Quite a few LSCBs have experience of using systems methodology, not necessarily for serious case reviews, but for other cases below the threshold," she says. "But it is still early days.
"While LSCBs have this new freedom, it is going to take us a while to test out methodologies and find out what works well."
The Social Care Institute for Excellence (Scie) is already working with one-third of all boards in England to develop their capacity to use its Learning Together systems approach.
So far, more than 60 case reviews have used the Learning Together approach. The lessons learned from the reviews are due to be published later this year.
Ray Jones, professor of social work at Kingston University, says the traditional approach relies too heavily on records, with no understanding of the sense of what people did at the time.
"It bases judgment on the 'perfect' scenario or way of doing things," he says. "Whereas the Scie model means meeting with people and speaking to them about what they did and why they made the judgments they did. Too many SCRs talk about communication without taking any account of how busy people were, what they were coping with and their workloads."
But Woolmore says LSCBs cannot rely on SCRs alone, and must maintain a "running commentary" on child protection services. "That can only be done by spending time with people on the frontline - trying to get feedback from children and families," she says.
David Jones, a member of the British Association of Social Workers (BASW), and former president of the International Federation of Social Workers, says SCRs had become "ritualistic".
"They were generally finding very similar things, but were not helping our understanding of why they were happening. We have to understand why these problems keep being repeated.
"It is not sufficient to keep blaming individuals. It has to be about what organisations can do to make the system safer for practice. That immediately puts the focus back on the organisation rather than the individual."
Learning from SCRs
However, Jones fears that even if the new SCR methods uncover issues that need to be addressed, changes may not happen because learning is not being disseminated effectively - both at a local and national level.
"The feedback BASW has had from members is that in many situations, learning from SCRs is not effectively disseminated to practitioners and doesn't feed back into training and learning.
"The government used to publish a national biennial review of serious case reviews, but has stopped doing that. I don't think we have a rigorous enough system for pulling together learning from SCRs."
Jones adds that the systems approach is likely to highlight the impact of local authority cuts in terms of increased workloads due to less investment in early help services.
"When there are significant reductions in support services and early help services it affects the ability to help families avoid getting into difficulties. Many chairs of safeguarding boards see it as the most difficult time for child protection in our professional careers."
Mor Dioum, director of the Victoria Climbie Foundation, wants SCRs to be more "inclusive" by involving family members, unless they have been convicted in connection with the case.
"In the case of Daniel Pelka, the biological father and grandmother should be involved and we have been trying to contact them," he says. Dioum also points to the fact that in some instances a child death review process is carried out rather than a full SCR.
In 2011, CYP Now revealed a sharp drop in the number of SCRs carried out following the coalition government's announcement that all reviews must be published in full.
"The only way to stop that is to make the process mandatory," Dioum says. "It is being perceived as washing their dirty linen in public. But the learning should override any other issues in these circumstances."
TRADITIONAL SCR
- Aims to establish if there are lessons to learn about the way in which local professionals and organisations work together to safeguard children.
- The Local Safeguarding Children Board gathers information about how relevant organisations and professionals dealt with the child and family.
- Information is collected in a standardised format called an Individual Management Review (IMR).
- IMRs include a chronology of an organisation's involvement with the child and family, an analysis of that, lessons learnt and action points.
- The method was criticised by Professor Eileen Munro for being too focused on errors rather than "looking at good practice and continually reflecting on what could be done better".
SYSTEMS-APPROACH SCR
- Originating in the aviation industry, it supports an analysis of a situation that goes beyond identifying what happened to explain why it happened, recognising that actions may be taken for good reason.
- It stems from the idea that workers' performance is a result of their skill and knowledge, and the environment in which they work.
- It lends more weight to interviews with staff to find out what they were thinking when they made decisions.
- It identifies which factors create unsafe conditions for safeguarding and highlights what supports good practice.
- It was advocated by Professor Eileen Munro in her review of child protection in 2011. Working Together guidance allows councils to use the systems approach in SCRs.
INVESTIGATION TIMELINE
January or February 2010: Magdelena Luczak and Mariusz Krezolek move into a flat together, assuming joint care of Daniel
5 January 2011: Daniel breaks his arm. Doctors, police and social services are told the injury occurred when Daniel fell off a sofa, but it was at the hands of Krezolek
14 June 2011: Social services investigate but close the case after evidence is reviewed
26 August 2011: A health visitor goes to Daniel's home on an unrelated matter. Luczak says that her son has a problem with his "excessive appetite" and a referral is made to the school nurse
September 2011: Daniel starts as a reception class pupil at Little Heath Primary School
7 October 2011: Text messages show that Daniel is routinely "imprisoned" in a box room
November 2011: Daniel's teacher starts to notice that he is "stealing" food from others
December 2011: Daniel's school attendance rate falls to 63 per cent. He eats food from bins
January and February 2012: Teachers notice Daniel appears to have lost weight over Christmas. They also notice a bump on his head, bruising around his neck and what appear to be two black eyes
10 February 2012: Daniel's doctor observes that he is thin but not "wasted"
1 March 2012: Daniel suffers a fatal head injury after being beaten
3 March 2012: Luczak reports her son is no longer breathing. Daniel is pronounced dead at 3.50am. He has 10 bruises on his shoulders and back, is very emaciated and his hair is thin
5 March 2012: A strategy meeting involves police and other agencies. A doctor is "horrified" by Daniel's emaciation. Luczak and Krezolek are arrested.