Sharp fall in serious case reviews triggers concern

Official figures reveal reluctance among councils to “wash dirty linen in public” after government’s decision to publish serious case reviews in full.

The number of official probes into child abuse, neglect and deaths has dropped sharply since the controversial policy of publishing serious case reviews in full was introduced, an investigation by CYP Now has found.

The number of official probes into child abuse, neglect and deaths has dropped sharply since the controversial policy of publishing serious case reviews in full was introduced, an investigation by CYP Now has found.

The number of official probes into child abuse, neglect and deaths has dropped sharply since the controversial policy of publishing serious case reviews in full was introduced, an investigation by CYP Now has found.

New figures show that 136 serious case reviews (SCRs) were initiated in England in 2009/10 — an average of 11.3 a month and a figure similar to 2008/09 and 2007/08.

But in the 10 months between 1 April 2010 and 31 January 2011, which includes the first months in which local safeguarding children boards (LSCBs) have been required to publish SCRs in full, just 58 have been initiated – an average of just 5.8 a month. The policy was implemented on 10 June last year. The number of times LSCBs are notifying Ofsted of serious incidents has also fallen.

Both the Conservatives and Liberal Democrats backed full publication of serious case reviews in the run-up to last year’s general election as a way to boost transparency and learning in the wake of the Baby Peter tragedy.


Anne Marie Carrie, chief executive of Barnardo’s, described the drop in notifications and reviews as “concerning”.

“The full publication of SCRs was introduced to ensure critical lessons are learnt which will save lives,” she said. “The welfare of the most vulnerable children must be the only focus here; transparency is key and not being willing to learn the lessons is not an option.”

Children’s minister Tim Loughton told CYP Now he was aware of concerns that full publication could lead to a reluctance to initiate reviews. “Certainly, people have warned that this might be the case,” he said. “It is something I’m sensitive to.”

He added that Eileen Munro is looking at serious case reviews and “looking at changing the whole way SCRs are done” as part of the review of child protection.

“Like me she doesn’t believe they (SCRs) are the be-all and end-all,” he said.

But fears have been raised that the government’s intention of introducing a more transparent safeguarding system has in fact had the unintended consequence of councils choosing to undertake internal reviews to avoid the glare of publicity that surrounds serious incidents.

Documents obtained by CYP Now under the Freedom of Information Act reveal a concern with the switch to full publication, combined with issues around cost and the possibility of negative publicity for councils.

“The challenges of ongoing government changes and reduced budgets, along with local authority reluctance to ‘wash dirty linen in public’ affecting decisions to initiate serious case reviews were expected to continue,” internal minutes of a Youth Justice Board meeting document, from August 2010, stated.

Guidance on SCRs, detailed in the government’s Working Together to Safeguard Children document, outlines when LSCBs should undertake SCRs as well as when SCRs should be considered, although it is the LSCB that takes the final decision.

Colin Green, chair of the families, communities and young people committee for the Association of Directors of Children’s Services, said councils are not failing to adhere to guidance but might be opting for cheaper review methods.

Green estimated that a SCR usually costs more than £10,000, whereas the use of alternatives, such as the multi-agency “systems approach” for case reviews developed by the Social Care Institute for Excellence, can result in “very substantial savings”.

The “systems approach” draws from other sectors that have to deal with risk and unpredictable conditions, such as aviation and health and attempts to identify factors that have contributed to poor practice rather than simply highlighting poor practice.

Green said it is likely that these alternatives are proving attractive to LSCBs amid the council cuts.

“A potential influence is the cost involved in preparing a review that is going to be published in full,” he said. This is likely to include extra legal checks to prevent identification of people. An SCR encompasses costs of an independent chair, overview report author and costs of each separate agency review.

The issue of LSCBs choosing not to carry out SCRs in some instances was cited in a government report published last October. The Department for Education analysis of SCRs initiated between 2007 and 2009 noted that there were occasions where “there appeared to be some debate or confusion about which notifications should lead on to a serious case review”.

“Despite notifications meeting the criteria, local LSCBs sometimes decided not to initiate a serious case review,” the report states. “Instead, an alternative review was occasionally proposed as a better method of learning lessons. The reports from these other processes for learning tend not to be published.”

Shared learning

Jane Brooks, NSPCC head of child protection assessment and review, said there are processes by which learning can be shared even if reviews are undertaken internally and not published in full like SCRs.

“What is important is that LSCBs have quality assurance in place and a process by which learning is embedded,” she said.

“A great deal of LSCBs do have those sub-groups that look at practice and analyse cases on a regular basis.”

The adoption of a “systems approach” is under consideration as part of Munro’s review of child protection. In her interim report, Munro recommended that Ofsted should cease having responsibility for evaluations.

A Department for Education spokeswoman said: “The Munro Review is considering a range of options to strengthen the review process to enable lessons to be learnt more effectively.”


Circumstance in which a serious case review (SCR) should always be carried out

When a child dies (including suicide) and abuse or neglect is known or suspected, irrespective of local authority children’s social care involvement with the child or family. In addition, a SCR should always be carried out when a child dies in custody, or where the child was detained under the Mental Health Act.

Circumstances in which a SCR should be considered

When a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect. A child has been seriously harmed as a result of being subjected to sexual abuse. A parent has been murdered and a domestic homicide review is being initiated. A child has been seriously harmed following a violent assault and there are concerns about the way in way in which local professionals and services worked.

Source: Working Together to Safeguard Children (Department for Education) 2010