Serious case review recommendations too confusing, claims study

Local safeguarding children boards (LSCB) have been criticised for the poor quality of their serious case reviews (SCR) into child deaths and abuse.

According to a Department for Education-commissioned research team from the universities of East Anglia and Warwick, the reviews offer far too many confusing recommendations and often fail to take into account wider issues such as poverty.

The recommendations also focus too much on improving training and developing new procedures rather than supporting and supervising social workers and other children’s professionals involved in cases, the team said.

The study follows criticism of SCRs last year from Professor Eileen Munro in her child protection review. She said SCRs were too focused on errors rather than “looking at good practice and continually reflecting on what could be done better”.

This latest research looked at recommendations made in the 33 SCRs carried out between 2009 and 2010. Of 20 SCRs they examined in depth, they found a total of 931 recommendations. In some cases more than 100 recommendations were made in just one review, despite guidance urging boards to keep them to a minimum.

Recommendations were also made based on the case, but not any wider issues facing the organisations involved. 

Researchers said: “There was rarely a research evidence base cited for the recommendation made: they tended, instead, to be based on learning from the single case, which was assumed to have wider implications.”

Their report urges LSCBs to “to take responsibility for curbing this self-perpetuating cycle of a proliferation of recommendations and tasks and allow themselves to consider other ways of learning from serious case reviews. Recommendations may not be the best way to learn from these cases”.

Colin Green, chair of the Association of Directors of Children’s Services’ families, communities and young people policy committee, said: “We backed the recommendation in the Munro Review that serious case reviews needed to be improved so that they can effectively take into account the system context in which social workers work.

“It cannot be effective to just say that procedures and training need to change. We are not surprised by the findings of this review.”