SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews

The report contains the following key messages and recommendations: * Developments in engineering and health indicate the potential benefits of using a ‘systems approach’ to understanding frontline practice in order to improve the quality and safety of service provision. * This report and the accompanying resource guide presents an adapted systems model for multi-agency safeguarding and child protection work. * It is an innovative approach that requires a respectful approach towards the practice experience of street-level workers and their managers. * It involves moving beyond the basic facts of a case chronology and appreciating the differing views that different workers had at the time. * The aim is to identify underlying patterns of factors in the work environment that support good practice or create unsafe conditions in which poor practice is more likely. * This kind of organisational learning is vital to improving the quality of services provision and needs to be applied to ordinary work, not just to tragedies.