Learning from Serious Case Reviews Lessons from national studies

1. Learning from Serious Case ReviewsLessons from national studies

2. In my report I have referred to, but not dwelt upon, the impact of the reorganisation [upon the front line workers] and the part this may have played in certain failures in supervision. Every field-level [practitioner] was placed at risk of such a tragedy by the organisational upheaval consequent upon the reorganisation and the sharp increase in the volume of work… It is to be hoped that X’s death and the grievous distress that it has caused… will prompt urgent consideration of the stresses upon the profession and the ever-increasing expectations of it, especially since we are now in the throes of yet more reorganisation1

3. Are they all the same? Jasmine Beckford Holly Wells Jessica Chapman Peter Connolly Kyra Ishaq Victoria Climbie Heidi Koseda

4. The purposes of SCRs • establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • improve intra- and inter-agency working and better safeguard and promote the welfare of children.

5. Evaluating SCRs • Are we better safeguarding and promoting the welfare of children? • Are we implementing actions to safeguard children? • Are we identifying lessons about safeguarding children?

6. Serious Case Reviews, 2005-10

7. Fatal assaults 1975-2005Deaths per 100,000 population Source: ONS Registrar General

8. Violent child deaths, 2009-10

9. Violent Child Deaths, England, 2005-9Rates per 100,000

10. Patterns of fatal maltreatment, England 2005-9

11. Categories of Fatal Maltreatment A Infanticide and “covert” homicide B Severe physical assaults C Extreme neglect / deprivational abuse D Deliberate / overt homicides E Deaths related to but not directly caused by maltreatment

12. Patterns of fatal maltreatment, 2005-9

13. Violent deaths in children • Rates and numbers of violent infant deaths have decreased by at least 50% • Rates and numbers of violent child deaths have decreased • Rates of violent adolescent deaths have remained static or risen • There are currently between 20-60 violent infant and child deaths per year in England & Wales

14. Severe, deliberate & persistent Inflicted physical or emotional abuse Neglect, poor physical care, emotional unavailability Casual attitudes, carelessness, poor parenting A pyramid of severity

15. Children subject to child protection plans, 1988-2009

16. NSPCC national prevalence study

17. Evaluating SCRs • Are we better safeguarding and promoting the welfare of children? • Are we implementing actions to safeguard children? • Are we identifying lessons about safeguarding children?

18. Evaluating SCRs • Are we better safeguarding and promoting the welfare of children? • Are we implementing actions to safeguard children? • Are we identifying lessons about safeguarding children?

19. An overemphasis on actions • Practitioners and their managers told the review that statutory guidance, targets and local rules have become so extensive that they limit their ability to stay child-centred. • The demands of bureaucracy have reduced their capacity to work directly with children, young people and families. • Services have become so standardised that they do not provide the required range of responses to the variety of need that is presented.

20. SCR Recommendations • Recommendations should usually be few in number, focused and specific, and capable of being implemented. (WT 8.40) • 2009-10 review of 20 SCRs • Total of 932 recommendations • Average 47 (range 10-94)

21. Common themes in recommendations from 20 SCRs • Training and awareness raising (20) • Information sharing between and within agencies (19) • Quality of recording (18) • Management and supervision (18) • Clarification of staff roles (16) • Ascertaining the ‘whole picture’ as regards the child/family (16) • Referral process (16) • Audit (15) • Responsibility for case, or avoiding case ‘drift’ (14) • Use of Common Assessment Framework (13)

22. SMART Recommendations? • “organisations must ensure that staff working with children always focus on the needs of the child, and never allow themselves to be distracted by the problems of the adults.” • “to review the health visitor caseload weighting tool, which should reflect vulnerability and disadvantage not numbers of children.”

23. Evaluating SCRs • Are we better safeguarding and promoting the welfare of children? • Are we implementing actions to safeguard children? • Are we identifying lessons about safeguarding children?

24. Evaluating SCRs • Are we better safeguarding and promoting the welfare of children? • Are we implementing actions to safeguard children? • Are we identifying lessons about safeguarding children?

25. Common themes in SCRs • The ‘invisible’ child • Limited inter-agency co-operation and lack of service integration • Poor communication both between and within agencies • A failure to interpret information gathered • Poor recording of information and decision making • Uncertainty in decision making • Different perceptions of the thresholds

26. New and emerging themes • Importance of an ecological framework for understanding the complexity of child abuse • Mirroring of behaviour in the family and in the agency responses • “Fixed thinking” • “Start again syndrome” • The “rule of optimism” • “Authoritative” child protection

27. Authority ‘The authoritative intervention is urgent, thorough, challenging, with a low threshold of concern, keeping the focus on the child, and with high expectations of parents and of what services should expect of themselves’ Haringey LSCB, 2010, p24

28. What does a child need in order to grow and develop?

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30. High Affection Low Expectation High Expectation Low Affection Dimensions of Parenting • Affection • Nurture • Provision • Response to needs • Emotional warmth • Expectation • Stimulation • Opportunities • Boundaries • Discipline

31. Authoritative Child Protection • Authority • Confidence and Competence • Empathy • Child Centred • Family Focused • Humility • Recognising limitations • Acknowledging strengths • Seeking to improve

32. Authority in Safeguarding • Confidence and Competence • Knowledge, skills and attitudes • Appropriate training • Supervision and support • Ability to challenge (parents and services) • Requires the application of appropriate evidence, combined with the experience of the practitioner and their responsiveness to the current context

33. Evidence Based Practice • Evidence based practice is the conscientious, explicit and judicious use of current best evidence, integrated with relevant expertise and an understanding of the context, to guide decision making in relation to individual cases Sidebotham, 2009 Based on Sackett, 1996

34. Empathy • Child Centred • A rights-based approach • Listen to/for the voice of the child • Family Focused • See things from the family’s perspective • Avoid collusion/prioritising the parents’ needs above those of the child • Being ourselves • It is possible to be thorough and systematic yet sensitive

35. Empathy ‘Authoritative practice will have high expectations of parents, will provide the support to enable them to try and meet those expectations, and will be prepared to challenge and act when they are unable to do so.’

36. Humility ‘A positive quality that enables practitioners to recognise their own limitations, to acknowledge and use their skills and strengths, and to seek to improve their practice.’

37. Humility • Recognising limitations • Interagency working • Working within our expertise • Acknowledging skills and strengths • Be confident in what we do well • Celebrating success • Seeking to improve • Continual professional development • Supervision and support • Reflective practice

38. Working Together, 2013Learning Lessons • Broader emphasis on regular learning • Culture of learning and improvement • Range of approaches • Involvement • Emphasis on systems approach • Not just what, but why? • Emphasis on actions resulting in lasting improvements • Transparency and independence

39. Local learning • Is most effective when embedded in the process of conducting the SCR • Can be enhanced by keeping the emphasis on learning lessons

40. Local Implications • Develop a more participative approach • Include plans for learning in the scoping of the review • Include practitioner/manager support in scoping • Clear methodology and briefing • Learning lessons and taking action are complementary