1. Faculty of Health & Social Care Improving Safeguarding Practice: Study of Serious Case Reviews 2001-2003 Wendy Rose and Julie Barnes

2. Aims and methods of second biennial study To explore the value and impact of serious case reviews in improving safeguarding practice Focus on emerging themes and on conduct of reviews, recommendations, action plans, implementation and impact on practice From study of 40 case reviews which were completed in 2001-3, followed up by interviews and national stakeholder seminar Published January 2008

3. Children in the study: n=45 Half under 2 years, two thirds less than one year; 9% were 3-4 years; 24% were 5-10 years; 20% were 11 years or older, 5 over 15 years Only 8 children currently on local child protection registers, 1 on interim care order; further 3 on interim care orders; 1 child adopted, living with adoptive parents Most children died (2 suicides); a quarter seriously injured &/or neglected

4. Key features and themes Disabled children - multiple family pressures Older children – an important group, different circumstances, needing more attention Children growing up in families experiencing neglect – a challenge for health, education and others in identification and intervention Significance of domestic abuse, co-morbidity with other problems (parental substance misuse, mental health) and the threat to children in the family

5. Implications for policy and practice Keeping a child or children in focus when attention is on adult family member needs Gathering knowledge about family history Ensuring children are seen by practitioners Recognising the emotional impact of working with children and families, when there is violence Training practitioners on assessment framework Addressing risk of harm in terms of evidence from systematic reviews and family information Focusing on analysis, decision making, planning Improving interagency communication

6. Conduct of serious case reviews Decision to hold a review not easy; rates varied Very resource intensive: some complex and difficult to complete, including inter-agency tensions and issues of confidentiality Varied enormously in length, style, presentation and time taken to produce, not necessarily related to complexity of case 14 overviews by internal author; 11 by external author; not recorded for 40% In 20% (8) evidence of family members contributing

7. Serious case reviews reports Most contained overview of information, genogram, chronology, analysis and summary of lessons Good practice highlighted in two thirds of reviews Key issues about recommendations, number and formulation - most up to 20 recommendations, 12 up to 40, one up to 60 and one had 80 Issues about confidentiality in writing the report Executive summary often hard to prepare Frequently confusing, busy period at conclusion of review – requiring careful management

8. Focus of recommendations Generally not SMART nor strategic Most frequently need for new or revision of existing procedures (total of 198 in 40 reports) Improved communication often cited (81 times) Also frequently cited, need to improve information sharing and recording Assessment practice, including developing risk assessments (74); training needs identified (72) Management issues (44), supervision (20), roles of staff (16) and decision making (15) Staffing issues rarely figured (total of 12)

9. Action plans Most actions directly linked to recommendations Most were not strategic in approach Half were single action plans for individual agencies Half specified lead officers and had dates for completion of actions Number of action points varied – 24% had 10 or less; 71% had 40 or less; l had over 100 Most clear about intended action, less about outputs, not about outcomes, what would be different? No costs included.

10. Mixed picture about impact of serious case reviews (interviews) New initiatives and procedures reported Uncertainty about extent to which recommendations were implemented fully Concern that impact was limited Concern that impact was not sustained Need for more follow-up and review to establish influence on policy and practice

11. Reflections and conclusions Challenge is to make use of lessons from serious case reviews and turn them into sustainable improvements in practice – need for commitment, leadership, investment across agencies Importance of using themes from reviews to address practice and management issues – locally, regionally and nationally Using near misses for generating cross agency learning but requires trust Learning from success is important but under- developed –what do we do well and how can we do more of it?