Thematic Analysis of Sheffield Cases of Concern
Completed between December 2005 – April 2012
Sheffield Safeguarding Children Board
Introduction
The thematic analysis of 12 reviews (including Serious Case (SCR) and Learning
Lessons Reviews (LLR)) completed between December 2005 – April 2012.
Methods
The analysis of the 12 cases has two main aspects:
 Content analysis to provide details regarding the children at the focus of
the reviews and known parent/carer vulnerabilities.
 A thematic analysis to identify any themes occurring across cases and/or
over significant time periods*.
*The stages of thematic analysis were adapted from those suggested by Braun & Clarke
(2006), ‘Using thematic analysis in psychology’.
Results: Content Analysis
Details of the children at the focus of the 12 reviews:
 8 focused on 1 child, 2 focused on 2 children & 2 involved families.
 78% of the children were between 0 – 5 years.
 There were 4 child deaths. The remaining 8 cases were for serious
injury, neglect or sexual abuse/rape.
The involvement of Social Care:
 67% (8 cases) had had contact with social care in the past.
 58% (7 cases) had contact at the time of the incident.
 None of the children were subject to a Child Protection Plan at the
time of the incident.
Parental Risks & Vulnerabilities
Factors known about the parent’s childhood
 7 cases (58%) involved one or more parent/carer that had
experienced a difficult/abusive childhood.
o
o
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5 cases had known social care referrals/involvement.
5 parents/carers had been sexually abused as a child.
5 fathers & 9 mothers first became a parent at 20 years or
younger.
3 parents/carers had Learning Disabilities, 2 had ADHD & 1
borderline ADHD.
Parental vulnerabilities
 75% (9 cases) involved one/more parent with mental health
difficulties, higher than found nationally.
 42% (5 cases) had parental substance misuse, domestic abuse
and mental health issues.
Results: Thematic Analysis
Thematic analysis is a method of qualitative research which involves
searching through data to identify patterns that can be developed into
themes. In this case, identifying themes across cases or over time.
The thematic analysis produced 6 main themes, each with a number of subthemes.
1.
2.
3.
4.
5.
6.
Public Involvement
Everything is ok
Assessment, Assessment, Assessment
Protection
Challenge and Responsibilities
Professional Knowledge and Support
These themes will be considered in more detail on the following slides
Theme 1 - Public Involvement
Apathy: In 2005 &2008 (in 2 cases) it was shown that members of the
public didn’t recognise or report safeguarding concerns.
‘Some relatives and public house regulars were worried about the condition of
the living quarters and believed the children were sometimes left alone for long
periods…….. It is a matter of great regret that no-one shared this information
with the care agencies ’ (2008)
Public Concerns: However, in 5 recent reviews (published 2010/11) there
was evidence of relatives/the public reporting concerns. However, the
response from professionals wasn’t always what they expected.
‘The same health visiting service not following up information from Ms A’s
neighbour that she did have a child (2011)
Theme 2 - Everything is ok
This theme demonstrated how professionals didn’t recognise the
safeguarding issues or vulnerabilities that existed. There were 2 main
reasons for this:
1. Normal for Community. In 3 cases professionals felt that the children were
one of a ‘number of children like this’ in the community:
‘There are lots of other families like this in their practice area so this family would
not have stood out. This is of concern… because of the clear level of risk that there
was in this family.’ (2011)
2. Misplaced Optimism. There was evidence (in 8 cases) of professionals
working with an overoptimistic view of the situation. The most common reason
was that they didn’t question, recognise, know or collate the family history or
vulnerabilities that exist.
‘Assessments failed to consider the historical information regarding this couple.
Agencies failed to consider the multiple risk factors’ (2011)
Theme 3 - Assessment, Assessment, Assessment
This highlights the importance of assessment and the difficulties that arise
when this isn’t thoroughly completed.
1. An Assessment Mindset is seeing every encounter with a family as an
opportunity to re-evaluate the situation. The lack of this was an issue in 6
cases.
2. Silo Thinking. In 6 cases professionals viewed situations in isolation, were
task focused and ‘episodic’. This also highlighted where professionals didn’t
consider the possible impact of the parents mental health on their
parenting.
3. Downgrading of risk (4 recent cases). In these professionals closed cases
when there was no evidence of any new information to inform this decision.
4. Recognition of risk by universal services. 3 cases highlighted that although
universal services had contact with a family, they didn’t recognise the
circumstances the children were living in.
5. Communication and information sharing was an issue in 10 reviews.
Theme 4 - Protection
Where professionals failed to keep their focus on the child(ren) and their
well being. As very young children (2 yrs or younger) have particular
vulnerabilities these are a separate ‘sub theme’:
1. Loss of Child Focus. In 3 reviews ‘Professionals failed to listen and consider
situations from the child’s perspective: they did not see the children, and
where possible, talk to them to find out what they thought and felt about
issues; and take action based on this information.’ (2010)
2. The vulnerability of the very young. There were 10 reviews that involved
children 2yrs or younger at the time of the incident. 4 Cases had earlier
injuries judged to be accidental/ explainable & 1 case an older sibling had,
had previous injuries. There were examples of professionals accepting
unrealistic explanations and working within the assumption that they must
be ‘beyond reasonable doubt’ (of Non accidental injury) before taking
action.
Theme 5 - Professional Challenges & Responsibilities
1.Challenging Parents. Professionals have a responsibility to challenge
parents when needed. In 3 cases this didn’t happen.
2. Evasive & Manipulative Parents In 6 reviews professionals had difficulties
in keeping parents ‘on side’, parents pressurising professionals to alter
reports, refusing access to the child/property or giving incorrect information.
3. Fathers - In 3 reviews the fathers/partners were either not known or their
role not fully considered. There were also 2 cases where fathers intimidated
the professionals, which led to the fathers controlling the situation.
4. Professional responsibility to challenge other professionals when
necessary. There were examples in 6 reviews were this did not happen.
5. Assumptions of responsibility. In 5 reviews professionals made
assumptions that others were monitoring the situation or they had made a
referral and therefore their responsibility ended.
Theme 6 - Professionals Support & Knowledge
• Knowing your client, what is important? Not holding knowledge or
understanding the issues in 2 cases led to difficulties
• Where were the good practice guidelines? In 7 cases professionals did
not follow the guidelines.
• Support, Supervision & Good Management In 5 reviews there were
issues around supervision & 4 cases where management and support
issues arose.
Conclusion
 Themes repeatedly being seen at a national level
 The analysis has provided evidence of the issues relevant to
Sheffield.
 Demonstrates that even though Sheffield agencies have
completed action plans (from reviews) in a timely and robust
manner, challenges continue.

These issues appear to be ones that will require a cultural
change in the way that professionals work and are thus more
difficult to achieve
For further information please see:
www.safeguardingsheffieldchildren.org.uk
or contact:
Sarah Adams
Research & Performance Officer
sarah.adams2@sheffield.gov.uk
References
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Brandon,M., Bailey,S. & Belderson, P. 2010. Building on the learning from serious case
reviews: a two year analysis of child protection notifications 2007 – 2009 – Brief. Department
for Education.
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2008. Analysing child deaths and serious injury through abuse and neglect: what can we learn?
A biennial analysis of SCR 2003 – 5. Department for Children, Schools and Families.
Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C. & Megson, M.
(2012) New Learning from SCR. A two year report for 2009 – 2011. Department for Education.
DFE-RR226
Braun, V. & Clarke, V. 2006. Using thematic analysis in psychology. Qualitative Research in
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Burton, S. 2009. The oversight and review of cases in the light of changing circumstances and
new information: how do people respond to new (and challenging) information? C4EO.
Safeguarding: Briefing 3.
References continued
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Jones, A. 2009. Serious Case Review: Baby Peter. Executive Summary. Haringey Local
Safeguarding Children Board & Department for Education:
Laming. 2003. The Victoria Climbie Inquiry. Report of an inquiry by Lord Laming.
Department of Health:
Ofsted. 2009. Learning lessons from serious case reviews: year 2. Ofsted’s second year of
evaluating serious case reviews: a progress report (April 2008 to March 2009). Ref 090101.
Ofsted. 2010. Learning lessons from serious case reviews 2009 – 2010. Ofsted’s evaluation of
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Ofsted 2010b. Learning lessons from serious case reviews: interim report 2009 – 10. Ofsted’s
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Ofsted. 2011. The voice of the child: learning lessons from serious case reviews. A thematic
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