London safeguarding conference December 8 2010
 The SCIE systems model for
case reviews: findings from the
North West pilots
 Dr Sheila Fish
 Senior Research Analyst, SCIE
The “systems approach”

Is a way of thinking or ‘conceptual framework’
for understanding practice
 How do we understand what causes good or
poor practice?

and a structured process for learning from
practice
 through analysing a particular case
What is the systems approach in essence?

Trying to answer the ‘why’ questions, and
tackle the ‘latent conditions’ of error
“Active failures are like mosquitoes. They can be
swatted one by one, but they still keep coming.
The best remedies are to create more effective
defences and to drain the swamps in which they
breed. The swamps, in this case, are the ever
present latent conditions.”
James Reason
Key parties involved
Process structured around key meetings

The review team meet with the case group for
 an introductory meeting,
 individual conversations and
 two group ‘follow on’ meetings

The review team meet alone for
 an initial planning meeting
 to review relevant documentation and for
 ‘analysis meetings’.
Tools provided include:

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Structure/schedule for individual
conversations with key staff
Framework of contributory factors
Table layout for organising analysis of
practice in ‘key practice episodes’
Typology of underlying patterns of systems
influence to organise the findings
North West Pilots

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Funded by RIEP
Supported by (then) Government Office NW
Undertaken by Wirral, Salford and Lancashire
Safeguarding Children Boards
SCIE team led the process, working
collaboratively with SCR Panel members to
form the ‘review teams’
Findings appear positive

3 case reviews were carried out:
 identified issues critical to how the case had


developed and aspects that explained how
professionals had handled it, and presented these
in a comprehensible format
identified underlying patterns that were not
conducive to, or supported, good safeguarding
practice and, as far as possible, translated these
in to recommendations
produced learning that is already, and will
continue to be, acted upon.
What were the findings like?
A. Learning encapsulated in the findings &
recommendations
B. Learning accomplished through the process
Learning encapsulated in the findings &
recommendations
 Aim is to make the case act as ‘a window on the
system’ (Charles Vincent 2004)

Good or problematic practice may look the different
in different cases but the sets of underlying
influences may be the same
 Involves moving from the case specific details to


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identify generic, underlying patterns
Patterns that support good practice or create
conditions in which poor practice is more likely
A six part typology supports this analysis
Starts to shape thinking about
recommendations
Typology of underlying patterns of ...
1.
2.
3.
4.
5.
6.
human-tool operation
family-professional interactions
human judgement/reasoning
human-management system operation
communication and collaboration in multiagency working in response to
incidents/crises
communication and collaboration in multiagency working in assessment and longerterm work
Examples from the pilots
1.
patterns of human reasoning
 The garden path error
2.
patterns of human-management system
operation
 Lack of financial oversight of total care
package
3.
patterns of multi-agency work

Lack of availability of schools to give timely
information
1. Patterns of human reasoning
 Much psychological research on cognitive


strengths and weaknessess
Building safe systems needs to be premised on
realistic ideas of cognitive abilities
Biased basis for judgement in this case typified a
classic error of human reasoning
 The garden path syndrome
 Part of broader error whereby once we have

formed a view we fail to notice or dismiss
evidence that challenges it
Garden path especially difficult as earlier clues
suggest plausible but false answers; later cues
weaker

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Linked to C4EO safeguarding briefing –
overview of cases in light of changing
circumstances and new information
Link to critical review aspect of supervision
Recommendation not admonishing
Drawing out logical consequences if this
aspect missing
Fudging accountability not acceptable
Assess cost-effectiveness
2. Human – management system
 Resourcing
 Controls on some forms of expenditure and not
on others
 Front line worker CAN allocate more time or refer to

family support without requiring consent,
CAN NOT do same for specialist assessment –
though could make a valuable contribution to
understanding family’s problems and peparing
appropriate plan
 This contributes to shaping the care plan by

making certain options easier than others
Compounded by lack of financial oversight of
overall cost of care package
3. multi-agency working
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Case specific issue: S47 during school
holidays
Input from staff highlighted how they would
never wait, overrun timescale, if case going to
be closed
NB. Not beating up on social worker but
thinking how do we make this easier?
Generic issue: lack of availability of schools to
provide timely info
Challenge to the Board: how to achieve
above
Reflections from the pilots


Found this step provided clarity about
‘findings’
Some substantiated with reference to
relevant research

Felt it encouraged them to grapple with quite
fundamental issues
‘The learning points
are also much more
fundamental – the
next question is
what does an action
plan look like that
reflects that

‘The learning has already
been richer, deeper and it’s
been better as a process.’
Could see how it would make collating
findings across multiple reviews easy
….and views from LSCBs
“we can’t unlearn what
we’ve learnt today – we
will be more critical of
recommendations that
suggest tinkering with
policies and procedures.
You can see how these
will change practice;
others just turn into
churn”
Learning accomplished through the process
 SCIE Guide states that staff directly involved in
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the case play an active role when using this
model
Quality of their engagement is linked to quality of
understanding of practice and of learning gained
But what of the impact of the process itself on
learning outcomes and impact?
A key learning point from the pilots is how the
process itself becomes a powerful learning
exercise for those involved
The extent to which surprised us
Secured effective learning and
change
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Participants were not waiting on a final report;
learning was happening from the word go
By the end some had reviewed their own
practice, & revised their own knowledge
Changes both for individual workers but also
examples of ‘ripple’ effect as they talk with
their colleagues about the process and
learning
Often learning gained was about
each other’s agencies & roles

about understandings e.g.
 misconceptions about other agencies, or
 clarity about what effective multi-agency working
actually means in practice

Nb. in pilots we didn’t adequately capture this
learning in the final reports
I’ve learnt ..in terms of
the outcomes of the case
review – now I always
have in mind the “garden
path” thing. I’ve gone
back to other cases and
thought; actually, why am
I working with this
family? (social care)
Comments from practitioners
What supported the attainment
of those learning outcomes?
1. Data collection methods –
individual conversations

Distinguishing features of the individual
conversations:
 Start by letting the staff member tell their story in

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
their way
Probe further to understand how they were
seeing the world
Identify any key episodes
Explore what was influencing them as workers,
using list of ‘contributory factors’
Contrast with usual process
How the conversations helped


Staff more open
Gained much richer data e.g.
 Whether a course of action was considered and

then rejected or just considered at all
Insight into what actually goes on on the ground‘usual’ ‘regular’ practice
 How are competing priorities being managed
 A view on how strategies actually impact on

direct work with families
An indication of how organisational priorities are
perceived at the front line
2. How you treat the data in the
SCIE model
 Not prioritising material from files over input from staff
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– whichever you do first is arbitrary
Collating information as you go along
Being led by the material, not by pres-set notions of
what is significant
Selecting ‘episodes’ that need detailed analysis
Judging practice not against an ideal or against
procedures but in context of actual practice realities
Explicitly trying to identify generalizable learning
through ‘underlying patterns’ concept
Having discussions about which
findings are should be prioritized
3. Doing the analysis work together


A collaborative learning process
‘review team’ of senior managers from across
agencies working together from the beginning
 Contrast usual IMR process
 Do conversations together
 Numerous ‘analysis’ meetings to pull the story
together, identify key episodes, underlying
issues etc

‘review team’ working with the ‘case group’ of
staff directly involved
 through two ‘follow-on’ meetings
How did review team set up help in
getting to the learning outcomes?

created a common purpose
 less defensive than the IMR process;

access to all data, and ‘un-digested’
 contrast to IMR process

developed joint ownership of the problems of
how staff work together and joint effort to find
solutions
4. Staff having chance to be part of
analysis – “follow-on” meetings
 Changed name from ‘feedback’ meetings to
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stress that these are key part of the process of
analysis
1st follow-on share ‘emerging’ analysis
Chance for staff to correct, challenge, amplify
2nd follow-on focus more on the underlying
issues; want input about practice realities around
these issues more generally
Staff get chance to help think about potential
solutions
How did ‘follow-ons’ help?
 Reinforces the focus on learning
 Allows staff to see the whole picture, not just the

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slice they were involved in and longer term
outcomes
keeps analysis and recommendations grounded
in realities of practice
Allows professionals to reflect and discuss
together -forges links across
agencies/professions and hierarchical positions
through review team & case group working
together
Not all plain sailing!
 Administration and Co-ordination
 ‘Fear of the unknown’
 “Getting your head around it is a really big

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deal and that shouldn’t be underestimated”
Because it is more open in lines of enquiry, it is a
messier process which can provoke anxiety
Involving the right practitioners at the right time to
militate against potential reluctance
Who would be leading the analysis if not SCIE?

Importance of social science research methods
knowledge & group facilitation skills
Summary. Learning outcomes were
supported by:
1.
2.
3.
4.
5.
6.
7.
Not having a detailed terms of reference but going in
‘with an open mind’
Gaining richer data through staff involvement
Multi-agency ‘review team’ working/learning together
from the beginning – no IMRs
Analysis focuses on ‘why’ – ‘key practice episodes’ &
‘contributory factors’ framework
Use of social science research methods – rigour and
reliability
Staff having chance to be part of developing analysis
Use of typology of underlying patterns to guide deeper
level of analysis
nb.

Would require change to statutory guidance
to be usable in SCRs
 Terms of Reference
 IMRs
 Comprehensive chronology
 How to be ‘child centred’
 Reference to procedures
ADCS recommendation:

There should be a clear focus on removing
the bureaucracy and levels of prescriptive
processes, including those surrounding the
current Serious Case Reviews (SCR)
process, in order to free front line
practitioners to adopt a ‘learning from
practice’ approach to their work. This must
include a radical overhaul of the current
statutory guidance Working Together to
Safeguard Children and Young People
For further info


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Evaluation report & example final report on
http://www.scie.org.uk/publications/learningto
gether/pilots.asp
SCTV film forthcoming

Contact: sheila.fish@scie.org.uk

Subsequent pilots:
 West Midlands; London; South West