Learning together
to safeguard children
London Safeguarding Board
annual conference
December 5th 2011
Dr Sheila Fish,
Senior Research Analyst
Current context
Munro Rec. 9: Govt.
require LSCBs to use
systems methodology.
July 2012 Govt. agreed
and plan transition
First test SCR
announced by Tim
Loughton 8th November
Brief history
Early development work
Pilot programme completed – NW & W Mids
Training & accreditation programme
 & network of accredited reviewers
Developing a tiered offer:
 Collaborative
 Condensed
 Focused
 Nb. ‘deep and narrow’ not ‘quick and dirty’
Supporting test SCRs
The methodological heart
 remains the same
 based on a
understanding of
human performance
 adapted from
aviation and NHS
Methodology hinges on how do we understand
the human role in good or poor practice
Or assume ‘to err is human’ and
that people are also the source of
Emphasis on flexibility and
adaptability, recovery from error;
spotting error inducing conditions
Focus on redesigning systems to play
to our strengths as human beings and
support our predictable weaknesses
Do we treat people as the
source of errors?
Emphasis on fallibility and
Requirement for procedural
interventions and standardization
Increase use of technical
Goal is to provide a ‘window on the system’
 An explicit last step moves beyond
case-specific learning to identify & prioritise the generalisable
An open enquiry is required with the focus of
analysis led by the data
 The focus/findings not pre-set at the beginning
Must be multi-agency from the outset
 Need to understand the interactions between agencies;
 Individual Management Reviews are not part of the process;
And collaborative with people at all levels
 Necessary in order to explore what
lay behind actions/decisions
And to indicate whether or not issues are usual/common
So back to that heart
 involves three key
1. Reconstructing how different
professionals saw the case as it unfolded
“Remember at all times, what you are trying to do. In order to
understand other people’s assessments and actions, you must
try to attain the perspective of the people who were there at the
time. Their decisions were based on what they saw on the
inside of the tunnel – not on what you happen to know today
(Dekker 2002: 79)
2a. Identifying Key Practice Episodes
(KPEs) for detailed analysis
spaces in between
2b. Analysing KPEs: appraising practice
& identifying the contributory factors
Description of episode & time span covered
Explanation of its significance to how the case developed
and/or was handled
Appraisal/Judgement of
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waop fail
Contributory factors
Aspects of the family:
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Multi-agency factors: aselfiu
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Personal aspects: Asfaweu oif
oawi raweior iu siiesa
3. Questioning what light the case has shed
on current strengths and problematic areas?
 Identification and prioritisation of generic,
underlying patterns (using consistent
Formulated as ‘challenges’ or
‘considerations’ for the Board and member
 leaving the Board to decide on appropriate
The findings
 tend to be “insights” into how the multi-agency
system is functioning
 More nuanced explanations of what lies behind
problematic areas
often issues themselves are not new, but the
systems framework allows us to formulate what
they are about in different ways
helps Boards and member agencies think
 issues need consideration; to be grappled with
with implications for ‘action plans’
resonates with Marion Brandon’s latest
research on SCR recommendations
Difference between the three tiers
Who conducts the data collection & analysis
 Multi-agency review team vs. pair of reviewers
 Former more resource intensive but generates
strong ownership of the findings
How to collaborate with people at all levels
 Includes both data collection and opportunities
for staff to correct, challenge and amplify the
 Individual conversations and/or workshop or
 Impacts on extent of the
‘training effect’ of the process
Time span
4-6 months
3-4 months
1-2 weeks
Picture window Portal
Letter box
20 days
10-15 days
5-10 days
2-4 days
1-2 days
Case workers
2-3 days
2 days
1 day
But what about the impact?
‘There are no studies in peer-reviewed
literature on the effectiveness of RCA in
reducing risk or improving safety, and there
are no evaluations of the cost or costeffectiveness of the procedures compared
with other tools to mitigate hazards’ (Wu, et
al. 2008: 686).
If we focus on quality and consistency of
application & requirement to monitor longer
term outcomes, we may be in a better
position in a decades time
So what of the process?
A SCIE Learning Together case review
can help in the following scenarios:
a particular practice theme or issue has been
identified as of concern
particular ways of working seem to be going
well and need to be better understood
a case that has been considered for an SCR
but didn’t meet the criteria where there is
nonetheless learning to be pursued
an serious untoward incident / SCR
Key players organised like this
Process is structured around key
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
 initial planning meetings
 to review relevant documentation and for
 ‘analysis meetings’.
1. LSCB and member agencies
2. Lead reviewers
3. Review team
4. Case Group
5. Family members
 In light of what you have heard so far, what might the
perspectives be of people in your group’s position?
 What might the biggest fears be for them about this
 What would they see as the biggest
challenges and what most exciting?
Three known key barriers to take up of this
approach have been identified
Knowing best
 ultimately the most total barrier to learning
Fear of loss of control
assumption that control is their job
Not knowing how to change thinking
lack of personal awareness and pressure of
Jake Chapman 2004 System failure: why governments must
learn to think differently. 2nd edition. London: Demos.
For further info
 Learning together publications
& social care tv films
available on
[email protected]

1. The SCIE` systems` model for case reviews and SCRs