Thematic Analysis of Sheffield Cases of Concern
Completed between December 2005 – April 2012
Summary Report
Introduction
This report is the thematic analysis of 12 reviews (including Serious Case Reviews (SCR) &
Learning Lessons Reviews) that were completed between December 2005 – April 2012. The aim
of the analysis was to identify the themes that have occurred across cases and/or over significant
time periods.
Method
This report has two main aspects:

A content analysis to provide details of the children at the focus of the reviews and the
known parent/carer vulnerabilities.

A thematic analysis of the 12 reviews (with comparisons to national SCR analysis1).
Results: Content Analysis
Details of the children at the focus of the reviews

Of the12 reviews, eight focused on one child, two focused on two children and two involved
families.

The majority of the children at the focus of the reviews were young, with 78% between 0 – 5
years. This is higher than the percentage reported nationally, for example, 60% of the 194
children of the 147 SCR completed in 2009-10 were 5 years or under (Ofsted, 2010).

There were 4 child deaths. The remaining 8 reviews were for 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 incident. Of those with contact at the time of the
incident, 2 were with the disabilities and/or specialist support services, 2 with looked after
children and 3 with children’s social care fieldwork services (the latter were more recent
cases). Nationally the numbers range, 68%: Ofsted, 2009, 42%: Brandon et al, 2012)
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It is important to note there is guidance for cases that reach the criteria for a SCR. Therefore there are limitations when comparing
data that includes both Learning Lessons reviews and SCR with national analysis for only SCR.
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
None of the children were subject to a Child Protection Plan at the time of the incident.
Each case differed in the time scale that it reviewed. The longest time period covered was 35
years. However, the remaining cases, covered periods from 1994 to June 2011, with the shortest
episode covering 14 months.
Parent Vulnerabilities
Four of the most recent cases involved families with many vulnerability factors. In particular, they
all involved parents/partners that had experienced abusive childhoods, all involved substance
misuse, mental health and some level of violence. Some of the cases included parental learning
difficulties, ADHD and history of sexual abuse as a child. However, it could be that these issues
were not reviewed (and therefore not known) in some of the ‘older’ reviews. Below is a summary of
parent vulnerabilities from all 12 reviews:

There were 7 fathers that experienced difficult/abusive childhoods and 4 mothers (this included
all the parents in the 4 most recent reviews). Five parents had been sexually abused as
children.

5 fathers and 9 mothers (75%) first became a parent for the first time at 20 years or younger.

2 mothers and 1 father had Learning Disabilities, 2 parents had ADHD and 1 father had
borderline ADHD (all from the most recent cases).

4 families had frequent house moves and for some their address was unknown to services for
sometime.
Toxic Trio: Substance Misuse, Domestic Abuse and Mental Health Issues
Previous research has shown the ‘toxic’ combination of substance misuse, domestic abuse &
mental health issues (Brandon et al, 2008) and concluded these were ‘much more common to exist
in combination than singly.’
In the local data, 42% of cases had all 3 factors present, higher than found nationally (34%,
Brandon et al, 2008, 22%, Brandon et al, 2012). On its own, mental health difficulties were 13%
higher than reported by Brandon et al, 2008.
Results: Thematic Analysis
The stages of thematic analysis were adapted from those suggested by Braun & Clarke (2006).
The aim of this analysis was to identify themes that have occurred across cases and/or over
significant time periods. The analysis resulted in 6 overall themes, each containing a number of
‘sub themes’.
Theme One. Public Involvement
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Apathy v’s Public concern: In 2005 & 2008 two reviews raised the issue that ‘neither the extended
family nor the community felt able to play their part in safeguarding the children’ (2005). This led to
the start of an ongoing campaign ‘making safeguarding everybody’s business.’ In five of the more
recent reviews there was evidence of relatives and members of the public reporting concerns to
professionals or becoming involved in situations. However, the response from professionals wasn’t
always what they expected. This issue has been recognised nationally, ‘A recurring message in
these serious case reviews is the important role of adults who are in a position to speak on behalf
of the child. The adults include parents, grandparents, neighbours and members of the
public…..but their views were not always taken seriously enough’ (Ofsted, 2011).
Theme Two. Everything is ok
There were examples of how professionals didn’t recognise safeguarding issues or the
vulnerability factors in the families.
Normal for community: In the two family based reviews professionals accepted that the
children were ‘one of a number of children like this’ (2005). This was highlighted again in a recent
review and therefore remains an issue ‘there are lots of 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).
Misplaced optimism: In 8 cases there was evidence of professionals working with an
overoptimistic view of the situation. The most commonly occurring reason for this was when
professionals didn’t recognise, know, or collate the full family history or the vulnerabilities that
exist. ‘Assessments failed to consider the historical information regarding this couple. Agencies
failed to consider the multiple risk factors…..would result in them struggling to parent.
Individually these parents would have struggled to provide effective care, together, the risks
increased and this was not recognised’ (2011).
However, there were other reasons for misplaced optimism to occur. For example, when
professionals allowed positive aspects of parenting to counteract the concerns they held; allowing
work pressures to affect their view of the case or relying on inaccurate reports/information.
Theme Three. Assessment, Assessment, Assessment
Holding an ‘assessment mindset’ is seeing every encounter with a family as an opportunity to reevaluate the situation. The lack of an assessment mindset was an issue in 6 cases and occurred
due to:

professionals working with the ‘start again approach’. This was also recognised by Brandon et
al (2008 & 2010) as an issue.

professionals getting ‘stuck’ (reaching a conclusion from which they didn’t move from even
when new information contradicted this), ‘there is evidence within this case that once an
assessment reached a conclusion it became static, even in the light of new emerging evidence
that should have led to a review of the assessment’ (2011). This issue is one that has also
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been recognised nationally, ‘Professionals need to constantly guard against the tendency to
cling to their original beliefs and overlook, devalue or re-frame any new information that
challenges those beliefs.’ (Munro, 1999, in Burton, 2009).

assessments lacking rigour (applicable to all agencies but was a specific issue for Children’s
Social Care).
This subtheme also included the importance of using assessment tools. In 7 reviews professionals
hadn’t used the tools available (in particular the CAF). However, recent reviews also highlighted
that some agencies do not consider the CAF as an assessment tool, but as a referral tool.
Silo thinking: In 6 reviews there was evidence of professionals working in ‘narrow silos’, dealing
with situations in isolation, being task focused, ‘episodic’ and not looking beyond this: ‘there is a
picture painted of services that focus on an individual task or issue rather than taking a holistic
approach to the care’ (2010).
This section also highlighted examples where professionals didn’t consider the possible impact of
the parent/carers mental health difficulties on their ability to parent.
Downgrading of risk: In 4 reviews (3 of these were recent ones) professionals closed cases
when there was no evidence of any new information to inform this decision. This was a particular
issue for Children’s Social Care and one example of this happening within the Children’s Hospital.
Recognition of risk: Universal Services. In 2005 a review highlighted that although many
agencies within universal services were in contact with the family, they didn’t recognise the
circumstances the children were living in. This issue has reoccurred in two of the more recent
reviews and therefore remains an issue locally: ‘there was adequate information to alert
practitioners to potential risk and with an effective risk assessment tool coupled with professional
judgement within universal services an earlier identification of potential risks could have occurred.’
(2011).
Communication: The results locally are in line with the national findings as communication and
information sharing was an issue in 10 reviews (83%), including some of those recently completed.
Although this occurred as a concern across a variety of agencies, it was a particular issue for
Children’s Social Care and health agencies: ‘the midwife was not aware prior to her visit that (the)
Child had been admitted to hospital or of any concerns that the injuries may have been non
accidental.’ (2011)
Theme Four. Protection
There were situations where the professionals failed to keep their focus on the child(ren) and their
well being. As young children (2 years or younger) have particular vulnerabilities these are
reported separately.
Loss of the child focus: in 3 reviews professionals failed to keep their focus on the child, failed
to see things from the child’s perspective, didn’t see and speak to the child on their own or failed to
hold the child’s safety and wellbeing as the most important aspect of their work. This has also been
found repeatedly in national analysis (Ofsted, 2010).
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Vulnerability of the very young: 10 of the 12 reviews involved children that were 2 years or
younger. There were four cases where there had been earlier injuries that had been judged by a
professional as accidental/explainable, in a further case an older sibling had, had previous injuries.
There were 2 examples of professionals working with the assumption they must be ‘beyond
reasonable doubt’ before concluding an injury was non accidental and situations where
professionals accepted the explanations given by parents without sufficient curiosity: ‘Although
there are occasions where a clear medical diagnosis of non accidental injury can be made there
are many other occasions when a diagnosis has to be made on ‘the balance of probabilities.’(2011)
Theme Five. Challenge and responsibilities
Challenging parents: Professionals have a responsibility to safeguard children and to challenge
parents when necessary. In 3 reviews this did not happen: ‘statements made by the parents were
too quickly accepted without professionals feeling the need to check the information out’ (2011)
Evasive/manipulative parents were an issue in 6 reviews (including some of the most recent),
the main issues were:

keeping parents ‘on side’

the challenges for universal services

parents pressurising professionals to alter reports or refusing access to the child and/or
property

parents giving professionals incorrect information.
The importance of professionals working with a ‘respectful uncertainty’ and ‘healthy scepticism’
was highlighted by Lord Laming in 2003 (Victoria Climbie inquiry) and the difficulties of working
with these parents was again highlighted in the Baby Peter SCR, Haringey (Jones, 2009).
Fathers/male carers are ‘not important’: In 3 reviews the fathers/mothers partners were either
not known or their role not fully considered.
There was some level of domestic abuse or history of assault or threatening behaviour in 8
families, with the majority of these cases linked to the father/male carer. In two cases
professionals were frightened and intimidated by the fathers, which led to the fathers, rather than
the professionals, controlling the situation: ‘Some professionals were afraid of Adult (father) but
prepared to leave children in the environment.’ (2010)
Professional responsibility: Professionals hold a responsibility to safeguard children, to protect
them and to challenge other professionals when necessary. There were situations in half of the
reviews where this did not happen. For example, in one situation a professional felt another was ‘to
close’ to a family, in 3 cases a professional viewed another as more qualified/more knowledgeable
and in one case there were concerns expressed but these were ignored until eventually the other
professionals stopped challenging.
Assumptions of responsibility: In 5 reviews professionals made assumptions that others were
monitoring the situation or that they had made a referral and therefore their responsibility ended:
‘On a number of occasions professionals felt secure because they assumed that action or
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monitoring was being undertaken by others in the inter-agency network. This assumption was
sometimes unfounded.’ (2011)
Theme Six. Professional knowledge and support
Knowing your client – what is important: there were 2 reviews that required specific knowledge
and without this the professionals lacked the confidence in intervening in the situation or did not
have the knowledge that was needed to enable them to support parents.
Where were the good practice guidelines? In 7 reviews there were examples of professionals
that did not follow the good practice guidelines that were in place at the time (3 of these were
recent cases). This has also been reported as an issue nationally, ‘there had been a failure to
implement and ensure good practice rather than an absence of the required framework and
procedures for delivering services’ (Ofsted, 2010).
Support, Supervision and Management: There were 5 reviews where issues around
supervision arose & 4 cases with issues regarding management and support. These issues varied.
Record keeping: The standard of record keeping was an issue in some reviews. However,
these were completed between 2005 – 08 and therefore it is unclear if this remains an issue.
Conclusion
The analysis has highlighted a number of interconnecting themes relevant to Sheffield. These are
similar to those found in the national summaries but the analysis has been able to provide clear
evidence of those that are specific to the local area:
Although it may seem surprising that there are themes that are still arising, even when
recommendations have been made and action plans have been completed, this is not just an issue
seen in Sheffield but has been identified nationally. Sheffield agencies have completed the action
plans from reviews in a timely and robust manner but the issues identified through this thematic
analysis show us that there are safeguarding challenges that cannot be resolved simply through
making SMART recommendations. For example a new procedure can be written, or a memo can
be issued to staff but this does not necessarily lead to this new practice being embedded into the
day to day practice of the frontline worker.
These themes and issues appear to be ones that will require a cultural change in the way that
professionals work and are thus more difficult to achieve. The SSCB are sharing the results of this
analysis with professionals and are developing a presentation package for single agencies to take
this work forward in order to raise awareness of the issues highlighted.
Sarah Adams. Research & Performance Officer. Sarah.adams2@sheffield.gov.uk
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