Messages from Serious
Case Reviews
Patrick Ayre
Department of Applied Social Studies
University of Bedfordshire
Park Square, Luton
email: pga@patrickayre.co.uk
web: http://patrickayre.co.uk
Learning from enquiries
Those who cannot learn from
history are doomed to repeat it
(George Santayana)
Serious Case Reviews: A systemic approach
Principles (with thanks to SCIE):
 Any worker’s performance is a result of both
their own skill and knowledge and the
organisational setting in which they are
working.
 Improving safety therefore means clarifying
which aspects of the work context make
errors more likely to happen, and which
support workers to accomplish their tasks
successfully.
Serious Case Reviews: A systemic approach

Instances of problematic practice may look
different in different cases, but underneath
may have much in common
 It is these similarities or common patterns that
need to be identified in case reviews.
 ‘Heroic workers can achieve good practice in
a poorly designed system, but efforts to
improve practice will be more effective if the
system is redesigned so that it is easier for
average workers to do so’.
Serious Case Reviews: Preparation
 Identifying
 Selecting
a case for review
the review team
 Identifying
who should be involved
 Preparing
participants
 The
importance of all workers’
views
Serious Case Reviews: Collecting and
organising data
 Selecting
documentation
 One-to-one
conversations
 Producing
a narrative of multiagency perpectives
 Identifying
and recording key
practice episodes and their
contributory factors
Serious Case Reviews: Analysing data
 Reviewing
the data and analysis
 Identifying
and prioritising generic
patterns
 Making
recommendations
The background
 Widespread and persistent concern over
standards
 Many enquiries and Serious Case Reviews
 Far reaching reforms
 Little evidence of improvement, in England at
least
Why haven’t we learned?
(Addictive behaviours)
 If
it doesn’t work, do more of it
 Procedures
and micromanagement
 Training
 Performance
indicators
Failure to learn from experience
 The proceduralisation, technicalisation and
deprofessionalisation of the professional task
 Process and procedures prioritised over
outcomes and objectives
 Targets and indicators prioritised over values
and professional standards
 Compliance and completion prioritised over
analysis and reflection
Deprofessionalisation

Part of a wider trend

Managerialism, McDonaldisation and the
audit culture

Management by external objectives

Professionals not to be trusted
The ‘scandal’ model of case review

Public pillorying

Public enquiry with many
recommendations

Law and guidance from the
government
Climatic conditions for safeguarding

Climate of fear

Climate of mistrust

Climate of blame
Responsible journalism at its best
“Today The Sun has demanded justice for Baby P — and vows not
to rest until those disgracefully ducking blame for failing the tot are
SACKED”
“The fact that Baby P was allowed to die despite 60 visits from
Haringey Social Services is a national disgrace.
I believe that ALL the social workers involved in the case of Baby P
should be sacked - and never allowed to work with vulnerable
children again.
I call on Beverley Hughes, the Children's Minister, and Ed Balls, the
Education Secretary, to ensure that those responsible are removed
from their positions immediately”.
(The Sun, 13 November 2008)
Climatic conditions

Climate of fear

Climate of mistrust

Climate of blame
Climate of mistrust
‘Child stealers’ who ‘seize sleeping children in
the middle of the night’; ‘abusers of authority,
hysterical and malignant’, ‘motivated by
zealotry rather than facts’ or ‘like the SAS in
cardigans and Hush Puppies’.
On the other hand, they are ‘naïve, bungling,
easily fobbed off’, ‘incompetent, indecisive and
reluctant to intervene’ and ‘too trusting with too
liberal a professional outlook’.
Climate of mistrust
The safeguarding worker
who took a child away
from its parents
The safeguarding worker
who failed to take a child
away from its parents
Climatic conditions

Climate of fear

Climate of mistrust

Climate of blame
Maximising learning
Serious Case Reviews must:

Explore WHY things were done (or not
done) and not just WHAT was done (or
not done)

Distinguish individual ignorance and
error from strategic and systemic issues

Interpreting what happened locally in
the wider context of practice knowledge
Exploring the WHYs (Level 1)
A Serious Case Review along these lines
is pretty much a waste of time :
Fact: This child was injured because we
did not do X
Recommendation: Do X in the future
We need to know WHY X was not done
Why was X not done?

Was it individual ignorance or error?
(Outcome: training, competency issues)

Was the requirement not expressed clearly
in procedures when it should have been
(Outcome: Procedural change)

Was this requirement not understood?
(Staff development; strategic or systemic
considerations)
Why was X not done?

Were resources/commitment absent?
(Strategic or systemic considerations)
And finally and most crucially:

Was the service environment
conducive to and supportive of good
practice?
(Strategic or systemic considerations)
Exploring the WHYs (Level 2)
Fact: This child was injured because we
did not do X
Recommendation: Train staff to know
they have to do X and/or write some new
procedures (or both)
(In fact, we know that people often don’t do X even
though they know, in theory, that they should and there
are procedures which tell them that they must. The key
question is often, why did they still not do it?)
Exploring the WHYs (Level 2)
BBC Regional News, 17 November 2011:
“The latest Ofsted inspection has found Children’s
Services in Peterborough to be inadequate in seven out
of nine categories. The Director of Children’s Services
announced that the council had embarked on a
programme of updating procedures and improving staff
training”
Blaming, training and writing procedures

Procedural proliferation

Blaming and training

The myth of predictability
Procedures as a net to catch problems
Procedures as a net to catch problems
Procedures as a net to catch problems
Procedures as a net to catch problems
Blaming and training
Causes of accidents can be traced to ‘latent failures and
organizational errors arising in the upper echelons of the
system in question Accident sequences begin with problems
arising in management processes such as planning,
specifying, communicating, regulating and developing.
Latent failures created by these organisational errors are
‘transmitted along various organizational and departmental
pathways to the workplace where they create the local
conditions that promote the commission of errors and
violations (e.g. high workload, deficient tools and equipment,
time pressure, fatigue, low morale, conflicts between
organizational and group norms and the like’ (Reason, 1995
p.1710). In this analysis, ‘people at the sharp end are seen
as the inheritors rather than the instigators of an accident
sequence’ (Reason, 1995 p.1711).
Exploring the WHYs (Level 3)
Fact: This child was injured because we did not
do X
Recommendation:

Review on an interagency basis the
adequacy of the child safeguarding services
available to, say, young people abused
through prostitution; or

Review quality assurance processes and
managerial processes to ensure that they
focus more on quality than quantity.
Exploring the WHYs (Level 3)
Fact: This child was injured because we did not
do X
Recommendation:
Review
whether the service environment was
conducive to and supportive of good practice?
Micromanaging recording and reporting

Format: Endless predetermined tick boxes
and text boxes

Content: Repetitive and disaggregated

Concept: Routinised and mechanistic

Purpose: Well, what is the purpose?
Micromanaging assessment and reporting

Format: Endless predetermined tick boxes
and text boxes

Content: Repetitive and disaggregated

Concept: Routinised and mechanistic

Purpose: Well, what is the purpose?
Understanding what it is like to be that child,
and what it will be like if nothing changes
Micromanaging assessment and reporting

Format: Endless predetermined tick boxes
and text boxes

Content: Repetitive and disaggregated

Concept: Routinised and mechanistic

Purpose: Well, what is the purpose?
Understanding what it is like to be that child,
and what it will be like if nothing changes 
Getting the assessment done 
Micromanaging assessment and reporting

What we want:
Coherent, confident and compelling

What we get:
Disassembled, disarticulated and
decontextualised
KPIs: Ministers and managers

Outcomes hard to measure, process easy

Easy to obtain, easy to digest (but what do
they tell us?)

Quality = KPI scores

False sense of security

Distort resource allocation

?A third of the mix
On the front line

Learn by doing more than by training

What is important in what I do?

What is good practice?

Supervision: qualitative or quantitative?
Escaping the spiral of decline requires
 Research-informed, reflective, confident and
critically-challenging practitioners
 Management systems which promote rather
than undermine their effectiveness.
 Ministers and senior managers committed to
a significant change of direction, both
practical and conceptual
Checkpoint 1
 Was any of this ‘true for us’?
 Three things we have done/are doing/could
do to put things right
Learning from Past Experience
Major themes from SCR reviews of the 90s:
Collecting and interpreting information

Importance of comprehensive family
assessments, especially male figures

Failure to give sufficient weight to relevant
case history

Understanding thresholds, especially the
importance of neglect and emotional
deprivation and the need to accumulate
evidence
Learning from Past Experience
Major themes from SCR reviews of the 90s:
Collecting and interpreting information

Importance of comprehensive family
assessments, especially male figures

Failure to give sufficient weight to
relevant case history

Understanding thresholds, especially the
importance of neglect and emotional
deprivation and the need to accumulate
evidence
Learning from Past Experience
Major themes from SCR reviews of the 90s:
Collecting and interpreting information

Importance of comprehensive family
assessments, especially male figures

Failure to give sufficient weight to relevant
case history

Understanding thresholds, especially
the importance of neglect and
emotional deprivation and the need to
accumulate evidence
Capturing chronic abuse

Judging the impact of long-term abuse is an
essential component of any assessment but
how well do we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event
Capturing chronic abuse

Judging the quality of care is an essential
component of any assessment but how well
do we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event
Our image of assessment
Assessment
The reality of assessment?
Assessment
Capturing chronic abuse

Judging the quality of care is an essential
component of any assessment but how well
do we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event
The pattern of neglect: atypical
The pattern of neglect: typical
Intervention
Intervention
The pattern of neglect
'Good enough' level
Intervention
Intervention
The pattern of neglect
Intervention ceases
'Good enough' level
Intervention
Intervention
The pattern of neglect
What we would hope to find
S
E
X
U
A
L
P
H
Y
S
I
C
A
L
A
B
U
S
E
A
B
U
S
E
N
E
G
L
E
C
T
N
E
G
L
E
C
T
N
E
G
L
E
C
T
Threshold for
intervention
What we found
S
E
X
U
A
L
P
H
Y
S
I
C
A
L
A
B
U
S
E
A
B
U
S
E
Threshold for
intervention
N
E
G
L
E
C
T
N
E
G
L
E
C
T
N
E
G
L
E
C
T
N
E
G
L
E
C
T
What we found
Chronic abuse and the principle of
cumulativeness
 Incidents scattered through files
 The problem of proportionality
 Acclimatisation
Checkpoint 2
 Do we have issues with acclimatisation of any
kind?
 What do we do/can we do?
Assessment Pitfalls

Information from family friends and neighbours
undervalued

Failure to give sufficient weight to relevant
case history; ‘Start again syndrome’

Parents’ behaviour, whether co-operative or
uncooperative, often misinterpreted

Coping with aggressive or frightening families

Mishandling resistance
Resistance
‘Involuntary’ work may be characterised
by

Guardedness or reluctance to share
information

Avoidance and a desire to leave the
relationship

Strong negative feelings such as
anxiety, anger, suspicion, guilt or
despair.
Context
We need to accept that:

The best we may be able to achieve is
honesty rather than positive feelings and
a high degree of mutuality

Conflict and disagreement are not
something to be avoided, but are realities
that must be explored and understood.

Some degree of resistance is natural but
we can make the situation better or worse
Checkpoint 3: Natural resistence
How might resistance show itself?





By only being prepared to consider
'safe' or low priority areas for
discussion.
By not turning up for appointments
By being overly co-operative with
professionals.
By being verbally/and or physically
aggressive.
By minimising the issues.
(Egan, 1994)
Potential parental responses

Genuine commitment

Compliance / approval seeking

Tokenism

Dissent / avoidance
(Howarth and Morrison, 2000)
Identifying resistance: 4 categories




Hostile resistance: anger threats,
intimidation, shouting
Passive aggressive: surface
compliance covers partly concealed
antagonism and anger
Passive hopeless: Tearfulness and
despair about change
Challenging: Cure me if you can!
Strategies for enhancing engagement

Have realistic expectations:
–
–
–
It is reasonable that involuntary clients resent
being forced to participate
Because they are forced to participate, hostility,
silence and non-compliance are common
responses that do not reflect my skills as a
worker
Due to the barriers created by the practice
situation, clients may have little opportunity to
discover if they like me
(Ivanoff et al, 1994)

Learn techniques proven to work such as
Motivational Interviewing or Solution
Focused work
What might we be doing to make it worse?






Becoming impatient and hostile
Doing nothing, hoping the resistance
will go away
Lowering expectations
Blaming the family member
Allowing the family member to control
the assessment inappropriately
Failing to acknowledge our fear
What might we be doing to make it worse?



Becoming unrealistic
Believing that family members must
like and trust us before assessment
can proceed.
Ignoring the enforcing role of some
aspects of child protection work and
hence refusing to place any demands
on family members.
(Egan, 1994)
Avoid

Expressions of over-concern

Moralising

Criticising the client

Making false promises

Displaying impatience
Assessment pitfalls

Rule of optimism

Natural love

Cultural relativism

Too much
not enough

Maintenance of focus on the child
A child centred approach
The purpose of assessment is to
understand what it is like to be that child
(and what it will be like in the future if
nothing changes)
Checkpoint 4
The purpose of assessment is to
understand what it is like to be that child
(and what it will be like in the future if
nothing changes)
Identify one area where this message
should be shared or implemented better
Assessment Pitfalls

Facts recorded faithfully but not
always critically appraised

Assessment of risk

Tendency to move from facts to
actions without ‘showing your working’
Risk assessment





The dangers involved (that is the feared
outcomes);
The hazards and strengths of the situation (that is
the factors making it more or less likely that the
dangers will realised);
The probability of a dangerous outcome in this
case (bearing in mind the strengths and hazards);
The further information required to enable this to
be judged accurately; and
The methods by which the likelihood of the feared
outcomes could be diminished or removed.
Assessment Practice

Facts recorded faithfully but not
always critically appraised

Assessment of risk

Tendency to move from facts to
actions without ‘showing your working’
Assessment Practice
Facts

Summary of facts and
conclusions to be drawn

Recommendations
Assessment Practice
Facts
(Key question: complete and
reliable?)
Bias and Balance
Born in 1942, he was sentenced to 5
years imprisonment at the age of 25. After
5 unsuccessful fights, he gave up his
attempt to make a career in boxing in
1981 and has since had no other regular
employment
Lies, damned lies and killer bread
Research on bread indicates that
 More than 98 percent of convicted felons are bread users.
 Half of all children who grow up in bread-consuming
households score below average on standardized tests.
 More than 90 percent of violent crimes are committed within
24 hours of eating bread.
 Primitive tribal societies that have no bread exhibit a low
incidence of cancer, Alzheimer's, Parkinson's disease, and
osteoporosis.
 In the 18th century, when much more bread was eaten, the
average life expectancy was less than 50 years; infant
mortality rates were unacceptably high; many women died in
childbirth; and diseases such as typhoid, yellow fever, and
influenza were common.
Can you trust a snapshot?
Assessment Practice
Facts

Summary of facts and
conclusions to be drawn
(Key question: so what?)
What is analysis?
You have gathered lots of information but now what?
All you need to do is ask yourself my favourite question:
“So what?”
You have collected all this data, but what does this
mean, for the service user, for the family and for my
setting?
Assessment Practice
Facts

Summary of facts and
conclusions to be drawn

Recommendations
(Key question: not what but why?)
Conclusions and recommendations





Summarise the main issues and the
conclusions to be drawn from them. (The
facts do not necessarily speak for
themselves; it is your job to speak for them.)
Define objectives as well as actions
Draw conclusions from the facts and
recommendations from the conclusions
Explain how you arrived at your conclusions
(Have you demonstrated the
factual/theoretical basis for each?)
Consider and discuss alternative possibilities
Conclusions and recommendations

In drawing conclusions be aware of the
extent and limitations of your own expertise.
 Conclusions may be supported by research
(Don’t go outside expertise; be careful with
new or controversial theories; be aware of
counter arguments)
 Your recommendation should usually be
specific (not either/or)
 Remember: conclusions may be attacked in
only two ways
– founded on incorrect information
– based on incorrect principles of social work
Conclusions and recommendations
Problems:

Unsupported assertions or judgements

Inability or unwillingness to analyse and
draw conclusions

Failure to answer the key question:
‘So what?’
Reaching a decision

‘Often a decision is made first and the
thinking done later’ (Thiele, 2006)

As humans, we resort to simplifications, short
cuts and quick fixes!

We reframe, interpret selectively and
reinterpret.

We deny, discount and minimise

We exaggerate information especially if vivid,
unusual, recent or emotionally laden and

We avoid, forget and lose information
Information handling

Picking out the important from a mass of data

Interpreting and analysing (asking ‘so what?’)

Too trusting/insufficiently critical; Facts
recorded faithfully but not always critically
appraised

Decoyed by another problem

False certainty; undue faith in a ‘known fact’

Discarding information which does not fit the
model we have formed
Department of Health (1991) Child abuse: A study of inquiry
reports, 1980-1989, HMSO, London
Analysing Child Deaths and Serious Injury through Abuse
and Neglect (2003-5)

‘Hesitancy in challenging

Hostile and ‘difficult to engage’ families

‘Start again syndrome’.

Very young children physically assaulted
known to universal services or adult services
rather than children’s social care

Well over half: domestic violence, or mental ill
health, or parental substance misuse

Hard to help’ young people
The background
“The reviews showed that state care did
not always support these young people
fully and that they experienced ‘agency
neglect’” Brandon and others (2008).
Checkpoint 5

In what ways does the response of the
CP system to teenagers differ from
that to young children?

Why might this be?
“Hard to Help”: The complexity of the
challenge
Young people may be
 Victims,
 Perpetrators
 Parents
 Any combination of the above
but have the same right to be
safeguarded as any other child.
The young people
Adolescence marks start of serious
problems for many children:
–
–
–
–
–
Onset of mental health issues
Family conflict
Drug use, offending
Sexual activity
Running away
The young people (Brandon and others)





History of rejection, loss and, usually,
severe maltreatment
Long term intensive involvement from
multiple agencies
Parents: history of abuse and current
mental health and substance issues
Difficult to contain in school
Typically self-harming and misusing
substances, often self-neglect
The young people (Brandon and others)

Numerous placement breakdowns

Running away, going missing

Risk of dangerous sexual activity
including exploitation

Sometimes placed in specialist
settings, only to be withdrawn because
of running away
The young people (My experience)




Long involvement, but not always intense
Sometimes few placements, but all wrecked
by the young person
Common factor that local services just did
not know what to do with them.
‘By the time of the incident, for many of the
young people, little or help was being
offered because agencies appeared to have
run out of helping strategies’ (Brandon and
others, 2008).
The response




Reluctance to identify mental illness and
suicidal intent (CAMHS)
Failure to respond in a sustained way to
extreme distress manifested in risky
behaviour (sex, drugs, suicide attempts)
Instead of ‘pulling together’, multi-agency
response shows fragmentation, ignoring,
responsibility shifting, freezing/inertia and
generally avoidant behaviour
Reasons for running not addressed
adequately
The response





Running away leads to discharge
[More generally, does rejection of
services lead to total abandonment?]
Age used as a reason for not imposing
services
No proper assessment of competence;
allowed/forced to choose
[Dealing with incidents but failing to
recognise patterns]
The obstacles






Hard to get a purchase on the system
Wrong children, wrong adults (Ayre, 2000)
Lack of off-the-shelf resources
The limited resources are poorly
coordinated and integrated
Government targets not child centred or
child driven
Different agency agendas and mutual
misunderstanding; falling down the gap
The solutions?



Biehal (2005) recommends adolescent
support teams in the community [but is
that enough?]
The complexity of the challenge
requires flexible collaborative,
individualised responses built around
the young person
Specialist assessment and treatment?
Young children

„Poor pre-birth assessments

„isks from the parents’ own needs
R
underestimated

Fragility of babies underestimated

„Insufficient support for young parents

„Fathers marginalised

„ ssessment of, and support for
A
parenting capacity (Ofsted, 2011)
Response to overload

Acclimatisation at individual, team and
agency levels

Lack of a strategic multi-agency
response
The Child Safeguarding System
(nominal)
The Child Safeguarding System
(actual?)
Collaboration and communication

Communication generally found to be
good but…

Communication with hospitals
– Referrals
– Medical reports

Mental health or drugs issues
Mental health or drugs issues

Working on the same case but not working
jointly

Mutual incomprehension and
misunderstanding

False expectations and assumptions

Abdicating responsibility

Need for ‘interpreters’
Child protection meetings

Attendance at conferences

Protection plans omit objectives and
outcomes

Removal from the register

Use of strategy meetings

Proliferation of meeting types
Case management

File management: reading, recording
decisions, auditing

Supervision

Chronologies

Resourcing of Emergency Duty Teams
Training
General disquiet over the level of
training in child protection
 Specific training for children's services
and mental health workers
 Enhanced training for conference chairs
and or independent professionals
 Interagency training to cover the roles
and priorities of the key agencies

A final thought
“Smart people learn from their
mistakes. But the real sharp ones
learn from the mistakes of
others.”
Brandon Mull Fablehaven
References









Ayre P and Preston-Shoot M (2010) (Eds) Children’s services at the
crossroads: A critical evaluation of contemporary policy for practice,
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