NSPCC Common Themes Serious Case Reviews

The Government has been saying for quite a while that there is a problem with Serious Case Reviews. In January 2016 the Department for Education  published a Policy Paper  which said “We need a deeper and more sophisticated understanding of why mistakes occur and how the system can learn to avoid them. This requires overhauling the serious case review process…”

The NSPCC is in an odd position here.

On the one hand it compiles “Thematic Briefings” where it hyperfocuses on a single topic and simply copies and pastes the recommendations from historic Reviews. On the other hand, the NSPCC is in discussion with experienced independent reviewers, SCIE [Social Care Institute for Excellence], and the National Association of Independent LSCB [Local Safeguarding Children Board] Chairs about the poor quality of SCRs [Serious Case Reviews], including the facile use of “SMART” recommendations. It has just published two sets of resources.


I am  pleased to see that the NSPCC is now analysing common themes instead of focusing narrowly on just one aspect, as it has done in the past with Thematic Briefings. This seems immensely  more productive and intelligent.

The NSPCC says “Problems with inter-professional communication and its impact upon decision making is a common theme in serious case reviews (SCRs).

Here are some of the key points about “communication” which the NSPCC has pulled out from Serious Case Reviews:

There isn’t an agreed common language amongst different professional groups so communication is open to misinterpretation, for example over what constitutes “a referral.”

It is widely believed that there is a hierarchy where some views matter more than others.

There isn’t an agreed risk threshold amongst different professional groups.

Legal services may have their own reasons for not bringing a prosecution but this can be interpreted by other professionals as meaning there are no significant concerns.

Medical professionals tend not to give a definitive ruling eg over whether something could be “accidental.”

The correct escalation procedures are often not understood or not followed, so people may stop even trying to communicate if they feel nobody is listening or it makes no difference.

Some professionals’ views are discounted, even though they see the child very frequently.

Some professionals say they can’t talk freely if parents are present and this also extends to what they say or write about parents, where they may use euphemistic or misleading language, or downplay problems.

There are drawbacks to the practice of convening a series of multi-agency meetings as a means both of carrying out an assessment and also of influencing what happens within a particular family.

The system favours those professionals who are able to attend meetings regularly and who can put their views across effectively in a group setting.

Health and police don’t attend meetings, leading other professionals to conclude that there isn’t a serious problem, or means that health evidence goes unquestioned.

Multi-agency meetings may not be an effective way to deal with longstanding neglect.

Finally, there may be misunderstandings about who is going to do what following a meeting.

NSPCC describes its new information as “a series of reports and resources to share what we’ve learnt and provide practical tools to help improve the quality and use of serious case reviews.”

Unfortunately, I don’t find these resources in the least user-friendly.

The overview is apparently best viewed as A3. There is no alternative format.


To read the supplementary detail about “Inter-professional communication and decision making” it is necessary to click on 14 separate icons (displayed 3 at a time horizontally across the page)


I can’t see anywhere this is all brought together, which makes it extremely hard to digest.

However, the second element of the NSPCC resources for Improving the Quality of Serious Case Reviews is much easier to follow.

The “Serious Case Review Quality Markers” appear as a list of pdfs and there is also a single 56 page pdf  comprising the overview plus the full set of markers.

Amongst all the NSPCC’s ideas for improving the quality of serious case reviews, I found no mention of making recommendations to Government for the law to be changed. The focus is on local culture, practice, circumstance and procedure.

Page 18 says
SCRs often provoke fear, for individuals and agencies, that the process involves looking for someone to blame for the incident or outcome of the case. In contrast, the purpose of SCRs should be organisational learning and improvement and, where relevant, the prevention of the reoccurrence of similar incidents. This framework accepts that errors are inevitable and, where they are identified, they become the starting point of an investigation. Individual and organisational accountability is manifest through being open and transparent about any problems identified in the way the case was handled, and demonstrating a commitment to seek to address the causes. In many SCRs this is what the LSCB wants the SCR to achieve. It is as simple as that. Communicating with clarity the learning and improvement purpose helps address fears and uncertainties over the function of the SCR. It also helps reduce defensiveness on the part of those affected. In some cases, the situation is not as straightforward. Certain cases and/or local circumstances can trigger government and/or media expectations about individual(s) and/ or agencies being held to account by disciplinary means. The need to identify someone to blame can also become a driving factor for senior managers. [my emphasis]

Page 30 says
The purpose of an SCR is to learn from past professional practice to support improvements in future safeguarding. This requires an analysis that evaluates and explains professional practice in the case, shedding light on routine challenges and constraints to practitioner efforts to safeguard children. The organisational factors that helped and hindered timely help to families and protection of children need to be ascertained. This requires a wide range of information types to be gathered including:
• The facts of what happened in the case – who did what, and when?
• The rationale for decision-making, action and inaction – why did people do what they did, what were they trying to achieve, what was influencing their practice?
• How normal was their behaviour – is this the way things are usually done?

Page 43 says
The drive to produce SMART recommendations (specific, measurable, achievable, realistic and time-bound) can deter from a full exploration of practice problems that are complex and for which there are no easy solutions.

Page 50 says
The learning and actions emanating from an SCR are only one source of learning and improvement action, and feed into a bigger programme of work run and overseen by an LSCB. It is important that the action resulting from a single SCR is both seen and evaluated in the context of that bigger whole and as part of a continual learning process. In complex systems such as multi-agency safeguarding arrangements, the impact of change is often hard to anticipate with total accuracy and there may be unintended consequences. It is important therefore to ascertain whether the original response was the right thing or if the action needs adjusting.  [my emphasis]

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