What is Really Wrong with Serious Case Reviews?

Abstract

Concern about the effectiveness of Serious Case Reviews for generating improvements in child protection in England led to proposals in the Wood review to replace the current system with rapid local learning inquiries and a national system of learning from significant incidents. This article challenges both the analysis in the Wood review and the proposals themselves. Whilst not uncritical of Serious Case Reviews, this article addresses five criticisms of the current review system. It explores how systemic the focus of reviews has been, and argues that findings and recommendations have become repetitive and lessons not fully appreciated because of an overly simplistic approach to change management. It suggests that there are methodologies that can effectively engage practitioners and managers in case reviews and that criticism of the review process itself can be addressed with refinements rather than wholesale change. The article concludes by questioning the assumptions upon which proposals for changing the current Serious Case Review are based. Copyright © 2017 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGES:• A systemic approach to Serious Case Reviews must engage legislative, social policy and societal systems as well as local policy and practice.• A linear approach to learning and service development, often reflected in recommendations for training and policy refinements, is a less effective change management approach than engaging with single and multiagency contexts.• Safeguarding children involves practice which is inherently social and relational, full of complexity and complicated truths; so too is the practice of reviewing cases.

Findings from a Thematic Multidisciplinary Analysis of Child Practice Reviews in Wales

“…From reading the CPRs, it was evident that, in 15 reports, some forms of knowledge were privileged over others. This resonates with a theme identified in our previous study (Robinson et al ., 2019) whereby professional knowledge was seen to take precedence over personal knowledge (Preston‐Shoot, 2018). This theme also resonated with the focus group participants, who highlighted difficulties in managing professional differences.…”

“…The decisions of professionals (e.g. medical diagnosis) were seen to be based on ‘objective’ knowledge, which was seen to be superior to the ‘subjective’ judgements or opinions of para‐professionals, family and community members (Preston‐Shoot, 2018). All professionals were listened to and their concerns privileged above those of parents; for example, in one CPR, the parents expressed concerns about their son and he later ended his life.…”

Addressing the Disconnects in Child Protection Practice

“…Within that context, the critique by Michael Preston‐Shoot () in this issue of Child Abuse Review is both timely and hopeful. Preston‐Shoot examines the recent Wood () review into children's safeguarding systems in England and the subsequent government response (Department for Education, ).…”

“…Serious Case Reviews undoubtedly have their weaknesses, as do Welsh Child Practice Reviews, Case Management Reviews in Northern Ireland and Significant Case Reviews in Scotland (Preston‐Shoot, ). These weaknesses are not unique either to the UK or reviews of fatal child abuse.…”

“…This is perhaps the key message of Preston‐Shoot's review, suggesting ways in which we can delve deeper, engage with the very real underlying systemic issues and support practitioners within a reflective, learning culture. As Preston‐Shoot () points out, this is not straightforward:

‘...just as safeguarding children involves a practice which is inherently social and relational, full of complexity, uncertainty, dilemmas, tensions and complicated truths, so too is the practice of reviewing cases and understanding how to go on better than before.’ (p. 21)

…”