75 years on from the Children Act 1948: A short history of Serious Case Reviews

Serious case reviews and equivalent enquiries into the deaths of children at risk have occurred regularly for more than sixty years.

Arguably the first modern review was in 1945, following the death of Dennis O’Neill. He was killed by his foster parents on their remote farm in Shropshire. Dennis and his brother Terence had been sent there in May 1944 while in the care of Newport Borough Council. His death was the subject of an enquiry led by Sir Walter Monckton, a lawyer and Conservative MP, and informed two government reports, by the Curtis Committee on the care of children and the Clyde Committee, on homeless children. Together they led to the Children Act of 1948, which created specific departments in local authorities for children at risk, the employment of trained children’s officers in local authority care, and improved supervision of foster parents by local authorities.

The next major inquiry was held in 1974, following the death of Maria Colwell, who was killed by her stepfather. It highlighted the lack of coordination between police, social services and the NSPCC in protecting her.

Consequently, legislation was introduced to improve multi-agency working, eventually leading to Area Review Committees, the forerunner of Local Safeguarding Children Boards and today’s partnership arrangements, responsible for coordinating information about children at risk and for training.

In 2003, the House of Commons Health Committee produced proposals based on Lord Laming’s report into the death of Victoria Climbié and commented, ‘Since 1948 there have been around 70 public inquiries into major cases of child abuse. The names of many of the children who have died have become well known, simply because of the terrible nature of their deaths. From Maria Colwell in 1973, to Jasmine Beckford and Tyra Henry (both in 1984), Kimberley Carlile (1986), Leanne White (1992), and Chelsea Brown in 1999, the deaths of these children all share many points of similarity. The pattern does not even end with the death of Victoria; since that time there have been at least two more high profile cases (Lauren Wright in 2000, and Ainlee Walker in 2002). In many of these cases the child has been the target of abuse from an adult who is not the natural parent (typically a step-father). While the particular circumstances of each case are different, there are also areas of considerable similarity. In particular, the following features recur time after time:
• Failure of communication between different staff and agencies.
• Inexperience and lack of skill of individual social workers.
• Failure to follow established procedures.
• Inadequate resources to meet demands.

Major changes followed including the Every Child Matters programme, which led to improvements in integrated, multi-agency services. The Children’s Commissioner was established and each local authority had a Director of Children’s Services. Also, for the first time, electronic national records were created to make it easier to trace children across England and Wales.

In 2009, in response to Lord Laming’s report into the death of Peter Connelly, further changes were brought in by Ed Balls, Education Secretary. A total of £58m was allocated to provide better training, new recruitment campaigns and changes in local safeguarding boards.

Major changes came in 2011, when Professor Eileen Munro reviewed the whole system of child protection in England. In her report, she said that frontline social workers were overloaded with too much paperwork and a need to do everything ‘by the book.’

Her report said, ‘We need people to keep their focus on keeping children safe, and giving them the help they need, when they most need it. We need better management of front line people working to keep children safe, to give them greater professional confidence and freedom.’

The Munro Report identified four key influences driving child protection services:
- the importance that members of the public attach to children and young people’s safety and welfare, and the strong reaction when a child is seriously hurt or killed
- that the unpredictable nature of child protection work can be removed if procedures are followed
- the reaction to child abuse deaths and the tendency to think that professionals have made mistakes without looking deeply enough to find out the causes, and
- the importance of performance targets and process over the quality of help given.

‘The system sometimes gets so caught up in doing other things (like having meetings, doing assessments and writing reports) that it forgets that to keep children safe it is very often a case of ‘actions needing to speak louder than words.’

As a result, ‘Many social workers now say that they no longer have time to work with children and families themselves, but just assess and refer them on for the help they need. This is because they are now so involved in administrative tasks (doing assessments, making referrals, writing reports, keeping records up to date and spending time in meetings). This is far from the view that many have of what social work should be about.’

The Conservative government accepted all 15 recommendations of the report. One key result was that guidance previously issued under the heading ‘Working Together’ was cut from 300 pages to 109. Another was the appointment of two chief social workers – one at the Department of Education and one at the Department of Health.

Following Munro, the focus on investigations into child deaths switched away from blame and towards causation. Serious Case Reviews were replaced by Child Safeguarding Practice Reviews, conducted by local panels or the national panel.

The latest reviews, into the deaths of Arthur Labinjo-Hughes and Star Hobson, produced nine recommendations:
- A new expert-led, multi-agency model for child protection investigation, planning, intervention, and review. •
- Establishing National Multi-Agency Practice Standards for Child Protection.
- Strengthening the local Safeguarding Partners to ensure proper co-ordination and involvement of all agencies.
- Changes to multi-agency inspection to better understand local performance and drive improvement.
- A new role for the Child Safeguarding Practice Review Panel in driving practice improvement in Safeguarding Partners.
- A sharper performance focus and better co-ordination of child protection policy in central Government.
- Using the potential of data to help professionals protect children.
- Specific practice improvements in relation to domestic abuse.

The Independent Review into Children’s Services by Josh MacAlister called for ‘No more Serious Case Reviews that point out the same flaws that we all already know about, again and again.’ This is unlikely to happen, according to David Jones, social work practice and policy expert who currently chairs the Social Work History Network and was formerly the Chair of the Association of Independent LSCB Chairs.

‘The fundamental question which the reviews rarely address is the resource context in which people are working.,’ he said. ‘We have had political disruption. We’ve seen the decimation of family support services and early help, and now the Macalister review comes along and says we’ve got to support families. That’s so blindingly obvious but it’s been ignored over the period of this government.’ The independent review called for initial funding of £2 billion but the government implementation strategy has been widely criticised for allocating just £200m.

Dr Jones said that Every Child Matters had improved services. ‘Scrapping it [in 2011] was an act of vandalism. It had been a multi-party programme which everybody supported, all the different professional groups were connected to it and felt that it made sense. The destruction of the ECM website broke the easy access to resources and research and made life more difficult for many different professionals.’

Beyond the issue of resources, Dr Jones said, ‘Serious case reviews have in a sense told the same story and come up with similar recommendations. The fact that that has persisted for so long might prompt us to ask if we are looking for the wrong thing or not learning the lessons properly. It isn’t that people aren’t wanting to do the right thing but they are obviously facing challenges and difficulties. Lessons have been learned and there are examples all over the country of organisations working better and staff delivering better services. The statistics on abuse are reasonably positive. But we need to step back and say are these occurrences inevitable in a service delivered by a complex, interlocking multi-professional system, which also involves members of the public?

‘What is the nature of the judgements people are being asked to make? People are evaluating really complex and risky situations, frequently on the basis of incomplete evidence. In the context of huge reductions in resources for people., That context cannot be ignored.

‘A serious criticism of SCRs is that they are individualistic and don’t look at the whole system in which decisions are taken. The focus is on individual judgements. It is not on the culture of the organisation, the support that staff were getting, nor on the management style. That is a serious omission.

‘One local authority Joint Review I was involved in identified signification deprivation in the area and we were quite surprised that we found they had no child deaths over a five-year period and no serious reviews.

‘We explored what this meant. And it seemed it was directly related to their stable workforce and a very professional management; they did not pay their staff above the going rate but they did give them more training and supervision, and our Review concluded that the service was ‘outstanding’. I argued at the time that we should draw this out as a significant lesson and as evidence of the impact of effective training, a good management support system and a positive environment in a local authority that was investing in family support. But nobody felt sufficiently confident to point that up as a lesson. The evidence to show what makes effective social service delivery is so difficult to find, but it is consistent with all the research on what creates effective organisations in the private sector and in government.

‘People Need People, my 2000 report for the Department of Health and the Audit Commission, found that there was clear evidence from the Joint Review Team study of 40 local authorities that these things made a difference. They also made a difference to the ways service users responded -- they were much more positive about the help that they were getting.

‘It is almost as if talking positively about social workers and talking compassionately about people in difficulties and the way you need to provide help has not been the discourse people want to hear. This is especially true of those politicians and managers who like to talk about ‘tough management’. But we know that an aggressive management style drives people away and causes problems.

‘What I learned as an inspector was how different local authorities are and how misleading it is to assume that they are all the same. The political context in which local government is delivered is crucial. Often the problems get more attention but it is sometimes difficult to talk about successes given the social work culture which is about valuing everybody and not being overly competitive and claiming successes! There is some really good management and there are some really good politicians - and that is not related to any particular political party in my experience. Delivering and improving social work is about valuing the people; where you have got a positive politicians and positive directors, it can work really well.’

‘I think there is a lack of honesty about the real cost of providing care at a level of quality that people expect. Widening inequality means more children coming into care, poorer health, more crime, -- it is a choice in this country that our politicians are reluctant to explore in honest debate with the electorate. Until that happens, sadly there will almost certainly be more child deaths and need for more inquiries’.