The benefits for social workers of keeping clear and robust case records
Shefali Shah discusses the importance of good-quality social work case
records and the gathering, preserving, and disclosing of vital evidence.
An increase in care proceedings means more and more social care professionals, whether from adults’ or children’s services, are at risk of having their evidence examined in court. An important case detailed below highlights the importance of keeping good social work case records.
Robust evidence in court proceedings is crucial, and reliable evidence starts with clear contemporaneous records. This was clearly demonstrated in the case of two children, M and N, in 2018, where the judge stressed the importance of gathering, preserving and disclosing evidence. Whilst this was a case regarding children and families’ social work, the issues that arose are equally applicable to cases regarding social work with adults.
Facts of the case
The case concerned two small children, M and N, who lived with their mother and her partner, referred to in the judgement collectively as “the parents”. N, the younger of the two children, suffered a serious injury to her clavicle as well as bruising to her neck. The parents gave two possible explanations. Initially, the parents suggested that this was an accidental injury caused by the child’s seatbelt. This was dismissed by the treating paediatrician. The parents’ second explanation was that N had been injured by her half-sister, M, who they said might have tripped and fallen on N.
The local authority commenced an immediate investigation. The social worker’s notes on the case formed the evidence in the subsequent care proceedings. The reliability and strength of the social worker’s recordings would be crucial to the case and would form the foundation of the evidence to support the local authority’s care proceedings application.
However, the social worker who undertook the critical interviews with the family members did not write up her formal case notes of these meetings until two weeks after they took place. In court, it became clear that the delay of writing up the case records had impacted on the reliability of the social worker’s memory of the events. As a result, the social worker’s retained handwritten notes were produced the next day at court.
The judge was critical of these handwritten notes. They were undated, unprofessionally prepared, illegible, disjointed, and ultimately failed to accurately record who was present. It was further noted that the social worker had to translate the handwritten notes, which were described by the judge as “illuminating”.
Another key issue was that the social worker’s formal case notes had not recorded the family living room plan, which had been recorded in the handwritten, contemporaneous notes. This floor plan was important as it was used to assist the understanding of the parents’ second explanation of how the injury had occurred.
Consequences of poor organisation
The local authority was subsequently criticised for failing to prepare its case in a way that demonstrated a clear sequence of events, supported by contemporaneous notes. The consequences of this poor evidence were that it was incorrectly relied upon by the medical experts. This resulted in these experts being deprived of corroborating evidence to explain how the neck could have been bruised, but not the body. The impact of this was that, at court, the medical experts agreed that N could have been injured by M falling on her as described by the mother in the second explanation. This resulted in the judge finding that the injury was accidental and the local authority applying to withdraw the care proceedings case.
Robust evidence starts with good notes
This case clearly demonstrates the need for robust, coherent and contemporaneous evidence, which starts with reliable and clear case notes that are themselves the result of correct gathering and recording procedures. Social work notes are vital and can be relied upon by other experts, most notably to assist in the medical experts’ analysis of events. The case highlights that clear, detailed, and contemporaneous notes are essential, particularly if there is a potential delay in writing up formal case notes.
Relying on your memory can leave you vulnerable to very difficult and complex cross-examination. Therefore, it is imperative that any notes are written up into formal case recordings without delay. If that is not possible, then ensure your case notes are more detailed than usual, so that they can assist you when are able to write up your case recordings.
Training is essential
The judge in the case of M and N took the view that the correct level of training for social workers in these instances is vital. I am often asked in my training programmes whether social workers should keep their notes, or if they should be destroyed after the formal case recordings are written up. The court’s view was provided in the case of Child L in 2002. In this case, the judge stated that all professionals should at all times keep clear accurate, full and balanced notes of all relevant conversations and meetings between themselves and family members. The judge also advised that the local authority should at an early stage of the proceedings make full and frank disclosure of all key documents.
Training on gathering and recording evidence will also support the presentation of robust evidence in court. It will not only support the local authority’s case, but will also assist the social worker in presenting their evidence effectively and confidently, even when faced with vigorous cross-examination during proceedings.
Shefali Shah is the founder of Kingsley Knight Training and the author of the book "Key Changes to Family Justice".
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