The Troubling History of Serious Case ReviewsThe Troubling History of Serious Case Reviews David N...

The Troubling History of Serious Case Reviews

David N Jones

Social Work History Network

24 November 2015

People Need People Consulting Realising the potential in human services

Source material

Serious Case Reviews in Child Protection: Historical Reflections David N Jones (2015) ADCS Virtual Staff College http://www.virtualstaffcollege.co.uk/wp-

content/uploads/historical_reflections_publish.pdf


http://www.virtualstaffcollege.co.uk/wp-content/uploads/historical_reflections_publish.pdf




Possible questions What generates public concern in

‘serious cases’? Has all the energy devoted to Serious

Case Reviews had any impact on policy and practice?

Does the history of SCRs throw light on service development and improvement?

How do SCRs fit alongside developments relating to risk management in other fields?

What pushes a ‘serous case’ into the public domain?


“Scandals do not just happen. They are made.

They are constructed out of such everyday tragedies as

the small carelessnesses and institutional brutality of the long stay hospital,

the abuse of children or the violent deaths of innocent bystanders”

(Butler and Drakeford, 2005).

Victorian scandals, inquiries and reform

Haydock Lodge scandal (1846-1852) involved the

transport around the country of large number of ‘paupers’ with mental illnesses and learning disabilities

Timothy Daly (1864) – St Bartholomew’s – death by exhaustion from bed sores & fever – Florence Nightingale – workhouse reform – Lancet Commission, etc

Mary Ellen (1874) - New York - NSPCC (1895)


Reviews since 1945

Children Act 1948 – Dennis O’Neill – Monkton inquiry 7 weeks – Curtis Ctte

Children Act 1975 - Maria Colwell Children and Young Persons Act 2008 –

Victoria Climbié – Laming 2003 – Every Child Matters 2003

From 1973 increasing use of public inquiries


Enquiries 1973 Graham Bagnall 1973 David Lee Naseby 1973 Maria Colwell 1974 Max Piazzani 1975 Auckland family 1975 Richard Clark 1975 Lisa Godfrey 1975 Stephen Meurs 1976 Neil Howlett 1977 Wayne Brewer 1977 H family 1978 Paul and L. Brown 1978 Stephen Menheniott 1978 Simon Peacock 1979 Lester Chapman 1979 Darryn James Clarke 1980 Paul Stephen Brown 1980 Claire Haddon 1980 Carly Taylor 1981 Maria Mehmedagi 1981 Malcolm Page


1981 Christopher Pinder/Daniel Frankland 1982 Jason Ceasar 1982 Lucy Gates 1984 Shirley Woodcock 1984 Heidi Koseda 1985 Jasmine Beckford 1985 Reuben Carthy 1987 Tyra Henry 1987 Cleveland - 121 children

1990 Orkney 2000 North Wales (Waterhouse) 2001 Caleb Ness 2003 Victoria Climbié 2006 Michael McGarrity 2007 Baby Peter 2009 ‘J’ children - ‘Edlington’ 2010 Khyra Ishaq 2012 Edlington case Carlile 2013 Daniel Pelka 2013 Hamzah Khan 2013 Operation Pallial (North Wales)


Enquiries

2013 Operation Yewtree 2013 Rochdale CSE 2013 HMIC’s review into (police handling of) allegations and

intelligence material concerning Jimmy Savile 2014 Rotherham 1997-2013 2015 Oxfordshire 2015 Independent oversight of investigations into matters

relating to Jimmy Saville at schools and children’s homes: 2015 Themes and lessons learnt from NHS investigations into

matters relating to Jimmy Saville Inquiry into non-recent abuse


Enquiries


Concern increased through 1980s – cost and public relations impact

Search for a credible, robust and cost effective inquiry system, which would convince politicians, the media and judges that there was a robust system of review and therefore that public inquiries were not necessary.

Resulted in Part 8 duty on LSCBs to undertake formal inquiries into serious cases.

Government guidance


Government guidance 1970 Battered babies DHSS 1980 Child abuse: central register systems DHSS 1986 Working together: arrangements for

interagency co-operation for child protection DHSS 1991 Working together 1999 Working together 2006 Working together 2010 Working together 2013 Working together 2015 Working together

Other sectors

1997 A New NHS: Modern; Dependable DH 2000 An organisation with a memory: report of an expert group on learning from adverse events in the NHS (DH) 2001 National Patient Safety Agency (DH) 2003 Keeping Children Safe (DH) - CDOPs Aviation International experience


A new direction?

Munro articles (1996–2008) – systems approach New government – Climbié impact Ofsted reviews Munro reports (2010-2011) Publication or not? Revised guidance National Audit Office (2016)? An industry or a service?


Factors shaping SCR impact


The type of case (severity and death do not

always lead to public outcry). The ‘response’ of the local agencies - how they

handle the case in public. How the response is perceived by ‘the public’ -

whether this is credible or ‘defensive’ - increasingly whether there is a sufficiently sincere apology.

Other news on the day of publication (impact of social media?).

Whether local politicians see scope for political advantage.

Whether national politicians or media see political advantage or Ministerial exposure to risk

Observations


UK experience consistent with other English

speaking countries – ‘learning’ or ‘blame’? Serious case reviews have had a major impact on

social policy and development of children’s services

Research and evidence has also had an impact but serious cases have shaped perceptions more than anything else

SCRs have not addressed the organisational context – system – which is perhaps why learning appears less effective – ‘repeating the same behaviours’ (cf aviation) – increased focus on ‘learning’

Understanding of human behaviour still partial

Observations


‘England is not unique in grappling with these challenges. Indeed it is arguable that our structured and formal systems, which have called forth considerable professional and academic enquiry and energy, are more robust, effective and consistent than those of many (even most) other countries. Despite this, there is professional, political and public frustration with the outcomes of many reviews and therefore a clear need to explore more effective ways to understand the dynamics within organisations and between individuals, including family members and children themselves, and why these sometimes result in tragedy but much more frequently provide positive support to people in profound and difficult circumstances.’ Serious Case Reviews in Child Protection: Historical Reflections’ David N Jones (2015)

Observations


‘Why did this happen?’ is inevitably a legitimate question and one which demands a credible answer through the Serious Case Review or whatever alternative process is used. “Scandals do not just happen. They are made.” (Butler and Drakeford, 2005)

References


Butler, I. and M. Drakeford, (2005) Scandal, social policy and social welfare, Bristol Policy Press

Butler, I. and M. Drakeford (2012) Social work on trial: the Colwell inquiry and the state of welfare, Bristol, Policy Press

Jones, D. N. (2015) Serious Case Reviews in child protection - historical reflections, ADCS Virtual Staff College. http://www.virtualstaffcollege.co.uk/wp-content/uploads/historical_reflections_publish.pdf (Accessed on 30 October 2015)

Virtual Staff College on behalf of partners (2015) The role of serious case reviews in improving the child protection system. Nottingham, ADCS Virtual Staff College. http://www.virtualstaffcollege.co.uk/wp-content/uploads/Role_Serious_Case_Studies_final_2.3.pdf (Accessed on 2 December 2015)



http://www.virtualstaffcollege.co.uk/wp-content/uploads/Role_Serious_Case_Studies_final_2.3.pdf

http://www.virtualstaffcollege.co.uk/wp-content/uploads/Role_Serious_Case_Studies_final_2.3.pdf

Thank you

[email protected] @JonesDavidN

SWHN – 24 November 2015


The Troubling History of Serious Case Reviews

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