Messages from Serious Case Reviews

1
Messages from Serious Case Reviews

• Patrick Ayre
• Department of Applied Social Studies
• University of Bedfordshire
• Park Square, Luton
• email pga_at_patrickayre.co.uk
• web http//patrickayre.co.uk

2
Learning from enquiries

• Those who cannot learn from history are doomed to
  repeat it
• (George Santayana)

3
Serious Case Reviews

• Held when a child has died or suffered serious
  harm and abuse or neglect suspected
• Aim to identify lessons to be learned
• Action plan drawn up
• Full report to become a public document

4
Serious Case Reviews

• A panel of senior managers drawn from key local
  agencies
• Final report normally written by an experienced
  external consultant
• Examine management reviews prepared by each
  agency

5
The background

• Widespread and persistent concern over standards
• Many enquiries and Serious Case Reviews
• Far reaching reforms
• Little evidence of improvement, in England at
  least

6
Why havent we learned? (Addictive behaviours)

• If it doesnt work, do more of it
• Procedures and micromanagement
• Training
• Performance indicators

7
Failure to learn from experience

• The proceduralisation, technicalisation and
  deprofessionalisation of the professional task
• Process and procedures prioritised over outcomes
  and objectives
• Targets and indicators prioritised over values
  and professional standards
• Compliance and completion prioritised over
  analysis and reflection

8
Deprofessionalisation

• Part of a wider trend
• Managerialism, McDonaldisation and the audit
  culture
• Management by external objectives
• Professionals not to be trusted

9
The scandal model of case review

• Public pillorying
• Public enquiry with many recommendations
• Law and guidance from the government

10

Climatic conditions for safeguarding

• Climate of fear
• Climate of mistrust
• Climate of blame

11
Responsible journalism at its best

• Today The Sun has demanded justice for Baby P
  and vows not to rest until those disgracefully
  ducking blame for failing the tot are SACKED
• The fact that Baby P was allowed to die despite
  60 visits from Haringey Social Services is a
  national disgrace.
• I believe that ALL the social workers involved in
  the case of Baby P should be sacked - and never
  allowed to work with vulnerable children again.
• I call on Beverley Hughes, the Children's
  Minister, and Ed Balls, the Education Secretary,
  to ensure that those responsible are removed from
  their positions immediately.
• (The Sun, 13 November 2008)

12

Climatic conditions

• Climate of fear
• Climate of mistrust
• Climate of blame

13

Climate of mistrust
Child stealers who seize sleeping children in
the middle of the night abusers of authority,
hysterical and malignant, motivated by zealotry
rather than facts or like the SAS in cardigans
and Hush Puppies. On the other hand, they are
naïve, bungling, easily fobbed off,
incompetent, indecisive and reluctant to
intervene and too trusting with too liberal a
professional outlook.

14

Climate of mistrust

The safeguarding worker who took a child away
from its parents
The safeguarding worker who failed to take a
child away from its parents
15

Climatic conditions

• Climate of fear
• Climate of mistrust
• Climate of blame

16
Maximising learning

• Serious Case Reviews must
• Explore WHY things were done (or not done) and
  not just WHAT was done (or not done)
• Distinguish individual ignorance and error from
  strategic and systemic issues
• Interpreting what happened locally in the wider
  context of practice knowledge

17
Exploring the WHYs (Level 1)

• A Serious Case Review along these lines is pretty
  much a waste of time
• Fact This child was injured because we did not
  do X
• Recommendation Do X in the future
• We need to know WHY X was not done

18
Why was X not done?

• Was it individual ignorance or error?
  (Outcome training, competency issues)
• Was the requirement not expressed clearly in
  procedures when it should have been
• (Outcome Procedural change)
• Was this requirement not understood?
• (Staff development strategic or systemic
  considerations)

19
Why was X not done?

• Were resources/commitment absent?
• (Strategic or systemic considerations)
• And finally and most crucially
• Was the service environment conducive to and
  supportive of good practice?
• (Strategic or systemic considerations)

20
Exploring the WHYs (Level 2)

• Fact This child was injured because we did not
  do X
• Recommendation Train staff to know they have to
  do X and/or write some new procedures (or both)
• (In fact, we know that people often dont do X
  even though they know, in theory, that they
  should and there are procedures which tell them
  that they must. The key question is often, why
  did they still not do it?)

21
Exploring the WHYs (Level 2)

• BBC Regional News, 17 November 2011
• The latest Ofsted inspection has found
  Childrens Services in Peterborough to be
  inadequate in seven out of nine categories. The
  Director of Childrens Services announced that
  the council had embarked on a programme of
  updating procedures and improving staff training

22
Blaming, training and writing procedures

• Procedural proliferation
• Blaming and training
• The myth of predictability

23
Procedures as a net to catch problems
24
Procedures as a net to catch problems
25
Procedures as a net to catch problems
26
Procedures as a net to catch problems
27
Blaming and training

• Causes of accidents can be traced to latent
  failures and organizational errors arising in the
  upper echelons of the system in question Accident
  sequences begin with problems arising in
  management processes such as planning,
  specifying, communicating, regulating and
  developing.
• Latent failures created by these organisational
  errors are transmitted along various
  organizational and departmental pathways to the
  workplace where they create the local conditions
  that promote the commission of errors and
  violations (e.g. high workload, deficient tools
  and equipment, time pressure, fatigue, low
  morale, conflicts between organizational and
  group norms and the like (Reason, 1995 p.1710).
  In this analysis, people at the sharp end are
  seen as the inheritors rather than the
  instigators of an accident sequence (Reason,
  1995 p.1711).

28
Exploring the WHYs (Level 3)

• Fact This child was injured because we did not
  do X
• Recommendation
• Review on an interagency basis the adequacy of
  the child safeguarding services available to,
  say, young people abused through prostitution or
  
• Review quality assurance processes and managerial
  processes to ensure that they focus more on
  quality than quantity.

29
Exploring the WHYs (Level 3)

• Fact This child was injured because we did not
  do X
• Recommendation
• Review whether the service environment was
  conducive to and supportive of good practice?

30
Micromanaging recording and reporting

• Format Endless predetermined tick boxes and text
  boxes
• Content Repetitive and disaggregated
• Concept Routinised and mechanistic
• Purpose Well, what is the purpose?

31
Micromanaging assessment and reporting

• Format Endless predetermined tick boxes and text
  boxes
• Content Repetitive and disaggregated
• Concept Routinised and mechanistic
• Purpose Well, what is the purpose?
• Understanding what it is like to be that child,
  and what it will be like if nothing changes

32
Micromanaging assessment and reporting

• Format Endless predetermined tick boxes and text
  boxes
• Content Repetitive and disaggregated
• Concept Routinised and mechanistic
• Purpose Well, what is the purpose?
• Understanding what it is like to be that child,
  and what it will be like if nothing changes ?
• Getting the assessment done ?

33
Micromanaging assessment and reporting

• What we want
• Coherent, confident and compelling
• What we get
• Disassembled, disarticulated and
  decontextualised

34
KPIs Ministers and managers

• Outcomes hard to measure, process easy
• Easy to obtain, easy to digest (but what do they
  tell us?)
• Quality KPI scores
• False sense of security
• Distort resource allocation
• ?A third of the mix

35
On the front line

• Learn by doing more than by training
• What is important in what I do?
• What is good practice?
• Supervision qualitative or quantitative?

36
Escaping the spiral of decline requires

• Research-informed, reflective, confident and
  critically-challenging practitioners
• Management systems which promote rather than
  undermine their effectiveness.  
• Ministers and senior managers committed to a
  significant change of direction, both practical
  and conceptual

37
Checkpoint 1

• Was any of this true for us?
• Three things we have done/are doing/could do to
  put things right

38
Learning from Past Experience Major themes from
SCR reviews of the 90s

• Collecting and interpreting information
• Importance of comprehensive family assessments,
  especially male figures
• Failure to give sufficient weight to relevant
  case history
• Understanding thresholds, especially the
  importance of neglect and emotional deprivation
  and the need to accumulate evidence

39
Learning from Past Experience Major themes from
SCR reviews of the 90s

• Collecting and interpreting information
• Importance of comprehensive family assessments,
  especially male figures
• Failure to give sufficient weight to relevant
  case history
• Understanding thresholds, especially the
  importance of neglect and emotional deprivation
  and the need to accumulate evidence

40
Learning from Past Experience Major themes from
SCR reviews of the 90s

• Collecting and interpreting information
• Importance of comprehensive family assessments,
  especially male figures
• Failure to give sufficient weight to relevant
  case history
• Understanding thresholds, especially the
  importance of neglect and emotional deprivation
  and the need to accumulate evidence

41
Capturing chronic abuse

• Judging the impact of long-term abuse is an
  essential component of any assessment but how
  well do we do it?
• Judgements subjective and prone to bias
• Intangible Difficult to capture and compare
• High threshold for recognition
• Neglect is a pattern not an event

42
Capturing chronic abuse

• Judging the quality of care is an essential
  component of any assessment but how well do we do
  it?
• Judgements subjective and prone to bias
• Intangible Difficult to capture and compare
• High threshold for recognition
• Neglect is a pattern not an event

43
Our image of assessment
44
The reality of assessment?
45
Capturing chronic abuse

• Judging the quality of care is an essential
  component of any assessment but how well do we do
  it?
• Judgements subjective and prone to bias
• Intangible Difficult to capture and compare
• High threshold for recognition
• Neglect is a pattern not an event

46
The pattern of neglect atypical
47
The pattern of neglect typical
48
The pattern of neglect
49
The pattern of neglect
50
The pattern of neglect
51
What we would hope to find
52
What we found
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What we found

• Chronic abuse and the principle of cumulativeness
• Incidents scattered through files
• The problem of proportionality
• Acclimatisation

54
Checkpoint 2

• Do we have issues with acclimatisation of any
  kind?
• What do we do/can we do?

55
Assessment Pitfalls

• Information from family friends and neighbours
  undervalued
• Failure to give sufficient weight to relevant
  case history Start again syndrome
• Parents behaviour, whether co-operative or
  uncooperative, often misinterpreted
• Coping with aggressive or frightening families
• Mishandling resistance

56
Resistance

• Involuntary work may be characterised by
• Guardedness or reluctance to share information
• Avoidance and a desire to leave the relationship
• Strong negative feelings such as anxiety, anger,
  suspicion, guilt or despair.

57
Context

• We need to accept that
• The best we may be able to achieve is honesty
  rather than positive feelings and a high degree
  of mutuality
• Conflict and disagreement are not something to be
  avoided, but are realities that must be explored
  and understood.
• Some degree of resistance is natural but we can
  make the situation better or worse

58
Checkpoint 3 Natural resistence
59
How might resistance show itself?

• By only being prepared to consider 'safe' or low
  priority areas for discussion.
• By not turning up for appointments
• By being overly co-operative with professionals.
• By being verbally/and or physically aggressive.
• By minimising the issues.
• (Egan, 1994)

60
Potential parental responses

• Genuine commitment
• Compliance / approval seeking
• Tokenism
• Dissent / avoidance
• (Howarth and Morrison, 2000)

61
Identifying resistance 4 categories

• Hostile resistance anger threats, intimidation,
  shouting
• Passive aggressive surface compliance covers
  partly concealed antagonism and anger
• Passive hopeless Tearfulness and despair about
  change
• Challenging Cure me if you can!

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Strategies for enhancing engagement

• Have realistic expectations
• It is reasonable that involuntary clients resent
  being forced to participate
• Because they are forced to participate,
  hostility, silence and non-compliance are common
  responses that do not reflect my skills as a
  worker
• Due to the barriers created by the practice
  situation, clients may have little opportunity to
  discover if they like me
• (Ivanoff et al, 1994)
• Learn techniques proven to work such as
  Motivational Interviewing or Solution Focused
  work

63
What might we be doing to make it worse?

• Becoming impatient and hostile
• Doing nothing, hoping the resistance will go away
• Lowering expectations
• Blaming the family member
• Allowing the family member to control the
  assessment inappropriately
• Failing to acknowledge our fear

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What might we be doing to make it worse?

• Becoming unrealistic
• Believing that family members must like and trust
  us before assessment can proceed.
• Ignoring the enforcing role of some aspects of
  child protection work and hence refusing to place
  any demands on family members.
• (Egan, 1994)

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Avoid

• Expressions of over-concern
• Moralising
• Criticising the client
• Making false promises
• Displaying impatience

66
Assessment pitfalls

• Rule of optimism
• Natural love
• Cultural relativism
• Too much
• not enough
• Maintenance of focus on the child

67
A child centred approach

• The purpose of assessment is to understand what
  it is like to be that child (and what it will be
  like in the future if nothing changes)

68
Checkpoint 4

• The purpose of assessment is to understand what
  it is like to be that child (and what it will be
  like in the future if nothing changes)
• Identify one area where this message should be
  shared or implemented better

69
Assessment Pitfalls

• Facts recorded faithfully but not always
  critically appraised
• Assessment of risk
• Tendency to move from facts to actions without
  showing your working

70
Risk assessment

• The dangers involved (that is the feared
  outcomes)
• The hazards and strengths of the situation (that
  is the factors making it more or less likely that
  the dangers will realised)
• The probability of a dangerous outcome in this
  case (bearing in mind the strengths and hazards)
  
• The further information required to enable this
  to be judged accurately and
• The methods by which the likelihood of the feared
  outcomes could be diminished or removed.

71
Assessment Practice

• Facts recorded faithfully but not always
  critically appraised
• Assessment of risk
• Tendency to move from facts to actions without
  showing your working

72
Assessment Practice

• Facts
• ?
• Summary of facts and conclusions to be drawn
• ?
• Recommendations

73
Assessment Practice

• Facts
• (Key question complete and reliable?)

74
Bias and Balance

• Born in 1942, he was sentenced to 5 years
  imprisonment at the age of 25. After 5
  unsuccessful fights, he gave up his attempt to
  make a career in boxing in 1981 and has since had
  no other regular employment

75
Lies, damned lies and killer bread

• Research on bread indicates that
• More than 98 percent of convicted felons are
  bread users.
• Half of all children who grow up in
  bread-consuming households score below average on
  standardized tests.
• More than 90 percent of violent crimes are
  committed within 24 hours of eating bread.
• Primitive tribal societies that have no bread
  exhibit a low incidence of cancer, Alzheimer's,
  Parkinson's disease, and osteoporosis.
• In the 18th century, when much more bread was
  eaten, the average life expectancy was less than
  50 years infant mortality rates were
  unacceptably high many women died in childbirth
  and diseases such as typhoid, yellow fever, and
  influenza were common.

76
Can you trust a snapshot?
77
Assessment Practice

• Facts
• ?
• Summary of facts and conclusions to be drawn
• (Key question so what?)

78
What is analysis?

• You have gathered lots of information but now
  what?
• All you need to do is ask yourself my favourite
  question
• So what?
• You have collected all this data, but what does
  this mean, for the service user, for the family
  and for my setting?

79
Assessment Practice

• Facts
• ?
• Summary of facts and conclusions to be drawn
• ?
• Recommendations
• (Key question not what but why?)

80
Conclusions and recommendations

• Summarise the main issues and the conclusions to
  be drawn from them. (The facts do not necessarily
  speak for themselves it is your job to speak for
  them.)
• Define objectives as well as actions
• Draw conclusions from the facts and
  recommendations from the conclusions
• Explain how you arrived at your conclusions (Have
  you demonstrated the factual/theoretical basis
  for each?)
• Consider and discuss alternative possibilities

81
Conclusions and recommendations

• In drawing conclusions be aware of the extent and
  limitations of your own expertise.
• Conclusions may be supported by research (Dont
  go outside expertise be careful with new or
  controversial theories be aware of counter
  arguments)
• Your recommendation should usually be specific
  (not either/or)
• Remember conclusions may be attacked in only two
  ways
• founded on incorrect information
• based on incorrect principles of social work

82
Conclusions and recommendations

• Problems
• Unsupported assertions or judgements
• Inability or unwillingness to analyse and draw
  conclusions
• Failure to answer the key question So what?

83
Reaching a decision

• Often a decision is made first and the thinking
  done later (Thiele, 2006)
• As humans, we resort to simplifications, short
  cuts and quick fixes!
• We reframe, interpret selectively and
  reinterpret.
• We deny, discount and minimise
• We exaggerate information especially if vivid,
  unusual, recent or emotionally laden and
• We avoid, forget and lose information

84
Information handling

• Picking out the important from a mass of data
• Interpreting and analysing (asking so what?)
• Too trusting/insufficiently critical Facts
  recorded faithfully but not always critically
  appraised
• Decoyed by another problem
• False certainty undue faith in a known fact
• Discarding information which does not fit the
  model we have formed
• Department of Health (1991) Child abuse A study
  of inquiry reports, 1980-1989, HMSO, London

85
Analysing Child Deaths and Serious Injury through
Abuse and Neglect (2003-5)

• Hesitancy in challenging
• Hostile and difficult to engage families
• Start again syndrome.
• Very young children physically assaulted known to
  universal services or adult services rather than
  childrens social care
• Well over half domestic violence, or mental ill
  health, or parental substance misuse
• Hard to help young people

86
The background

• The reviews showed that state care did not
  always support these young people fully and that
  they experienced agency neglect Brandon and
  others (2008).

87
Checkpoint 5

• In what ways does the response of the CP system
  to teenagers differ from that to young children?
• Why might this be?

88
Hard to Help The complexity of the challenge

• Young people may be
• Victims,
• Perpetrators
• Parents
• Any combination of the above
• but have the same right to be safeguarded as any
  other child.

89
The young people

• Adolescence marks start of serious problems for
  many children
• Onset of mental health issues
• Family conflict
• Drug use, offending
• Sexual activity
• Running away

90
The young people (Brandon and others)

• History of rejection, loss and, usually, severe
  maltreatment
• Long term intensive involvement from multiple
  agencies
• Parents history of abuse and current mental
  health and substance issues
• Difficult to contain in school
• Typically self-harming and misusing substances,
  often self-neglect

91
The young people (Brandon and others)

• Numerous placement breakdowns
• Running away, going missing
• Risk of dangerous sexual activity including
  exploitation
• Sometimes placed in specialist settings, only to
  be withdrawn because of running away

92
The young people (My experience)

• Long involvement, but not always intense
• Sometimes few placements, but all wrecked by the
  young person
• Common factor that local services just did not
  know what to do with them.
• By the time of the incident, for many of the
  young people, little or help was being offered
  because agencies appeared to have run out of
  helping strategies (Brandon and others, 2008).

93
The response

• Reluctance to identify mental illness and
  suicidal intent (CAMHS)
• Failure to respond in a sustained way to extreme
  distress manifested in risky behaviour (sex,
  drugs, suicide attempts)
• Instead of pulling together, multi-agency
  response shows fragmentation, ignoring,
  responsibility shifting, freezing/inertia and
  generally avoidant behaviour
• Reasons for running not addressed adequately

94
The response

• Running away leads to discharge
• More generally, does rejection of services lead
  to total abandonment?
• Age used as a reason for not imposing services
• No proper assessment of competence
  allowed/forced to choose
• Dealing with incidents but failing to recognise
  patterns

95
The obstacles

• Hard to get a purchase on the system
• Wrong children, wrong adults (Ayre, 2000)
• Lack of off-the-shelf resources
• The limited resources are poorly coordinated and
  integrated
• Government targets not child centred or child
  driven
• Different agency agendas and mutual
  misunderstanding falling down the gap

96
The solutions?

• Biehal (2005) recommends adolescent support teams
  in the community but is that enough?
• The complexity of the challenge requires flexible
  collaborative, individualised responses built
  around the young person
• Specialist assessment and treatment?

97
Young children

• ?Poor pre-birth assessments
• ?Risks from the parents own needs underestimated
• Fragility of babies underestimated
• ?Insufficient support for young parents
• ?Fathers marginalised
• ?Assessment of, and support for parenting
  capacity (Ofsted, 2011)
• ?

98
Response to overload

• Acclimatisation at individual, team and agency
  levels
• Lack of a strategic multi-agency response

99
The Child Safeguarding System (nominal)
100
The Child Safeguarding System (actual?)
101
Collaboration and communication

• Communication generally found to be good but
• Communication with hospitals
• Referrals
• Medical reports
• Mental health or drugs issues

102
Mental health or drugs issues

• Working on the same case but not working jointly
• Mutual incomprehension and misunderstanding
• False expectations and assumptions
• Abdicating responsibility
• Need for interpreters

103
Child protection meetings

• Attendance at conferences
• Protection plans omit objectives and outcomes
• Removal from the register
• Use of strategy meetings
• Proliferation of meeting types

104
Case management

• File management reading, recording decisions,
  auditing
• Supervision
• Chronologies
• Resourcing of Emergency Duty Teams

105
Training

• General disquiet over the level of training in
  child protection
• Specific training for children's services and
  mental health workers
• Enhanced training for conference chairs and or
  independent professionals
• Interagency training to cover the roles and
  priorities of the key agencies

106
A final thought

• Smart people learn from their mistakes. But the
  real sharp ones learn from the mistakes of
  others. 
• Brandon Mull Fablehaven

107
References

• Ayre P and Preston-Shoot M (2010) (Eds)
  Childrens services at the crossroads A critical
  evaluation of contemporary policy for practice,
  Russell House, Lyme Regis
• Brandon M. et al (2008) Analysing child deaths
  and serious injury through abuse and neglect
  What can we learn? London, Department for
  Children. Schools and Families
• Falkov, A. (1996) A Study of Working Together
  Part 8 Reports Fatal Child Abuse and Parental
  Psychiatric Disorder, London Department of
  Health
• James, G. (1994) Study of Working Together Part 8
  Reports, London Department of Health
• Ofsted (2008) Learning lessons, taking action,
  London Ofsted
• Ofsted (2009) Learning lessons from serious case
  reviews year 2, London Ofsted
• Ofsted (2011) Ages of concern learning lessons
  from serious case reviews. London Ofsted
• Owers, M., Brandon, M. and Black, J. (1999)
  Learning How to Make Children Safer An Analysis
  for the Welsh Office of Serious Child Abuse Cases
  in Wales, University of East Anglia/Welsh Office
• Sinclair, R and Bullock, R (2002) Learning from
  Past Experience A Review of Serious Case
  Reviews, London Department of Health