Reviews into abuse-related deaths or serious harm of children remain focused on changing frontline practice, rather than addressing systemic issues, a report has found.
Fourteen years after Professor Eileen Munro called for a shift to a systemic approach to reviews, they continue to focus on what happened, rather than how and why harm to children occurred, said the report.
As a result, local child safeguarding practice reviews (LCSPRs) tend to recommend training for practitioners, updates to practice tools and procedural changes, rather than address underlying practice conditions related to harms to children, it added.
The report, commissioned by the Child Safeguarding Practice Review Panel, also found that some practitioners associated the process with blame and that there was sometimes little therapeutic support or follow-up for those taking part in reviews.
The study, by Research in Practice, University of East Anglia and police evidence body the Vulnerability & Knowledge Practice Programme, called on the panel to develop a learning framework to set out "how systems learning needs to be identified and enabled at every level of the system".
It also urged the government to respond annually to key recommendations for it from the panel's national and thematic reviews, to "address the current gap in response to issues of national importance and complex, system wide issues".
Munro's critique of serious case reviews
In her 2011 government-commissioned report on child protection, Munro found recommendations from serious case reviews (as they were then known) took the form of "admonishments to professionals of what they ‘should’, ‘need’ or ‘must’ do in specific situations in the future", without explaining why practitioners made the decisions that they did.Instead of a "blame culture", reviews should adopt a "systems approach" that sought to identify the deeper, underlying issues and the wider context influencing practice.
While the 2013 update of Working Together to Safeguard Children specified that a systems methodology may be one that might be adopted for an SCR, a 2016 government-commissioned report on local safeguarding children boards (LSCBs) found that, despite this, "too often the purpose of a local SCR is considered to be to find out who made a mistake".
2017 safeguarding reforms
Sir Alan Wood's report shaped the Children and Social Work Act 2017's reforms to safeguarding, including the replacement of LSCBs by the three statutory safeguarding partners (councils, NHS and police) and of SCRs by LCSPRs, along with the establishment of the national panel to oversee the system of learning from serious cases.The then government set out in law - through the Child Safeguarding Practice Review and Relevant Agency (England) Regulations 2018 - that review reports must include "an analysis of the systemic or underlying reasons why actions were taken or not taken in respect of matters covered by the report".
The 2018 update to Working Together set an explicit expectation that "the principles of the systems methodology recommended by the Munro review" must be followed when safeguarding partners determined what method to use for a review. This remains in place in the current, 2023, version of the statutory guidance.
'Radical shift still needed towards systems approach'
However, despite this, the report commissioned by the national panel found that, while there had been a "partial" move in the direction of a systems approach" to LCSPRs, a "radical shift" was still needed to make this a reality.The study was based on a rapid review of existing evidence, interviews with representatives from 10 safeguarding partnerships - each based around a particular case - along with eight of the reviewers of these cases and 15 practitioners, focus groups with health and police practitioners and national workshops.
A "lack of analysis of why things happen, and defensive reasoning persists" in reviews, it concluded. Unlike other sectors, such as the NHS and engineering, children's safeguarding had "no framework to help identify contributing factors to serious incidents and drive improvement" at national, regional and local levels.
Consequently, learning was often focused only on ‘what happened’, rather than why or how, resulting in action plans that were "based on practice issues without a focus on the system in which practice occurs".
Focus on practitioner learning
Proposed learning "nearly always" comprised further training, updated tools, changes to process or new or adapted polices, disseminated through practitioner events and briefing materials, the uptake of which was subsequently reviewed, in a "cycle" that followed every case.The report identified various potential causes for this approach, one of which was resource.
Under the Children Act 2004 (section 16C), councils must notify the panel if a child dies or is seriously harmed in their area, or if this happens outside of England to a child normally resident in their area, and they knows or suspect they have been abused or neglected (a serious incident notification).
Within 15 working days of the notification, safeguarding partners are expected to send the panel a rapid review, in which they should set out known facts, immediate protective actions, potential safeguarding improvements and next steps, including whether a full LCSPR should be carried out.
The Children Act 2004 (section 16E) stipulates that partnerships must carry out LCSPRs of cases that raise issues of importance where they consider this to be appropriate.
Resource and timescale pressures
Several participants in the research referenced how demanding rapid reviews were, due to the short timeframes and resources needed, with some having to carry out the process on top of their day jobs.The timeframes also prevented engagement with children and families and, sometimes, with practitioners and made it difficult for partnerships to make a "robust decision" over whether to undertake a full review, with such decision making noted as "inconsistent" by participants in the research.
There was a suggestion that some partnerships, at times, undertook rapid reviews in place of LCSPRs, "with potential implications for depth and breadth of learning".
Partnership business units were reportedly unequally resourced by statutory partners, with wide variation in the capabilities, capacity and expertise of business managers, and in the deployment of resources to carry out reviews.
Quality of reviewers
Despite both the Munro and Wood reports recommending that those carrying out reviews should be accredited, this has not been implemented. While Working Together stipulates that safeguarding partnerships should consider whether reviewers have relevant knowledge and understanding, the latest report found a "lack of quality assurance and variability in quality of independent reviewers".Reviewers used a combination of methodologies, tools and approaches, it found, with such variability, along with the lack of a professional framework for reviewers, "likely to be leading to a lack of consistency in the ‘quality’ of the analysis in LCSPRs".
While the panel's guidance on reviews referred to "systems methodologies", the panel did not provide partnerships with a framework for adopting a systems approach.
The report also found a reluctance to make national recommendations in LCSPRs due to perceptions that it would not be acted upon, which meant that, in some cases, relevant issues were not mentioned in reports.
Practitioners 'feel anxiety and blame'
The research team heard that practitioners were generally involved in the review process through multi-agency events, supplemented by individual interviews.Though reviewers and partnerships felt that the events were generally positive for practitioners, with agencies highlighting the importance of safeguarding staff wellbeing, professionals who took part in the research were more ambivalent.
Some found the events threatening or pointed to hierarchies between agencies and power dynamics when managers attended events alongside practitioners, while professionals also pointed to a lack of support or preparation for involvement in reviews.
The report added that it was "difficult to eliminate anxiety about blame from the LCSPR process" for practitioners, based on the feedback from professionals who took part in the research.
Recommendations for change
The report recommended that:- The government increase the capacity of safeguarding partnerships to carry out reviews, including through supporting collaboration across regions.
- The government and the national panel introduce accreditation of independent reviewers and improve support and professional development of them, to tackle existing gaps in expertise and attract more professionals into the role.
- The panel develop and implement a ‘learning framework’, setting out how systems learning should be identified and enabled at local, regional and national levels.
- The panel develop an equity, equality, diversity and inclusion (EEDI) protocol to increased confidence, skills and capabilities in respect of EEDI and decision making, helping to strengthen analysis and learning from reviews.
- The panel set out clear expectations for safeguarding partnerships in relation to involving children and families and practitioners in reviews.
- The government respond annually to key recommendations for it in national and thematic reviews by the panel.
Reviews 'must focus more on structural and organisational factors'
In the light of the report, the panel has updated its guidance for safeguarding partners in relation to serious incident notifications and reviews.The guidance now says that leaders "have a responsibility to role-model multi-agency collaboration throughout the process which starts with identifying serious harm and ensuring that review panel members and reviewers are equipped with the knowledge and skills to utilise a systems approach to learning from serious incidents".
Giving the panel's response to the report, Annie Hudson, who recently stepped down as chair, said it shone an "important light on how reviews need to identify better learning about both the effects of structural factors (such as poverty and racism) and organisational cultures on the lives of children and families and on multi-agency practice".
She said the panel, government and safeguarding partnerships would need to reflect on the research and proposed priorities for change, and how to take these forward in the context of the government's reforms to children's social care.
These include the creation of a Child Protection Authority, initially within the panel, to oversee the quality of practice in England, the creation of multi-agency child protection teams and the imposition of a duty on partnerships to include relevant education and childcare agencies in their arrangements.
