What have we learnt from SCRs?

There seems little doubt that SCRs and the earlier public inquiries into child abuse deaths have had a substantial impact on the development of child protection policy and practice in England.3 4 However, both policy and practice are influenced by a wide variety of factors including public opinion, the media and the political climate, as well as individual learning and behaviour. Demonstrating whether outcomes for children have actually changed is, however, immensely difficult. Perhaps the most robust measure of the effectiveness of child protection is whether the rates of serious and fatal maltreatment are changing. Two studies of national death registration data have concluded that the numbers and rates of violent deaths in infants and children have fallen over the past 30 years, suggesting that we are, at least to some extent, protecting the most vulnerable young children from abuse and neglect.5 6 Assessing whether there has been any impact on less severe forms of maltreatment is much more difficult, and a recent multi-country analysis suggests that in the UK, as with all other countries examined, there has been no significant overall trend in wider markers of maltreatment rates.7 In contrast, a recent national study by the National Society for the Prevention of Cruelty to Children (NSPCC) showed that fewer 18–24-year olds in 2009 reported experiencing severe physical or verbal aggression from their parents or coerced sexual activity, compared to a similar sample in 1998.8 9 In summary, there is some evidence that we are doing better at safeguarding and promoting the welfare of children, but this is not reflected in all measures. To attribute any fall in rates of maltreatment to the impact of SCRs, however, is a huge extrapolation. While it is acknowledged that SCRs have influenced the development of child protection policy and practice, there will be many other factors with equal or greater influence. In addition, while SCRs focus on improving inter-agency working to protect children, most child maltreatment affects children unknown to child protection services. It is likely that wider preventive measures will have a greater impact on maltreatment rates. Thus it is important to examine proxy measures which may provide some indication of whether we are identifying lessons and implementing actions to safeguard children.

A review of the national biennial analyses of SCRs10,–,14 and previous published studies of inquiry reports15 16 demonstrate a number of consistent themes in relation to professional practice (box 3). The same biennial analyses also identify a number of new and emerging themes (box 4). However, although these recent analyses have shed fresh light on aspects of professional working, many of the ‘new’ concepts identified actually can be found in much earlier work. For example, concepts such as ‘static assessments’, the ‘rule of optimism’ and ‘fixed thinking’ were all identified in the 1980s and 1990s.17 One less obvious measure is the extent to which issues identified in early reviews are no longer significant issues. For example, in a comparison of the Colwell and Climbié inquiries, Parton3 pointed out that in the Maria Colwell case one of the key difficulties was in getting Maria examined by a doctor. Nowadays, while it may not always happen, or may not happen to the hoped for standard, no-one would question the relevance of a medical examination of a child with suspected physical abuse.

These themes suggest that some aspects of learning keep recurring, but that other aspects are new, and still others cease to be so important. The fact that some issues come up repeatedly, however, does not necessarily mean that lessons have not been learnt or that nothing is changing. Some lessons are so important that they need to be re-emphasised and potentially relearnt as people, organisations and cultures change. We tend to learn best, both as individuals and as teams, when the material we are learning is contemporary and clearly relevant to our local context and circumstances. SCRs provide an opportunity for that, bringing issues powerfully home in a local context and in a way that can directly influence front line workers.

Recognising that some lessons will continue to crop up in SCRs does not mean that we should simply sit back and accept that mistakes continue to be made and that children continue to suffer harm. Rather, we should seek to go deeper, to understand the systems, structures and cultures within our society and organisations which allow such mistakes to be made. Professor Eileen Munro has argued this powerfully in her recent review of child protection in England.18,–,20 SCRs are designed as local in-depth reviews which can identify local issues. They can be used by LSCBs to influence local practice, but this needs to be done in the context of other influences, local issues and individual and organisational accountability. Where common issues come up repeatedly, it is important to look beyond the question of ‘what went wrong’ to examine the deeper system issues of why such mistakes could be made.

Looking ahead

In keeping with the findings and recommendations of the Munro review, I would suggest that a number of changes in our approach to SCRs could improve their efficacy in influencing practice and helping to protect children. First, we need to distinguish between learning lessons and making recommendations. Recommendations can be helpful if they are limited, focused and lead to definitive action, but they should not be seen as implying that learning has taken place. Too great a focus on recommendations can lead to practice becoming increasingly procedure-driven with little room for professional judgement. Second, for learning to be effective, practitioners need to be more integrally involved throughout the process. The current approach, based primarily on a review of records with or without interviews of practitioners, does not encourage learning. The Munro review calls for a much more interactive process whereby practitioners themselves engage directly with the review team to identify learning points. Third, we need to support practitioners through the process. The SCR process is extremely stressful for practitioners. This is not helped by the current system of ‘securing’ records, which tends to imply attribution of blame and leaves practitioners feeling vulnerable and unsupported. A supportive approach does not mean that issues of accountability are not addressed, rather, it allows for this to be done in a more effective and appropriate way, while still allowing learning to take place. Finally, as argued by Munro, learning needs to be taken to a deeper level. Rather than focusing on what went wrong, or whether mistakes were made, the focus of the review should be on why services failed to protect the child. This requires a combination of understanding the characteristics of the case itself, and a robust analysis of the systems, structures and cultural factors underlying service provision.

As well as improving the approaches to carrying out reviews and analysing factors at a local level, there is an ongoing need to collate and disseminate the learning at a national level. This will not be achieved effectively simply by publishing and circulating all overview reports – with over 100 SCRs conducted each year, it is neither possible nor effective for individual practitioners to read and learn from each one. Rather, the system for national analyses needs to be continued and strengthened, and fresh ways of disseminating knowledge from these analyses need to be developed.4

Our system for SCRs in England is one of the most comprehensive systems in the world. I have argued above that these reviews have led to considerable learning and have had an impact on our approaches to protecting children. In order for them to continue to be effective, they need to change with the times. With the publication of the Munro review, we have an opportunity to build on the successes of the past and rethink our approach, bringing in more effective and supportive approaches to learning.