What's wrong with Serious Case Reviews?
The answer is lots; there is a long list of things that are wrong with Serious Case Reviews (SCRs).
SCRs were introduced into child protection in the UK in the 1990s, as an alternative to costly public enquiries which had hitherto been the only formal means of enquiring into the death of a child, or other serious incident, when services were involved with the family. SCRs involve each of the relevant agencies preparing a 'management report' on the events within that agency surrounding the death or serious injury of a child. An independent report author brings these separate management reports together in an 'overview report'. The preparation of all these reports involves a variety of data gathering, depending on the circumstances of the case: interviews with relevant practitioners or managers, reading case files, speaking to members of the family, reviewing court papers and other official documents. The aim is to given an accurate account of what happened and to make recommendations to prevent a reoccurrence.
That all sounds fairly straightforward until you begin to think through some of the issues with a process like that. The first set of problems concern time. Clearly gathering all that information, combining it into agreed reports and waiting for all the agencies to produce their final documents takes time - quite a lot of it. It is not unusual to hear of a SCR that has taken years to produce the overview report. But the other aspect of time is the time (and, of course, effort) of all those people involved in being interviewed or summarising case information or attending meetings to agree and approve documents. Nobody really knows how much time, and therefore money, is involved but it has been said that in difficult or high profile cases the cost can run into millions. Arguably some of this would be better spent on improving services than on conducting reviews.
The second set of problems concern blame. Although SCRs by tradition do not name names (either of the family involved or of the workers) it is not hard for journalists and members of the public to work out who is who; and within agencies the names of those involved and their roles are all known to managers. Of course people are cautious, and sometimes reluctant, to give full and frank accounts of their parts in the serious service failure, simply because they fear that if some facts become known they could face disciplinary action as a consequence. Likewise agencies are not surprisingly keen to minimise the damage to reputation that might result from a candid SCR report. Managers, especially top managers, may see their own futures and those of their agencies closely aligned.
The third set of problems concerns analysis. Many SCR reports contain copious detail about the case, and many have pages of recommendations, but few that I have seen have a a great deal of analysis. The absence of a framework for analysis at the root of this problem. The authors of the reports are often not well versed in the sociology of organisational behaviour or the psychology of the workplace, so they have tended to report facts and to make procedural recommendations. An incident was not fully recorded in a case record, so it is recommended that all incidents of this type be recorded in future. A child whose main language is not English was interviewed without an interpreter, so it is recommended that all such children be accorded interpreter services. A hospital patient was not asked about her child caring responsibilities, so it is recommended that all hospital patients should be asked about their family circumstances.
The kind of analysis I think is most helpful when things go wrong stems from the sociology of organisational behaviour and the psychology of human error. We know a great deal about how people behave in groups and teams - and about what can go wrong. 'Group think' and 'risky shift' can occur. Groups can convince themselves that they are doing the right thing, we they aren't or underestimate risks because others agree with them. In authoritarian situations people keep their noses down and makes sure they are following the rules. They don't speak out when things are beginning to go wrong.
Individual slips and lapses occur because we all have a tendency to error - to see what we expect to see or hear what we expect to hear. Sometimes something which is staring us in the face is invisible. Alternatively violations - departures from the rules - often occur because people cannot get their jobs done by following the rules. Many of us are reluctant to challenge authority or the status quo, even when it seems that senior colleagues have 'got it wrong'. A knowledge of human factors of this kind can be a very sound base for analysis.
To sum up: SCRs as an approach to understanding what goes wrong and how to put it right have serious weaknesses. I believe that we need to develop alternative systems for learning in child protection. These should be easy to use and not involve excessive amounts of time or resources. They should avoid wherever possible blaming or shaming people. They should be based on sound principles about how people behave in safety critical situations.