Saturday, 28 April 2012

An impressive Serious Case Review Report

In the past I have complained bitterly about the usefulness (or rather lack of it) of the executive summaries of Serious Case Review (SCR) reports.

But I was very impressed by the report - it is the full report, not just a summary - of a Serious Case Review undertaken in Haringey into the case of Family Z. 

The review was based on the ‘SCIE approach’ which was developed by Fish, Munro and Bairstow (

It draws heavily on a human factors perspective.

The contrast with traditional SCRs could not be more striking. And in sharp contrast to SCR reports which just provide a long list of procedural recommendations, this report provides an impressive analysis of underlying issues (summarised in paragraph 20). Some of the main conclusions are:

  • Management systems lacked “… a coherence between family support services and emergency response…”  
  • There was an “autocratic management style” that created fear and paralysed thinking so preventing “constructive case work challenge”
  • There was an “… absence of systems to promote review of professional judgements…” and “…no effective challenge to, or ability to work with, non‐engaging families”
  • A “… poor understanding of the causation and impact of neglect across agencies…” was identified and there was “... no shared culture of authoritative challenge amongst professionals allowing for the exploration of disagreements”
  • The design of work processes and procedures made it difficult to respond effectively to incidents of neglect, a problem exacerbated by the design of computer systems
To my mind, the most important thing about this analysis is that it provides a substantial agenda of issues which both managers and practitioners need to address constructively. 

This contrasts strongly with the traditional approach to implementing the recommendations of SCRs such as the issuing of new top down instructions and the updating of procedural documents.

The Haringey Safeguarding Children Board is to be congratulated for this review and a most interesting and useful report.

A brief report of the case is provided in today’s Daily Mail, but do go to the Haringey Safeguarding Children Board’s website and download the full SCR report which contains a full and balanced summary.