Saturday, 5 December 2015

Scope for confidential enquiry?

Last month the BBC reported on a study that reveals that UK hospitals are missing key opportunities to save the lives of hundreds of babies every year.

What is of interest to me, and of relevance to child protection, is not the subject matter of this study, important as it is, but rather its methods.

Although the BBC report does not make it clear, this study used a method of confidential enquiry, which is explained in the full report (which can be downloaded at:

Paragraph 1.5 of the report (page 11) explains how a random sample of cases resulting in a stillbirth was selected and submitted for review by confidential enquiry. This involved case reviewers coding each case according to four levels of care:

• No issues - good quality care identified
• Minor issues with the quality of care identified
• Significant issues with the quality of care identified
• Major issues with the quality of care identified

The study found that in more than half the cases improvements in care were identified that could have made a difference to the outcome. The study goes on to make important recommendations about how perinatal mortality in the UK can be reduced.  

It seems to me that this is precisely the kind of study we should be undertaking in child protection, particularly focused on cases in which maltreatment recurs following intervention. Such a study would show what proportion of recurring maltreatment happened despite good high quality intervention and what proportion was associated with various kinds of lapses in services. It might suggest changes that could result in improved practice which would make recurrence of maltreatment following intervention less likely.