1.
Learning from Serious Case Reviews:
Messages from the triennial analysis
1
Peter Sidebotham
University of Warwick
Marian Brandon
University of East Anglia

2.
Agenda
Introduction and Background Participant Poll
Pathways to harm Understanding the model for
systems review
Pathways to protection: Managing
individual cases
Exploring vulnerability and risk
Assessment
Working with families
Pathways to protection: Working
together
Authoritative practice
Balancing support and scrutiny
Long-term working
Reflection: How does this apply to your
learning/ practice?
2

3.
Webinar objectives
› To understand the model of pathways to
harm and pathways to protection
› To recognise the key learning arising from
this triennial review in relation to managing
individual cases and working together in
order to prevent maltreatment and better
protect children
› To identify some of the agency structures,
processes and cultures that help promote
better prevention and protection
› To be able to reflect on your own practice in
light of the key learning for practitioners in
different agencies
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4.
Participant Poll 1
› What is your professional
background?
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5.
Participant Poll 2
› In the past 3 years, how many
SCRs have you been involved
in?
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6.
Participant Poll 3
› In what capacity were you involved?
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7.
Pathways to Harm
Child seriously or
fatally harmed
Context
Harmful actions/
omissions by
perpetrators or
carersPredisposing
risk
Predisposing
vulnerability
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8.
Pathways to prevention and protection
Child
seriously
or fatally
harmed
Context
Harmful actions
/ omissions by
perpetrators or
carersPredisposing
risk
Predisposing
vulnerability
Preventive
actions by
society
Protective
actions by
parents/carers
Preventive
actions by
statutory/other
agencies
Protective
actions by
statutory/other
agencies
Systems and processes to support
prevention/protection
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9.
Serious Case Review Mini-site
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10.
Pathways to protection:
Managing individual cases
› Exploring vulnerability and risk
› Assessment
› Working with families
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11.
Child vulnerabilities
› Innate vulnerability of babies and
young children – stress of caring
› Disabled children – also stress of
caring, and poor care can be left
unchallenged or attributed to child’s
disability
› Adolescents – 88% of older
adolescents had mental health
problems. Adolescents carry the
legacy of long-standing abuse and
neglect with them
› Get to know children and recognise
adolescent vulnerability
‘…there were
several
consecutive days
when [premature
baby in hospital
for 12 weeks] had
no contact with
mum or family,
the longest being
a period of 11
days’
11

12.
Cumulative and interacting risk of
harm: Parents
› Domestic abuse, mental health, drug
and alcohol misuse (combined or
singly)
› Adverse childhood experiences
› A history of crime (especially for
violence)
› Patterns of multiple consecutive
partners
› Acrimonious separation
‘As a result of
Father’s
arrest… any
concerns
regarding risk
of domestic
violence were
[thought by
professionals
to have been]
effectively
eliminated’
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13.
Assessment
› Hearing the voice of the family - use
family expertise in collaborative
working between professionals and
families
› Families may be unaware of the
risks / vulnerability
› Families may not know where to go
with concerns
› Family concerns may not have been
heard or acted on
› Families may see their role as
support not scrutiny
‘Father was not
aware of the
assessment… His
views were never
sought, despite
him having
parental
responsibility,
and… he had made
allegations to court
about his concerns
regarding Mother’s
drinking, mental
health and her
potential
aggression’ 13

14.
Context of managing individual
cases
› 12% of children had a child protection plan –
neglect by far the most common category (a further
12% had been on a CP plan in the past)
› 45% of cases were open to children’s services but
almost two thirds (64%) had been known to
children’s services in the past
› Significant role for universal services in protecting
children
› Debates about thresholds into/out of services, and
safe escalation and de-escalation
14

15.
Pathways to protection:
Working together
› Balancing support and scrutiny
› Moving from episodic to long-term models of
support and intervention
› Managing appropriate information sharing
› Authoritative child protection
15

16.
Balancing support and scrutiny
› Most child protection
work is complex and
long-term
› Parents need support
and to be able to trust
professionals
› A caring, supportive
approach does not
compromise
professional challenge
and scrutiny
‘The first primary school was
in a position to know about
the struggles Mother had had
in her own upbringing and in
her relationship with Father.
They were child-centred in
their concerns, as well as
sympathetic towards Mother.
The school staff were
consistently involved in
attending and sharing
information at Child in Need,
and later CP, meetings.’
16

17.
Moving from episodic to long-term
models of support and intervention
› Recognising the
ongoing, fluctuating
and at times cyclical
interplay of
vulnerability and risk
› Chronologies and
systematic review
› Promoting resilience
› Building in monitoring,
review and revision
‘Most incidents were dealt
with in isolation and the
cumulative effect of domestic
abuse was not sufficiently
recognised by any of the
involved agencies. The
interventions which did take
place appeared to do nothing
to cease the pattern of
alcohol abuse and domestic
abuse continuing.’
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18.
Appropriate information sharing
› Recognising the
centrality of
communication
› 65/66 SCRs specifically
identified information
sharing
› All national guidance
and legislation supports
sharing information to
safeguard children and
vulnerable people
‘Data protection legislation
and concerns about
information sharing is leading
to anxiety and confusion
about when information can
be shared, and with whom,
with or without consent. The
culture of patient
confidentiality in some
organisations, such as those
working within “health”,
means that the focus tends to
be on protecting this right
rather than on the safety of
children.’
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19.
Authoritative child protection
› Developing models
and cultures of
working that mitigate
the complexity and
ambiguity
› Providing effective
supervision and
support
Authority
Involves both
confidence and
competence; enables
professionals to adopt
a stance of
professional curiosity
and challenge from a
supportive base
Humility
Enables
practitioners to
recognise their
limitations, to
acknowledge and
use their skills and
strengths, and to
seek to improve
their practice
Empathy
Grounded in the
centrality of the
rights and needs
of the child, while
being sensitive
but not colluding
with the needs
and views of the
parents
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20.
Reflection: How does this apply to
your learning/practice
› Identify 2-3 key learning points that
you will take away from today
› Is there any aspect of this webinar
that you would like to explore
further?
› Can you commit to building in any
change to your practice?
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21.
Questions and comments
SCR Mini-site:
− Introductory films
− PowerPoint with audio on systems methodology
− Practice briefings and video introductions
− Links to other resources on SCRs
› seriouscasereviews.rip.org.uk/
› Watch out for BASPCAN regional seminars at
www.baspcan.org.uk 21

22.
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23.
Contact details
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