This document summarizes key themes from reviews of Serious Case Reviews (SCRs) of child protection cases in England from 2017-2019. It identifies five themes for social work practice: 1) challenges of neglect and poverty, 2) issues with information exchange and communication between professionals, 3) importance of understanding children's behavior and experiences, 4) risks posed by deliberately deceitful abusers, and 5) examples of positive local initiatives for change. It also discusses themes for reviews and policy, including focusing on unique case aspects, recognizing complexity, and learning broader organizational and systemic lessons rather than just individual ones. The review found cases often involved neglect, domestic abuse, and parental mental health issues, and many children were already known to

1. Key messages from the final review of SCRs, 2017-
19, and the overview of SCRs since 1998
1
Prof Jonathan Dickens, University of East Anglia
Prof Julie Taylor, University of Birmingham
With thanks to our research colleagues Dr Jeanette Cossar, Dr Laura Cook, Dr Natasha
Rennolds, Dr Cynthia Okpokiri, Dr Julia Rimmer, Dr Penny Sorensen and Dr Russell Wate
(UEA); and Dr Jo Garstang, Dr Nutmeg Hallett and Dr Eleanor Molloy (UoB)

2. Introduction:
Setting the context
• SCRs and LCSPRs
• The profile of cases in
the 2017-19 review
Five key themes for
practice in the
report:
• Neglect and poverty
• Information exchange
and effective
communication
• Noticing and
responding to
children’s behaviour
• Responding to the
signs and the dangers
from deliberately
deceitful abusers
• Change does happen!
Local initiatives
Key themes for
reviews and policy
• ‘Learning lessons’
• Focus on uniqueness
and practice
• Recognise the
complexity

3. Setting the context (1)
SCRs started in 1988, but over the period 2018-19 they were
replaced by a new system of rapid reviews, Local Child
Safeguarding Practice Reviews (LCSPRs), and national reviews.
This was linked with the introduction of the national Child
Safeguarding Practice Review Panel and the replacement of
LSCBs by local child safeguarding partnerships.
There have been DfE-commissioned periodic overviews of SCRs,
cases going back to 1998. The overview reports are all available
free of charge on the RiP SCR website.

4. Setting the context (2)
› April 2017-Sept 2019: 235 cases, and we had the SCR report for 166.
› 56% where the child had died (131), 44% non-fatal ‘serious harm’ (104).
› Ages: 37% were under 1, 35% 11 and over (19% 16-17 years).
› Ethnicity: 73% white, 27% Black and other ethnic heritages.
› 30% of the deaths were SUDI; 30% were suicides.
› Of the non-fatal cases, 45% were physical abuse and 23% neglect.
› 57% of the children were open cases to CSC, but relatively few (17%) on a CP plan; 19%
were closed cases, and 23% never known.
› Domestic abuse was a feature in 55% of the cases, mental health problems for one or
both parents in 55%, and poverty in 49% (up from 35% in 2014-17).

5. Five key themes for practice (1)
Neglect and poverty
› Poverty as a ‘contributory causal factor’ for neglect (Bywaters et al 2016).
› Two challenges for practice: the ‘normalisation of neglect’ – practitioners
become inured to it in highly deprived areas, and its effects on children;
but also, there is a danger of over-focusing on poverty, tackling the poor
conditions rather than the neglectful treatment.
The potential signs of abuse/neglect observed by the professionals who
visited the family at home were largely left unchallenged, the view was that
the parents were doing as well as expected in the circumstances…

6. Five key themes for practice (2)
Information exchange and effective communication
› Information exchange may not happen, for various reasons; even if it does,
it isn’t necessarily the same as effective communication!
Information exchange is not the same as good communication. The latter is
more nuanced, questioning, collaborative and reflective, and seeks to
explore why something is “as it is”, … professionals need to ask themselves
and each other “what does this mean...”

7. Five key themes for practice (3)
Noticing and responding to children’s behaviour
› A lack of focus or loss of focus on the child’s lived experience was a common theme
across the SCRs – and it is a long-standing issue. Three key tips from SCRs:
› Don’t think about children through only one ‘lens’ - think about them in the
different contexts in which they live, including home, school, peer group and
community.
› If access to the child is being refused or controlled (however subtly), concerns
should be heightened.
› Changes in behaviour, or where children behave markedly differently in
different contexts, should be a reason to be curious.
I totally changed [after the sexual abuse started], they never asked about the
change in the way I dressed, changes in my eating. I started to self-harm. No one
looked between the lines. No one took me away from the house. I had counselling
for self-harm, and I kept myself to myself.

8. Five key themes for practice (4)
Responding to the signs and the dangers from deliberately deceitful abusers
› We have a chapter that focuses on intra-familial child sexual abuse. The SCRs show that
clear signs (verbal and behavioural) were not adequately responded to:
The issue of the children using sexually explicit language and exhibiting sexualised behaviour
was explored in single assessments, at strategy meetings, CIN Meetings, core group meeting
and ICPC but only in a superficial way. There was no real analysis of why it was occurring or
formal recognition that abuse could be happening in the family setting.
› They also show how ‘repeat perpetrators’ can target vulnerable families and deliberately
deceive professionals and family members
Unknown to the family or any of the professionals working with [the child] and her mother at
the time, [mother’s partner] was a registered sex offender, regularly visited by police in his
home town in line with multi-agency public protection arrangements (MAPPA). He repeatedly
reported that he had no contact with children and was not in a relationship with anyone.

9. Five key themes for practice (5)
Change does happen! Local initiatives
› Messages are disseminated in many ways: training sessions, staff
supervision, ‘bite size’ learning sessions, single-page briefings, online
seminars, powerpoints and ‘Sways’, safeguarding newsletter, ‘challenge
events’ – following up/auditing what difference they have made is
important.
› And not just training but service developments – e.g. one area spoke about
working with the licensed trade, hotel staff, taxi drivers to raise awareness
of the signs of sexual exploitation and how to report it – and this continues
with regular free training and advice.

10. Key themes for reviews and policy
‘Learning lessons’
• It can feel like the
same old lessons …
generalisations and
cliches.
• Looking for general
lessons can mask
differences and
difficulties.
• The ‘lessons’ need
to include matters
such as resources,
working
conditions,
organisational
changes, rising
demand.
Focus on
uniqueness
and practice
Recognise the
complexity
• Very difficult
risk
management
in a field of
competing
policy goals.

11. 11
Thank you