Brandon,29 et al., reviewed the cases of children subject to serious case reviews during the period 2009–2011. The research identified that 42% of cases were receiving a service from children’s social care at the time of the incident and that 23% had previously been known to children’s social care. These figures suggested that some cases were being closed prematurely by children’s social care. In a further 14%, referrals were received but not accepted for assessment by children’s social care. The research noted that thresholds to children’s social care were set too high, particularly when neglect was the primary concern. This raised significant issues about children being provided with the right help at the right time. The help and protection of children relies on all professionals being able to identify triggers that may indicate children are at risk of harm or being harmed and taking appropriate action to protect them.
Almost all professionals had an awareness of serious case reviews and what they were. Social work professionals working within children’s social care were most able to give practice examples of how findings from serious case reviews had informed their individual work with children or how findings had been used by the organisation to inform practice changes to whole services. While they had an awareness of serious case reviews, non-social-work professionals were less able to demonstrate the impact, with just over a quarter indicating that findings from serious case reviews had impacted directly on their practice. A small but significant group of non-social-work professionals, working with children, indicated that they had no real awareness of findings from serious case reviews.
A sample of the most recent findings from serious case reviews,30 which relate to early help, reflect the findings of this thematic inspection. This confirms that insufficient attention is given to serious case review findings and how these inform and improve practice. In relation to early help, serious case review findings tend to identify either that early help was provided but was not successful for a variety of reasons or that the need for early help was not identified. The following is a summary of issues that relate to recent findings from the serious case reviews considered:
a lack of focus on the child that in some cases resulted in children’s views and voices not being heard or being given value
thresholds not understood across partnerships and set too high, which prevented the necessary support being offered
adherence to procedures over common sense protection of children and young people, even where there was clear evidence of concerns about abuse
poor understanding and assessment of the circumstances, including a failure to re-assess when new information became available
poor communication and interagency working, especially in relation to challenging decisions made by other agencies
workers from across the agencies lacking a suitable level of understanding of key factors relating to particular cases, such as cultural norms, mental health, legislation and domestic abuse – specialist advice was not sought where it would have improved decisions
delays to early help services being provided and a lack of follow-up if a child did not take up the use of the service
a lack of satisfactory management oversight of practice in relation to early help
a lack of critical analysis, which sometimes led to professional ‘personal bias’ not being challenged or professionals not adopting sufficient sceptical enquiry into issues which arose; accepting information at face value
risks from fathers/partners not sufficiently considered.
Almost all of this evidence reflects findings from our thematic inspection. Attention given to improving practice from the findings of serious cases reviews is not robust enough.
Specifically, and reflecting findings from serious case reviews, inspectors asked professionals about the training they had received to support their work with families who are reluctant or resistant to engage with professionals. Almost two thirds of professionals had received some training. As a result, they reported that their confidence in this area had improved; they felt empowered to be more questioning rather than accepting of parental responses. Training had helped them to identify triggers and warning signs, had highlighted good practice in speaking to the child and in hearing and understanding the child’s experience, and had assisted in sharing concerns and information with other professionals. However, one third of professionals had not benefited from such specific training. Many commented that it would be welcome, particularly on a multi-agency basis. One professional commented:
‘'I find it difficult to talk to parents. My heart sank when dad answered the phone. We need more support in how to talk to parents about allegations.’
Evidence from Ofsted’s single inspections of local authorities and from this thematic inspection shows clearly that the offer of help to families when concerns first arise is increasingly prioritised by local authorities and their partners. As a result, more children are benefiting from better focused and coordinated support earlier. Early help workers increasingly feel part of professional networks and therefore are less isolated and more supported. The quality and effectiveness of early help services however remains too variable both between areas and within the same services. Children’s need for additional support is often not identified or acted on at the right time, with earlier opportunities to provide support often missed. The assessment and planning of services for individual children are too often insufficiently focused on improving outcomes for the child. Plans are not consistently or effectively reviewed and management oversight is not rigorous enough.
Planning for early help services is not informed by robust needs assessments. Neglect, parental substance misuse or ill health and domestic abuse are key factors undermining the welfare of children but not enough priority is given to understanding the nature and extent of these needs in local communities. It is therefore unclear whether early help services are being commissioned effectively to best address these needs. More generally, evaluation of the overall impact of early help services is not well developed.
LSCBs have become more engaged in monitoring early help and in most areas have ensured the adoption of an agreed threshold framework. However, they are not routinely monitoring the application of these thresholds or, more generally, holding each other to account for their early help work.
At the heart of these difficulties, however, is a lack of clarity about statutory roles and responsibilities for the provision of early help. For many agencies, early help continues to appear as an add-on rather than central to or required as part of their core business of improving the life chances of children.
In the current scenario for local areas, where demand for help for families is increasing alongside the more formal and coercive child protection work, it is critical that there is clarity about the responsibilities of local agencies to help families early. The recommendations from this thematic inspection should be urgently considered by government so that the costs and poorer outcomes of later intervention can be avoided.
Annex A.Local authorities subject to this thematic inspection
Annex B. Serious case reviews considered
Child D – Death of three-week-old baby girl in October 2012 following injury by her mother. The child’s mother had multiple overlapping needs such as learning difficulties and mental health problems.
Serious case review: Child D. Published by the NSPCC on behalf of an unnamed local safeguarding children board, 2012; Read full overview report (PDF).
Child J – Suicide of adolescent girl in January 2013; victim of sexual assault and history of bulimia and self-harm and suicide ideation.
Muir, M., Serious case review: Child J, Cumbria Local Safeguarding Children Board, 2013; www.cumbrialscb.com/eLibrary/Content/Internet/537/6683/6687/6700/ 4182185614.pdf.
Child C – Death of 17 week old baby girl in November 2013; teenage mother significant maternal history of domestic abuse.
Haley, A., Serious case review: Child C, Dorset Safeguarding Children Board, 2014; Read full overview report (PDF).
Family A – Neglect, physical and sexual abuse of seven brothers and sisters (aged six to 14 years) between 2004 and 2011. Father from Traveller community.
Harrington, K., Serious case review: Family A, Southampton Local Safeguarding Children Board, 2014; Read full overview report (PDF).
Child H – Death of a three-year-old Somalian boy and serious injury to his two-month-old brother in March 2013.
Trench, S. and Miller, G. Serious case review: Child H, Lambeth Safeguarding Children Board, 2014; Read full overview report (PDF).
Family S11– Death of a 15-year-old boy in March 2013 as a result of overdose of drugs prescribed to father.
Tudor, K., Serious case review: overview report: in respect of Family S11. Dorset Safeguarding Children Board, 2014; Read full overview report (PDF).
Young person: suicide of 14-year-old boy in April 2013 who had moved to the UK from China.
Wonnacott, J., Overview report on the serious case review relating to: Young Person: Hiers, Surrey Safeguarding Children Board, 2014; Read full overview report (PDF).
Child FW – death of a baby who suffered cardiac arrest. Family well known to wide range of family services. Report final version 12 February 2013.
Baker, G., Serious case review: executive summary: in respect of the death of FW [executive summary], Worcestershire Safeguarding Children Board, 2014; Read executive summary (PDF).
‘Daniel’: Death of 14-year-old boy in November 2009 who was exposed to many risk factors.
Gallagher, C., 'Daniel': the overview report from a serious case review, Kent Safeguarding Children Board, 2013; Read full overview report (PDF).
Baby H – death of four-month-old baby boy in November 2010 from serious head injury; significance of mother’s young age on parenting capacity and lack of agency engagement.
Maddocks, P., A serious case review: 'Baby H': the overview report, Lancashire Local Safeguarding Children Board, 2013; Read full overview report (PDF).
1 In this report, ‘early help’ means ‘providing support as soon as a problem emerges, at any point in a child’s life’.
Working together to safeguard children – a guide to interagency working to safeguard and promote the welfare of children, Department for Education, 2013;www.gov.uk/government/publications/working-together-to-safeguard-children.
2 Professor Eileen Munro, The Munro review of child protection: final report – a child-centred system, Department for Education,2011; www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-system.
3 Working together to safeguard children – a guide to interagency working to safeguard and promote the welfare of children, Department for Education, 2013; www.gov.uk/government/publications/working-together-to-safeguard-children.
4 Swept under the carpet: children affected by parental alcohol misuse, Alcohol Concern and The Children’s Society, 2010; www.childrenssociety.org.uk/sites/default/files/tcs/swept__under_the_carpet_briefing_paper_oct_2010.pdf.
5 Drug treatment in England 2013–14, Public Health England, November 2014;
6 A place of greater safety, Co-ordinated Action Against Domestic Abuse (CAADA), 2012; www.caada.org.uk/policy/A_Place_of_greater_safety.pdf.
7 Parents with mental health problems,Mental Health Foundation, 2013; www.mentalhealth.org.uk/help-information/mental-health-a-z/P/parents/.
8 Characteristics of children in need in England, 2013-14, Statistical First Release SFR 43/2014, Department for Education, October 2014; www.gov.uk/government/uploads/system/uploads/attachment_data/file/367877/SFR43_2014_Main_Text.pdf.
9 Inspecting local authority children’s services: the framework, Ofsted, 2014; www.gov.uk/government/publications/inspecting-local-authority-childrens-services-framework. Arrangements for the protection of children; Inspection of services for children in need of help and protection, children looked after and care leavers;Review of the effectiveness of the local safeguarding children board, June 2014, Ofsted; www.gov.uk/government/publications/inspecting-local-authority-childrens-services-framework.
10 Professor Eileen Munro, Munro review of child protection: final report – a child-centred system, Department for Education,2011; www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-system.
11 Graham Allen, Early intervention: smart investment, massive savings – the second independent report to Her Majesty’s Government, Cabinet Office, July 2011; www.gov.uk/government/publications/early-intervention-smart-investment-massive-savings.
12 Dame Clare Tickell, The early years: foundations for life, health and learning, Department for Education, 2011; www.gov.uk/government/collections/tickell-review-reports.
13 The foundation years: preventing poor children becoming poor adults,Frank Field, 2010; www.frankfield.com/campaigns/poverty-and-life-changes.aspx.
14 Professor Eileen Munro, Munro review of child protection: final report – a child-centred system, Department for Education,2011; www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-system.
15 Full response to named day question by Tim Loughton 13 December 2011, Department for Education; www.gov.uk/government/news/munro-review-of-child-protection-government-response.
16 Working together to safeguard children – a guide to interagency working to safeguard and promote the welfare of children,Department for Education, March 2013;www.gov.uk/government/publications/working-together-to-safeguard-children.
17 Roles and responsibilities of the Director of Children’s Services and the Lead Member for Children’s Services,Department for Education,2013;www.gov.uk/government/publications/directors-of-childrens-services-roles-and-responsibilities.
18 Carolyn Davies and Harriet Ward, Safeguarding children across services: messages from research, Department for Education, 2011;www.gov.uk/government/publications/safeguarding-children-across-services-messages-from-research.
19 We should have been helped from day one: a unique perspective from children, families and practitioners,Local Authorities Research Consortium, Research in Practice and National Foundation for Education Research, September 2013; www.nfer.ac.uk/publications/LRCF01/LRCF01_home.cfm.
20 The Signs of Safety model is a strengths-based and safety-organised assessment and planning framework for child protection practice and was originally developed in Western Australia by Turnell and Edwards; www.signsofsafety.net/signs-of-safety.
21 Working together to safeguard children – a guide to interagency working to safeguard and promote the welfare of children,Department for Education, March 2013; www.gov.uk/government/publications/working-together-to-safeguard-children.
22 Professor Eileen Munro, Munro review of child protection – a child centred system, Department for Education,2011.
23 Progress report: moving towards a child centred system,Department for Education, May 2012; www.gov.uk/government/publications/progress-report-moving-towards-a-child-centred-system.
24 Professor Eileen Munro, Munro review of child protection – a child centred system, Department for Education,2011; www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-system.
25 Joint Strategic Needs Assessment and joint health and wellbeing strategies explained,Department of Health, 2011; www.gov.uk/government/news/jsnas-and-joint-health-and-wellbeing-strategies-explained.
26 Brandon et al., Building on the learning from serious case reviews: A two year analysis of child protection database notifications 2007-2009, Department for Education, 2010; www.gov.uk/government/publications/building-on-the-learning-from-serious-case-reviews-a-2-year-analysis-of-child-protection-database-notifications-2007-to-2009.
27 Working together to safeguard children – a guide to interagency working to safeguard and promote the welfare of children,Department for Education, March 2013, pp. 11–12; www.gov.uk/government/publications/working-together-to-safeguard-children.
29 Brandon et al., Building on the learning from Serious Case Reviews: A two year analysis of child protection database notifications 2007-2009, Department for Education, 2010; www.gov.uk/government/publications/building-on-the-learning-from-serious-case-reviews-a-2-year-analysis-of-child-protection-database-notifications-2007-to-2009.