SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews

Appendix 6: Typology of underlying patterns

Patterns of systemic factors that contribute to good practice or make problematic practice more likely

1. Patterns in human–tool operation

• The influence of assessment forms
  • No detail on the quality or depth of assessments, or difficulties faced in completing them
  • Discourages documentation of the rationale or complexity behind conclusions drawn
  • Encourages factual statements and assertions and discourages the recording of a healthy unease or gaps in understanding
• The influence of the assessment framework
  • Focus on the assessment of need discourages articulation of risk factors
• The influence of case management framework e.g. assessment, planning, implementation and review (APIR)
• Revision becomes an interruption in the flow of practice

2. Patterns in human–management system operation

• Resource-demand mismatch
• Difficulties accessing expert assessments
• Gaps in service provision
• Funding disputes and practitioners creating safety
• Performance indicators and borrowing from safety
• Trade-offs between competing priorities; overt and covert messages
• Conceptual blurring
• Supervision

3. Patterns in communication and collaboration in multi-agency working in response to incidents/crises

• Organisational culture around priority setting
• Understanding the nature of the task; overlooking the wider needs of the children in child protection response
• Reserve capacity
• The importance of knowing each other
• Referral procedures and cultures of feedback

4. Patterns in communication and collaboration in multi-agency working in assessment and longer-term work

• Understanding the nature of the task; assessment and planning as one off event or on-going process?
• Clarity of roles and responsibilities
• How much shared responsibility is there?
• Who is responsible for thinking?
• What and how much should be shared?
• What barriers and facilities exist contribute to good team work in longer-term case work?
• Are conflicts of opinion repressed or is there a shared culture in which it is acceptable and even desirable to query each other’s assessments?
• Group think
• Ascribed and perceived occupational status
• Overestimating the remit of service provision of different agencies

5. Patterns in family–professional interactions

• Salience of the mother in social services involvement
• Classic gendered presentation of problems by family members

6. Patterns in human judgement (thinking, reasoning)

• Failure to review judgements and plans
• Drift into failure
• Attribution error
• Tunnel vision

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