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

Introduction - Why do we need new methods of learning?

  • The findings of serious case reviews (SCRs) and public inquiries tend to be familiar and repetitive, raising questions about their value for improving practice.
  • Similar circumstances in engineering, health and other high-risk industries led to the development of the ‘systems approach’.
  • This gets to the bottom of why accidents occur and so allows for more effective solutions.
  • Academics have demonstrated that the approach also works for the field of safeguarding and protecting children in theory. To work in practice, the approach needed to be tested out and adapted.

To date our most public way of learning has been through the investigation of the death of a child from child abuse or neglect. In the UK, as in many other countries, these serious case reviews (SCRs) or public inquiries have been a major influence on the way services have developed (Parton, 2003; Stanley and Manthorpe, 2004; Parton, 2004). However, their value has been increasingly questioned as it has become apparent that they regularly identify the same problems in frontline practice and make similar recommendations (e.g. Dale et al, 2005; Rose and Barnes, 2008).

This situation is remarkably similar to the experience of accident inquiries in other sectors such as aviation and health. In those fields steps have been taken to improve matters through the development of the systems approach. This looks for causal explanations in all parts of the system. Rather than stopping once faults in professional practice have been identified, the systems approach explores the interaction of the individual with the wider context to understand why things developed in the way they did.

Social work academics have argued the need to appropriate this method in theory (e.g. Munro, 2005; Lachman and Bernard, 2006) but almost no research has been conducted on the feasibility of such a move. The Victoria Climbié tragedy underlined the urgent need to explore alternative approaches. Consequently, SCIE decided to try to adapt the model for child welfare work.

The basics of the approach

The goal of a systems case review is not limited to understanding why specific cases developed in the way they did, for better or for worse. Instead, a case is made to act ‘as a “window” on the system’ (Vincent, 2004: 242). It provides the opportunity to study the whole system, learning not just of flaws but also about what is working well.

The cornerstone of the approach is that individuals are not totally free to choose between good and problematic practice. The standard of their performance is influenced by the nature of

  • the tasks they perform
  • the available tools designed to support them
  • the environment in which they operate.

The approach, therefore, looks at why particular routines of thought and action take root in multi-agency professional practice. It does this by taking account of the many factors that interact and influence individual worker’s practice.

Ideas can then be generated about ways of re-designing the system at all levels to make it safer. The aim is to ‘make it harder for people to do something wrong and easier for them to do it right’ (Institute of Medicine, 1999: 2).

Next in this section: How has the model been developed?