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

Introduction - How has the model been developed?

  • The model builds on Managing risk and minimising mistakes (Bostock et al, 2005).
  • It is underpinned by a review of the safety management literature (Munro, 2008).
  • Two pilot case reviews were conducted using the systems approach, working closely with two local safeguarding children’s boards in England.
  • Valuable feedback was provided by staff at all stages in order to adapt the model during the process.
  • The experience of these pilots was vital to subsequent fine-tuning of the model.

Taking an approach from a radically different area of work such as engineering requires detailed work to adapt it to children’s services. Initial explorations focused on the potential of learning from ‘near misses’ and culminated in SCIE Report 06: Managing risk and minimising mistakes (Bostock et al, 2005).

This second phase of work has been a two-year SCIE project in which the work was reframed as a systems approach and trialled with the cooperation of two local safeguarding children’s boards (LSCBs) in England. Two detailed case reviews were conducted and valuable feedback was provided by staff at all stages in order to adapt the model during the process. A scoping review of the safety management literature provided the theoretical underpinning (Munro, 2008) and is available in the Appendices section of this resource.

Is this model the same as root cause analysis?

Root cause analysis is a term familiar to health colleagues and others in the UK because it has been taken up and promoted by the National Patient Safety Agency as a method for the investigation of patient safety incidents. It is a concept that overlaps closely with a systems approach but because the term itself is misleading we have chosen not to use it (c.f. Taylor-Adams and Vincent, 2004).

The term implies that there is a single root cause to any incident, but incidents often arise from a chain of events and the interaction of a number of factors. It also implies that the purpose of the investigation is restricted to finding out the cause of the particular incident under investigation, rather than learning about strengths and weaknesses of the system more broadly, and how it may be improved in future.

We have chosen instead to put the word ‘system’ in the name because this draws attention to a key feature of the model – the opportunity it provides for studying the whole system, learning not just of flaws but also about what is working well.

Next in this section: What will the systems model help with?