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

Introduction - What will the systems model help with?

The model can be used:

  • in serious case reviews (SCRs) to improve the quality and rigour of analysis and effectiveness of recommendations to ensure that the process is a learning exercise in itself
  • in reviews of routine case work to understand progress on the implementation of new working practices and accompanying tools (e.g. CAF), and to identify solutions to improve effectiveness
  • in the collation of findings from multiple case reviews at a local, regional and national level.

Serious case reviews

Serious case reviews (SCRs) in England and Wales and case management reviews (CMRs) in Northern Ireland form one important sub-category of case reviews and are unique in that they are a specific legal requirement. They are triggered, in the main, by the serious injury or death of a child who had been known to social care services.

There is a good match between the systems model and the English government’s Working Together guidance (HM Government, 2006) for SCRs. Both prioritise an analysis of practice that gets behind what happened to understanding why it did so, in order to understand what changes need to be made to improve safety. The systems model supports the implementation of Working Together guidance by providing local safeguarding children’s boards (LSCBs) with an explicit methodology for how those conducting SCRs should achieve this aim. It should aid LSCBs and children’s services authorities (CSAs) fulfil Ofsted’s criteria for positive evaluation of SCRs, particularly by encouraging a transparent, systematic and rigorous process for analysis.

Both Working Together and the Ofsted’s inspection criteria also stress the need to conduct SCRs in such a way that the process is a learning exercise in itself and promotes a culture of learning. The systems model also supports LSCBs in this aspect because it is an explicitly collaborative method that encourages open and active participation by workers and so facilitates joint ownership of the review process.

Considerable interest has also been expressed in the approach from other countries with similar child protection systems, particularly those with child death review teams responsible for the equivalent of SCRs. These include states within the USA, Canada, New Zealand, Australia and Germany.

Case reviews of routine practice

SCRs fit well into the systems model but should not be the only cross-agency opportunity for learning from practice. Throughout the countries of the UK, the various services dealing with children are currently undergoing major changes in their goals and tasks, the tools they use and the way they cooperate with each other to improve outcomes for children. In times of such major change in service delivery, there are particular benefits to using the systems approach to review and learn from routine case work.

The systems model can be used to understand progress on the implementation of new working practices, such as integrated teams, and accompanying tools, such as the common assessment framework (CAF). It helps identify what is working well and where there are problematic areas. Crucially, it can help to identify why things are going smoothly so that supportive factors can be protected. It also enables explanations to be found for why there are difficulties, so that solutions to improve effectiveness can be found. Usefully, it provides clarity about where in the system change can be initiated. Some issues are within the power of LSCBs to address; some may need action on regional or national levels.

The collation of findings from multiple case reviews

The systems model can facilitate the collation of findings from multiple case reviews because it helps to ensure that cases are reviewed (both SCRs and others) in a consistent way. This would aid the drawing of wider lessons from similar findings at a local, regional and national level.

Is the approach about learning from incidents/accidents and ‘near misses’?

In engineering and high risk industries, systems analysis is used primarily in accident investigations and to review ‘near misses’. In health, similarly, root cause analysis tends to be used for the analysis of so-called ‘patient safety incidents’ and ‘serious untoward incidents’ – where things have gone wrong and harm has been, or could have been, caused. However, in child welfare it would be premature, we argue, to use equivalent typologies of error, linked to degrees of harm, as triggers for case reviews or the basis of reporting systems.

Identifying ‘incidents’ or ‘near misses’ presupposes consensus about what should have happened and what counts as a deviation, error or mistake on the part of a professional. It also assumes that the link between that deviant action and the potential negative outcome can be reliably made. Lastly, it takes for granted agreement/consensus about the nature of adverse outcomes and degrees of harm.

All these are problematic in the field of child welfare, which involves charting a course between two potentially adverse outcomes – leaving children in danger and causing them and their families harm through intervening – and in which intended outcomes are often long term. Compared with engineering and health, the field is also marked by significant uncertainty. There are far fewer processes where there is consensus on exactly the right way to work with families in all cases. There are few instances where one can confidently say ‘this is the correct course of action’ or ‘if I do X then the outcome will be Y’. Practitioners also have relatively little scope to control the whole environment where change is sought. Therefore poor or even tragic outcomes for children and young people may or may not be the result of professional action or omission.

Next in this section: Who needs to learn and from whom?