At a glance 34: Piloting the SCIE ‘systems’ model for case reviews: Learning from the North West of England

Published: November 2010

Key messages

  • The ‘learning together’ systems approach has been successfully applied in three pilot case reviews in the North West of England. This is now commonly known as ‘the SCIE model’.
  • The model produces explanations about why professionals had acted in the way they did.
  • The approach identifies conditions supporting good safeguarding practice, as well as those influencing professional practice in negative ways.
  • Having a multi-agency ‘review team’ working together from the beginning created a common endeavour, greater challenge and confidence to find new ways of working and effective solutions.
  • Actively involving frontline workers and team managers throughout the process is a vital aspect of the model.
  • Participants using the model for the first time stressed that taking a ‘systems’ perspective is a new and different way of thinking that means learning new skills.
  • The pilots suggest that the SCIE model has the potential to be used for SCRs and so address current questions about the need to improve learning from SCRs. This would require changes to the 2010 statutory guidance.
  • SCIE is collaborating with three other areas to conduct further pilots in order to develop, implement and evaluate the model. Colleagues interested in being involved should contact SCIE.


Public confidence is undermined when professionals are perceived not to learn from cases in which children suffer or die from abuse. There is also a negative impact on staff morale. Yet the potential learning opportunities provided by serious case reviews (SCRs) are not being fully realised (see Sidebotham et al 2010). Among the issues that the Government has asked Professor Munro to assess in her review of child protection in England, is whether there are other methods for learning from SCRs that are more effective and efficient, including work in other sectors.

About the SCIE ‘systems’ model

Since 2004, working with Professor Eileen Munro and in collaboration with the sector, SCIE has been leading the development of a ‘systems approach’ for use in case reviews and serious case reviews (SCRs) of multi-agency safeguarding and child protection work. This builds on safety management developments in the fields of engineering and, subsequently, health. The adapted model is published under the title Learning together and is commonly referred to as ‘the SCIE model’. Readers new to SCIE's work are encouraged to read At a glance 1 to gain an understanding of the model.

This model requires a real culture shift – it's a bottom up approach, so it requires learning that it's ok to get frontline workers in from the beginning

Review team member

This At a glance summarises learning from piloting of the approach in the North West of England. Further details can be found in the full report and accompanying Social Care TV video on the SCIE website.

Overview of the process

The SCIE systems approach proposes that the people involved in a case review are organised into two main groups:

  • Review Team – the multi-agency group of people conducting the review, usually senior managers.
  • Case Group – the staff and managers who were directly involved in the case being reviewed.

It recommends that the process is structured around key meetings of these groups.

  • The review team meet with the case group for
    • an introductory meeting,
    • individual conversations
    • two group ‘follow on’ meetings.
  • The review team meet for
    • an initial planning meeting
    • reviewing relevant documentation
    • ‘analysis meetings’.

Reports should be written by a member of the review team for both follow-on meetings as well as the final report.

The model provides a theoretical framework and practical tools for the collection of data about professional practice in the case and its analysis. This aims to help participants to find out ‘why’ the case developed as it did and identify underlying patterns of systemic influence on practice. The tools include:

  • a structure or ‘schedule’ for the individual conversations
  • a framework of contributory factors
  • a table layout for organising analysis of practice
  • a typology of underlying patterns.

About the pilots

Publication of the newly developed systems model, at the end of 2009, attracted high levels of interest from Local Safeguarding Children Boards keen to try it out in practice. The North West region put itself forward first for a pilot project. Case reviews were conducted by Lancashire, Wirral and Salford Local Safeguarding Children Boards (LSBCs) using the systems approach. The project was funded by the Regional Improvement and Efficiency Partnership (RIEP) and supported by the Government Office North West (GONW). It was overseen by a regional project management group.

The cases used did not require a SCR although they were serious cases. Two focused on children who had died of natural causes and the third focused on a child who had attacked another child causing serious injury. The case reviews were conducted by multi-agency teams of local senior professionals (SCR subcommittee members or IMR authors), led and supported by members of the SCIE team.

About the evaluation

The evaluation of the North West pilots aimed to answer the following questions:

The region was also keen to find out how this approach, or parts of it, could be used in the current systems for undertaking SCRs.

SCIE took a participative action research approach to answering these questions. That is, continual cycles of action, reflection and adaptation were undertaken by all parties involved, at all stages throughout the process. This cyclical process was documented in a variety of ways and that documentation forms the source of data for the evaluation. The report has been written by the SCIE leads for the project. Efforts to minimize the authors’ choosing from the available findings in a biased fashion (investigator bias) included explicitly looking for counter evidence in the source data and involving the pilot leads in quality assurance of the document.

Summary of findings

Case reviews were successfully carried out by multi-agency review teams, led by SCIE staff, in each of the localities. The experience in all three sites suggested that using the systems approach enabled professionals to undertake a case review that:

I’ve benefitted in terms of the outcomes of the case review – now I always have in mind the “garden path” thing. I’ve gone back to other cases and thought; actually, why am I working with this family? What was the initial reason for our involvement?

Social worker, case group member

We found also that:

What supported effective learning?

These recommendations are more strategic, so that’s a struggle, but that’s as it should be. You can imagine these more easily informing the business plan or CYP’s plan, rather than tick-off action plans.

LSCB member

Areas for development of the SCIE model

Some further areas for development of implementation identified were:

Supports and challenges in implementing the approach

The pilots also produced a number of learning points regarding the process by which the model is implemented:

Working Together 2010

The use of the SCIE model for SCRs would require some changes to the statutory guidance. This is in line with the Association of Directors of Children’s Services (ADCS) recommendation for the Munro review:

There should be a clear focus on removing the bureaucracy and levels of prescriptive processes, including those surrounding the current Serious Case Reviews (SCR) process, in order to free frontline practitioners to adopt a ‘learning from practice’ approach to their work. This must include a radical overhaul of the current statutory guidance Working Together to Safeguard Children and Young People

Association of Directors of Children's Services ADCS 2010: 4

There are, however, various aspects of the SCIE model that the North West pilot LSCBs suggest can be incorporated into SCR processes according to the current statutory guidance. These include:

Strengthen participation of staff in the process

Use SCIE conversation structure to inform IMR interviews with staff

This would include:

People struggled with not having the chronology at the start but I’m coming to think that it has been useful. You can ask quite searching questions about why this happened in a particular way.

Review team member

Keep a relentless focus on the ‘why’ questions in both IMR and overview reports

Encouraging authors to use the list of contributory factors and categories of underlying patterns of systemic influence to move away from focusing on individuals and think about how effective single and cross agency systems are at supporting and encouraging good quality work with families.

Next steps

Building on the learning gained from the North West pilots, SCIE is continuing to work in collaboration with the sector to develop the evidence base about the systems model. Further pilot case reviews are being conducted in the West Midlands, South West and London. SCIE is keen to try using the model on cases other than those involving the death or serious injury of a child, including cases where good outcomes for the child have been achieved, as well as cases selected on a thematic basis of practice areas that need to be better understood. We are also responding to interest from the adult safeguarding sector in potential application of the model to SCRs involving vulnerable adults.

We encourage anyone active or interested in this area to get in touch. Contact:

Further information

It was a very different atmosphere with this model. Usually you defend your corner, whereas here the barriers came down, which allowed for those conversations to happen. We were having dialogues at a deeper level, asking the further questions all the time – “if we make this decision, how will it impact on your system?

Case group member


This summary is written by Dr Sheila Fish, Senior Research Analyst, SCIE; Eileen Munro, Professor of Social Policy, LSE; Sue Bairstow, SCIE Associate. It draws on input from participants in the North West pilot sites and the North West project management group.


All SCIE resources are free to download, however to access the following download you will need a free MySCIE account:

Available downloads:

  • Piloting the SCIE ‘systems' model for case reviews: Learning from the North West of England