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


Axelrod, R. and Cohen, M. D. (1999) Harnessing complexity: organizational implications of a scientific frontier, New York: The Free Press, Simon & Schuster.

Bostock, L., Bairstow, S., Fish, S. and Macleod, F. (2005) 'Managing risk and minimising mistakes in services to children and families', London, SCIE.

Chapman, J. (2004) System failure: why governments must learn to think differently, London: Demos.

Dale, P., Green, R. and Fellows, R. (2005) Child protection assessment following serious injuries to infants, Chichester: John Wiley & Sons.

Fish, S., Munro, E. and Bairstow, S. (2008) Learning together to safeguard children: developing an inter-agency systems approach for case reviews, London: SCIE.

Gano, D. (2003) Apollo root cause analysis, Yakima, WA: Apollonian Publications.

HM Government (2006) Working together to safeguard children: a guide to interagency working to safeguard and promote the welfare of children, London: The Stationery Office.

Hood, C. and Jones, D. K. C. (eds) (1996) Accident and design: contemporary debates on risk management, London: Routledge.

Institute of Medicine (1999) To err is human: building a safer health system, Washington DC: National Academic Press.

Lachman, P. and Bernard, C. (2006) 'Moving from blame to quality: how to respond to failures in child protective services', Child Abuse & Neglect, 30: 963–968.

Munro, E. (2005) 'A systems approach to investigating child abuse deaths', British Journal of Socal Work, 35: 531–546.

MUNRO, E. (2008) A review of safety management literature, SCIE, Unpublished interim working document.

Parton, N. (2003) 'From Maria Colwell to Victoria Climbié: reflections on a generation of public inquiries into child abuse', BASPCAN conference (July), plenary paper.

Parton, N. (2004) 'From Maria Colwell to Victoria Climbié: reflections on public inquiries into child abuse a generation apart', Child Abuse Review, 13: 80–94.

Reder, P. and Duncan, S. (1999) Lost innocents: a follow-up study of fatal child abuse, London: Routledge.

Reder, P., Duncan, S. and Gray, M. (1993) Beyond blame: child abuse tragedies revisited, London: Routledge.

Rose, W. and Barnes, J. (2008) 'Improving safeguarding practice: study of serious case reviews 2001–2003', London: Department for Children, Schools and Families.

Stanley, N. and Manthorpe, J. (eds) (2004) The age of inquiry: learning and blaming in health and social care, London: Routledge.

Taylor-Adams, S. and Vincent, C. (2004) 'Systems analysis of clinical incidents: The London Protocol', London: Imperial College Clinical Safety Research Unit.

Taylor, C. and White, S. (2006) 'Knowledge and reasoning in social work: educating for humane judgement', British Journal of Social Work, 36: 937–954.

Vincent, C. (2004) 'Analysis of clinical incidents: a window on the system not a search for root causes', Quality and Safety in Health Care, 13: 242–243.

Vincent, C. (2006) Patient safety, London: Elsevier.

White, S., Hall, C. and Peckover, S. (2008) 'The descriptive tyranny of the common assessment framework: technologies of categorization and professional practice in child welfare', British Journal of Social Work, bcn053.

Woodcock, K. and Smiley, A. (1998) 'Organizational pressures and accident investigation', Proceedings of the Human Factors Association of Canada, Mississauga, ON: Human Factors Association of Canada.

Woods, D. (2003) 'Discovering how distributed cognition systems work', in Hollnagel, E. (ed) Handbook of cognitive task design, Hillsdale, NJ: Lawrence Erlbaum.

Woods, D. D. and Cook, R. I. (1999) 'Perspectives on human error: hindsight biases and local rationality', in Durso, R. S. (ed) Handbook of applied cognition, New York: Wiley.

Woods, D. D. and Cook, R. I. (2001) 'From counting failures to anticipating risks: possible futures for patient safety', in Zipperer, l. and Cushman, S. (eds) Lessons in patient safety: a primer, Chicago, IL: National Patient Safety Foundation. Available at http://csel.eng.ohio-state.edu/woods/error/future_pat_saf.pdf, accessed 8 July 2008.