SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews

By Dr Sheila Fish, Dr Eileen Munro and Sue Bairstow

Published: October 2008

Key messages from the report

The report contains the following key messages and recommendations:

  • Developments in engineering and health indicate the potential benefits of using a 'systems approach' to understanding frontline practice in order to improve the quality and safety of service provision.
  • This report and the accompanying guide presents an adapted systems model for multi-agency safeguarding and child protection work.
  • It is an innovative approach that requires a respectful approach towards the practice experience of street-level workers and their managers.
  • It involves moving beyond the basic facts of a case chronology and appreciating the differing views that different workers had at the time.
  • The aim is to identify underlying patterns of factors in the work environment that support good practice or create unsafe conditions in which poor practice is more likely.
  • This kind of organisational learning is vital to improving the quality of services provision and needs to be applied to ordinary work, not just to tragedies.


Children's safety and welfare are key concerns in all countries, with continual efforts being made to improve child welfare and child protection services. Learning is central to these endeavours so that problems and their solutions can be identified. However, it has been questioned as to whether current learning approaches are adequate for the task. In light of this, SCIE presents a 'systems' model of organisational learning that can be used across agencies involved in safeguarding and child protection work.


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. It is a method for identifying what works well as well as where there are problems. Academics have demonstrated that the approach also works for the field of safeguarding and protecting children in theory, which is the basis for this report. To work in practice, the approach needed to be tested out and adapted. 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)


The systems model can be applied to serious case reviews (SCRs). It also has particular value in times of major change in services delivery, when it can be used to understand progress on the implementation of new working practices and accompanying tools such as the Common Assessment Framework (CAF). It will therefore be useful for both frontline staff and senior management. The model is collaborative and encourages joint working.


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Available downloads:

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

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