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What really happened?: child protection case management of infants with serious injuries and discrepant parental explanations

Summary of research and findings

Front cover of What really happened?: child protection case management of infants with serious injuries and discrepant parental explanationsBy Peter Dale, Richard Green and Ron Fellows (July 2002)

What really happened? Child protection case management of infants with serious injuries and discrepant parental explanations - summary of research and findings (PDF, 10KB)

Clinical and evaluation experience of child protection assessments over a twenty year period indicates that there is a particular group of cases that present significant challenges to child protection systems and courts in relation to decision-making about future risks. These involve babies who have sustained serious physical injuries, and where there are discrepant parent / carer explanations regarding the cause of the injury. For brevity we refer to these cases by the acronym SIDE (serious injury - discrepant explanation).

There has been very little research which focuses upon child protection assessment and case management in these situations. What really happened? reports on a study which examined child protection system assessment and case management of SIDEs in 38 families involving 45 seriously - or fatally - injured children (aged 0-2 years) from two perspectives:

  • a clinical assessment sample of 21 SIDE cases involving 26 babies and young children

  • an analysis of 17 Part 8 Review reports of SIDE cases that culminated in the deaths of 17 (and serious injury to two other) babies and young children.

Drawing from analysis of both samples, we describe the types of injuries that these children sustained, explanations that were provided, and the family circumstances in which they occurred. We review the child protection system initial responses and subsequent case management, highlighting factors of effective and detrimental practice. We conclude that many (but by no means all) of the deaths, and occurrences and recurrences of serious injuries, were preventable from the perspective of reasonable expectations of informed professional practice.

Within this context, we make recommendations for improvements in the quality and consistency of child protection system processes and outcomes, which we believe could lead to a reduction in the incidence of SIDE cases. We highlight some principles of evidence-based assessment practice intended to reduce the occurrence of aberrant judgements regarding a child's safety.

At the prevention level, we call for National standards for child protection to be developed by central government. Such standards should specify quality process and outcome requirements at each key stage of the progress of a child protection referral.

Existing Area Child Protection Committees (ACPCs) should be charged with the responsibility to implement and audit the operation of National Child Protection Standards, and to achieve specific targets for decreased incidence and improved outcomes. We make proposals for the steps that each ACPC should take to develop a strategy for a reduction in fatal and non-fatal SIDE cases in each area over a five-year period.

In addition to their retrospective role in reviewing cases that have adverse outcomes, operational case-tracking responsibilities of Area Child Protection Committees (ACPCs) should be significantly strengthened. ACPCs should provide an expert consultation and monitoring role to current cases involving high-risk infants.

Public confidence in child protection services is possibly at an all time low. The public is much less aware that child protection systems, which have developed over the past 30 years, do work well for thousands of children each year. Out of sight, skilled and diligent professionals arrange vital protection for vulnerable children, and provide or organise effective support for their parents and wider families. Without this level of successful, but hidden, child protection practice, rates of serious and fatal child abuse in the UK would undoubtedly be substantially higher than they currently are.

However, it remains unfathomable to the general public that children continue to die as a consequence of basic child protection failures. In response, it is imperative that child protection practice in the UK becomes subject to consistent explicit quality standards, supported by more sophisticated evidence-based protocols to assist professional judgements. Also, that services are sufficiently resourced to enable these standards to be achieved, sustained and continually improved.

Full report:

Dale, P., Green, R. and Fellows, R. (2002) What really happened? Child protection case management of infants with serious injuries and discrepant parental explanations. London: NSPCC. [NSPCC Policy Practice Research Series].
ISBN: 1842280287

Available from NSPCC Publications