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Research reports on case reviews following the death or serious injury of a child

NSPCC reading list

November 2013

A chronological list of reports analysing the details and recommendations from case reviews.

These reports provide a valuable overview of the common themes that can make children vulnerable and help to highlight how professionals and organisations can improve the way they work together to safeguard children.

Reports published in:

2013
2012
2011
2010 and before.


Research reports on case reviews published in 2013

Neglect and serious case reviews.
Brandon, M., et al
London: University of East Anglia/NSPCC, 2013
A systematic analysis of neglect in serious case reviews in England, between 2003 and 2011.Looks at how risks of harm accumulate and combine and the points at which intervention might successfully have helped to contain these risks.

Translating learning into action: an overview of learning arising from case management reviews in Northern Ireland 2003-2008 (PDF, 2.08MB) .
Devaney, J. et al.
Department for Health, Social Services and Public Safety. Northern Ireland, [Belfast], 2013 Reviews lessons learnt from Case Management Reviews in Northern Ireland between 2003 and 2008. Analyses 24 reviews into the death or serious injury of 45 children. Draws out key recommendations, including: services becoming involved with families at an earlier stage; services staying involved with families for longer to consolidate improvements; access to therapeutic services for children to address the psychological harm of poor parenting.
Read the NSPCC briefing on the findings: A summary of "Translating learning into action: an overview of learning arising from Case Management Reviews in Northern Ireland 2003-2008".

Preventing child deaths: learning from review.
Vincent, S.
Edinburgh: Dunedin Academic Press, 2013
Reviews and compares the mechanisms used for reviewing child deaths across New Zealand and Australia, North America, and England and Wales. Final chapters pull out key themes and prevention initiatives and examine issues and challenges faced by child death review teams in relation to monitoring recommendations and demonstrating impact and effectiveness.


Research reports on case reviews published in 2012

New learning from serious case reviews: a two year report for 2009-2011 (PDF).
Brandon, M. et al
Department for Education, 2012
Sixth biennial evaluation of serious case reviews (SCRs) in England looking at lessons learned. Analyses SCRs from 1 April 2009 to 31 March 2011, considering new learning as well as recurring messages. Chapters cover: background characteristics of the children and families, and agency involvement; a thematic analysis of SCRs involving children 5 to 10; child and family practitioners' understanding of child development; recommendations arising from SCRs; and new learning from SCRs. Includes findings and data from the three previous biennial analyses (2003-5, 2005-07, 2007-09).

Audit and analysis of initial and significant case reviews (PDF).
Vincent, S. and Petch, A.
Edinburgh: The Scottish Government, 2012
Report analysing 43 initial case reviews (ICRs) and 56 significant case reviews (SCRs) conducted in Scotland between 2007 and 2011. Findings showed: a lack of consistency in how reviews were undertaken. Of the SCRs half of were about child deaths; criminal proceedings had been instigated in half; parental mental health was an issue in 43%; parental substance misuse was an issue in nearly two thirds domestic abuse featured in over half the cases. Presents 10 recommendations to improve the SCR process in Scotland.
Read the NSPCC briefing on the findings: A summary of the Scottish Government's "Audit and analysis of significant case reviews".


Research reports on case reviews published in 2011

A study of recommendations arising from serious case reviews 2009-2010 (PDF).
Brandon, M. et al
Deparment for Education, 2011
A critical, thematic analysis of the recommendations from 33 serious case reviews. Focuses on how many recommendations were made, common themes from the recommendations, how closely the recommendations reflect the themes of the case and critiques the use of SMART (specific, measurable, achievable, relevant and timely) recommendations.
Read the NSPCC briefing on the findings: A summary of the DfE's "A study of recommendations arising from serious case reviews 2009-2010".

Child and family practitioners' understanding of child development: lessons learnt from a small sample of serious case reviews (PDF).
Brandon, M. et al
Department for Education (DfE), 2011
Examination of six serious case reviews completed in 2009 or 2010. Assesses how greater knowledge of child development could have alerted social workers to the warning signs of maltreatment. Identifies key development related signs of abuse or neglect: bruising and faltering weight in infants and young children and behavioural stress in young people, including those with disabilities. Looks across age groups at how parent-child relationships can help professionals understand a child's development. Concludes that greater interagency cooperation is needed; greater attention needs to be paid to the child's perspective; and that professionals need more child development training.

A child-centred system: the government's response to the Munro review of child protection (PDF).
Department for Education, 2011
States the government will consider Professor Munro's recommendation 9 on serious case reviews at a later date.
Read the NSPCC briefing: A summary of the government's response to the Munro report

The Munro review of child protection: final report: a child-centred system (PDF).
Munro, E.
The Stationery Office, 2011
Considers the role of serious case reviews and learning. Recommendation 9 on using systems methodology when undertaking a serious case review and developing national resources to improve serious case review practice.

An analysis of serious case reviews concerning children under one.
NSPCC, 2011
A brief analysis of the serious case reviews held by the NSPCC Library that concern children aged under one year and were published between 1 January 2008 and 12 September 2011 in England or Wales. Looks at the prevalence of domestic violence, substance misuse or mental health issues in these cases.

Ages of concern: learning lessons from serious case reviews: a thematic report of Ofsted's evaluation of serious case reviews from 1 April 2007 to 31 March 2011 (PDF).
Ofsted, 2011
Analyses serious case reviews evaluated by Ofsted between April 2007 and 31 March 2011. Focuses on cases concerning babies under one year and young people aged over 14. Outlines lessons that can be learnt from the reviews, using case studies to illustrate the points made, and includes practice implications for both practitioners and LSCBs. Includes a more detailed breakdown of serious case reviews evaluated by Ofsted between 1 April 2010 and 31 March 2011.

The voice of the child: learning lessons from serious case reviews (PDF).
Ofsted, 2011
Analysis of 67 serious case reviews evaluated by Ofsted between 1 April and 30 September 2010. Focuses on the importance of listening to the voice of the child.
Read the NSPCC briefing on the findings: A summary of Ofsted's "The voice of the child: learning lessons from serious case reviews".

Serious and fatal child maltreatment: setting serious case review data in context with other data on violent and maltreatment-related deaths in 2009-10 (PDF).
Sidebotham, P. et al
Department for Education (DfE), 2011
Compares available data on serious and fatal child maltreatment in England. Estimates drawn from a combination of SCR notifications from 1 April 2009 - 31 March 2010 and comparator data include: the total number of violent and maltreatment-related deaths of children is around 74 per year, with around 50-55 directly caused by violence, abuse or neglect, and a further 20-25 in which maltreatment was considered a contributory factor.
Read the NSPCC briefing: A summary of the DfE's "Serious and fatal child maltreatment: setting serious case review data in context with other data on violent and maltreatment-related deaths in 2009-10".


Research reports on case reviews published 2010 and before

Learning lessons from serious case reviews 2009-10 (PDF).
Ofsted, 2010
Analysis of the evaluations of serious case reviews that Ofsted completed between April 2009 and March 2010. Learning from serious case reviews: report of a research study on the methods of learning lessons nationally from serious case reviews (PDF).
Sidebotham, P. et al
Department for Education, 2010
Contains recommendations on how to improve approaches to learning from serious case reviews.

An evaluation of the case management review process in Northern Ireland: including a scoping exercise of adverse incident reporting and alternative investigative systems.
Lazenbatt, A., Devaney, J. and Bunting, L.
NSPCC and Queens University Belfast, 2009
Identifies the strengths and weaknesses of the case management review (CMR) process and presents recommendations for improvement. Includes a literature review of incident systems and processes used nationally and internationally and their advantages and disadvantages.


Search the NSPCC Library Online for older research reports on case reviews or contact the NSPCC's information service for more information on case reviews or any child protection topic


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