A summary of the DfE's "A study of recommendations arising from serious case reviews 2009-2010"
This briefing summarises some of the findings from the Department for Education publication A study of recommendations arising from serious case reviews 2009-2010 (PDF)
The study analysed recommendations from 33 serious case reviews.
The report argues that, although recommendations are becoming more focused, there are still far too many of them (the average number was 47).
It goes on to examine in depth recurring themes and recommendations within the serious case reviews (SCRs) and identifies themes which receive few recommendations, despite appearing in a large number of cases.
The report also argues that some themes do not lend themselves to the recommendation format and suggests that other ways of learning lessons from SCRs should be explored.
Recurring themes in recommendations
There were a number of themes that kept appearing across the 33 serious case reviews. The importance of taking a child-focused approach.
The need to take into account the child's family and environment
, especially in relation to:
The management of cases
- cumulative concerns (as opposed to treating incidents in isolation)
- family history
- wider family members
- males in the household (both fathers and other significant males)
- repeated house moves
- the importance of observing the child and their family in a number of environments (especially the home)
- the need to have a realistic assessment of a family's ability to support the child's needs.
The need to improve record keeping processes and information sharing The need to address various staffing issues
- referral and assessment processes (specifically timeframes involved, feedback given to the referrer, and the use of assessments)
- the need to challenge both parents and other professionals about their decisions
- the need for new approaches to working with hard to engage families
- improving provision of out of hours services.
The need for further training and awareness-raising
- staffing levels
- use of unqualified staff
- clarity of staff roles
- awareness and appropriate use of staff's knowledge and skills.
The importance of raising awareness amongst the general public
- the need to raise general awareness amongst professionals of safeguarding and case management issues
- the importance of training in specific issues arising from particular cases.
. Targeting messages about safeguarding children at parents, carers and the wider community. The need to address a broader regional/national audience
. Some reports looked at ways of extending the lessons learnt from cases beyond the local context, recommending changes in government thinking or policy, the development of new national guidance, or the need for change within regional bodies or professional organisations.
Relevance of recommendations
The report found that some themes resulted in more recommendations than others.
Areas where recurring themes led to few recommendations tended to focus on issues within the family
(such as low birth weight, teenage parents, parental learning disability) and issues looking at wider problems within society
(such as poverty and poor living environment).
- Family issues
Family issues varied from case-to-case, and as such required individual attention and professional judgement, not easily translated into recommendations. The report suggests that recommendations related to increased staffing levels and supervision could help address these complex issues.
- Societal issues
"Big" issues such as poverty tended to be treated as beyond the scope of the Local Safeguarding Children Board (LSCB). The report suggests that SCRs could be used as an effective means of raising national issues.
Themes which were frequently linked to recommendations tended to focus on professional issues
(such as those relating to training and communication).
- Professional issues
Professional issues tended to lend themselves more readily to concise and measurable recommendations, but often included repetitive messages. The report suggests that although repetition can reinforce learning, it can also result in a daunting and time consuming list of recommendations.
The future of recommendations
The report points to evidence that: "recommendations which are the easiest to translate into actions and implement may not be the ones which are most likely to foster safer, reflective practice"
Possible ways of increasing the depth of lessons learnt from reviews include the adoption of a systems approach
and the combination of what is known about serious case reviews with whole population studies
Brandon, M, and Sidebotham, P, and Bailey, S, and Belderson, P (2011) A study of recommendations arising from serious case reviews 2009-2010 (PDF)
. [London]: Department for Education. This briefing contains edited excerpts from A study of recommendations arising from serious case reviews 2009-2010. It should not be taken as NSPCC policy.
Related NSPCC resourcesSerious case reviews
Our pages on the case reviews of child deaths and serious injury collating guidance, research reports and a list of published case reviews. Safeguarding through audit: a guide to auditing case review recommendations
Mary Handley and Richard Green
London: NSPCC, 2009 NSPCC training courses
We offer a range of course and bespoke training on all aspects of safeguarding across the spectrum of child protection. CASPAR news
View the latest child protection news or sign up to our current awareness email that delivers a bitesize summary of all the new developments in research policy and practice to your inbox every Monday.