Learning from significant case reviews in Scotland

Key findings and recommendations from The Care Inspectorate review of significant case reviews (SCRs) in Scotland

The Care Inspectorate has published Learning From Significant Case Reviews in Scotland: a retrospective review of relevant reports completed in the period between 1 April 2012 and 31 March 2015 (PDF).

20 reports involving 23 children and young people were analysed and findings are presented to support learning for the future.

This report follows on from the audit and analysis of significant case reviews carried out by Vincent and Petch in 2012.

The significant case review (SCR) process

From 1 April 2012 to 31 March 2015, 14 of the 30 child protection committee areas in Scotland carried out SCRs. The criteria used for deciding whether to carry out a SCR were varied. This suggests some committees are more willing than others to seek the learning that an SCR can provide.

The reports varied in terms of their title; format and length; approach; time taken to carry out the review; thoroughness of the analysis; who carried out the review and who was invited to contribute to it; how the findings, strengths or recommendations were presented.

Characteristics of children and families involved in the SCRs

    • In the cases where a child suffered from mental health problems, the agencies involved in working with the child did not always understand the impact that these can have.
    • The risk of harm to a child is greater in families where there are 3 or more siblings, especially if other factors such as domestic abuse, substance misuse and poor supervision of the children add to the family’s difficulties.
    • The risks for some children and young people may become more difficult to manage at times of key transition and change, such as if a child is being taken off the child protection register but their family still needs support.
    • The role of the father was highlighted as a key factor impacting the wellbeing of a child; including whether the father was present in the child’s life, whether he was known to services/agencies and had a good working relationship with them, and the nature of his relationship with the child’s mother.
    • Parental mental health issues were present in 65% of the SCRs. It was noted that adult mental health services need to recognise the potential impact on parenting capacity.
    • Domestic abuse was present in 65% of the SCRs. It was noted that professionals need to understand the serious impact that this can have on a child.
    • Substance misuse was present in 55% of the SCRs. This did not just impact a parent’s ability to look after a younger child or infant, but it was highlighted as a concern for older children who had regular contact with parents who misuse substances.
    • Parental involvement in criminal behaviour was a factor in 35% of cases. This may have involved domestic abuse, assault, drug offences, possession of weapons, driving offences and anti-social behaviour. It is pointed out that other people such as older siblings in the home can also expose a child to criminal behaviour and that this can result in a child thinking that violent behaviour, for example, is normal.
    • 20% of parents had a troubled childhood or suffered abuse as a child. It is noted that the majority of the SCRs do not give information about the parents’ childhood but that this can have a huge impact on their parenting capacity and must be considered by professionals.

Factors affecting agency working which are highlighted in the SCRs

    • 15 of the 20 SCRs highlighted problems with how different agencies functioned or worked together, which had had an impact on the outcome of the case.
    • 7 of the 20 SCRs identified staffing and deployment as a factor in the case. This included staffing gaps which meant that decisions about the case were made according to staff availability rather than the best interests of the child.
    • Training needs were highlighted in most of the SCRs. This included professionals needing to be able to recognise the symptoms of different types of abuse and understanding behaviours which may be displayed by the child or family members.
    • Poor information sharing and communication were identified in 11 SCRs. This included failing to share information with the relevant parties or using the information available to help with decision making.
    • Improvement in assessment and planning was needed in 14 of the SCRs. The importance of carrying out thorough, realistic, well informed assessments in good time was highlighted.
    • Sometimes the SCRs found that professionals had not engaged with children, young people and families effectively. This included having ‘false optimism’ about the situation; taking what was said by parents and children at face value; and not investigating further.
    • Some children were not recognised by professionals as having been neglected. The report also notes that 2 SCRs failed to identify neglect even though it was clearly indicated in the available information.
    • Guidelines and review processes were not always carried out in a timely, consistent and constructive way. This includes using legal measures to protect a child where necessary.
    • Lack of supervision for professional staff was identified as a factor affecting outcomes for children, particularly in complex cases.

Recurring risk factors

There were several recurring risk factors present in the SCRs. As well as the key characteristics above, these include:

    • the family had poor levels of attendance and punctuality at meetings and appointments
    • the parents and/or child did not engage or co-operate with professionals, or displayed variable patterns of engagement
    • the family had repeat attendance at the accident and emergency department
    • the child or family had been involved with children’s services for a long time
    • the child had poor levels of attendance, behaviour and cleanliness at school or nursery
    • the child or young person, or their siblings, were known to have previously suffered abuse or neglect or have been cared for by others
    • the child displayed risk-taking behaviour e.g. self harm, substance misuse, going missing, offending; or, associated with peers who displayed this behaviour
    • an older sibling had mental health problems
    • the child had experienced several house moves, or several changes of placement if in care
    • there was family conflict and/or a lack of family support
    • the child has been referred to the wrong service e.g. they were seen as a homeless adult rather than a vulnerable young person
    • several professionals were involved with a child or family, sometimes resulting in a fragmented service.


Key recommendations include:

    • all child protection staff should have regular, high quality supervision
    • the child protection committees should oversee improvement in the following areas:
    • how information is shared and used to inform understanding, assessment and decision making, especially within multi-agency working
    • clarifying roles and responsibilities during transition periods so that children do not lose support
    • improving the quality of assessments including more consistent use of national risk-assessment tools
    • managing the response to risks once a child is “in the system”
    • raising awareness of risks for older young people, particularly during times of transition and where they display risk-taking behaviour
    • the need for collective responsibility in keeping children safe should be reinforced
    • child protection committees must provide clear information on decisions made following initial case reviews to the Care Inspectorate. The opportunities for learning and practice improvement which SCRs provide should be recognised
    • the Scottish Government and Scotland’s child protection committees should work together to improve the quality and consistency of SCRs. This includes building capacity for using nationally recognised approaches
    • Chief Officers and child protection committees should ensure that learning from SCRs leads to demonstrable practice change
    • when making recommendations, SCRs should be clear about whether they are referring to systems and processes themselves or their implementation.

Find out more about significant case reviews and child protection in Scotland

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  1. Vincent, S. and Petch, A (2012) Audit and analysis of initial and significant case reviews (PDF). Edinburgh: The Scottish Government