Ofsted considers lessons to be learned from serious case reviews

Ofsted has evaluated 147 serious case reviews (SCRs) relating to 194 children in a new report, Learning lessons from serious case reviews 2009-2010.

Serious case reviews are local enquiries into the death or serious injury of a child where abuse or neglect is known or suspected to be a factor. They are carried out by Local Safeguarding Children Boards to identify any issues that need to be addressed in local children's services.

The report covers SCRs carried out between April 2009 to March 2010 and judged  42% of them as good, 42% adequate and 16% were judged inadequate. However, many of the cases reviewed reveal the persistence of some key issues in practice which have contributed to shortcomings in the protection of the children involved, the report says.

A consistent finding from the reviews was that there had been a failure to implement and ensure good practice rather than an absence of the required framework and procedures for delivering services.

Most of the serious case reviews identified sources of information that could have contributed to a better understanding of the children and their families. They also highlighted concerns about the effectiveness of assessments and shortcomings in multi-agency working.

Reviews also found that there had been insufficient challenge by those involved. The statements of parents or others in the family should not have been accepted at face value; individual professionals and agencies should have questioned their own and others' views, decisions and actions; and there were shortcomings in the supervision and intervention by managers.

Local Safeguarding Children Boards also identified failures to ensure that the necessary action was taken because of gaps in the services that were available; decisions which, with the benefit of hindsight, were found to be wrong; insufficient consideration of the child's individual needs; and ‘professional drift' resulting in a lack of action.

Of the 194 children, 90 died. The other 104 were involved in serious incidents, following a history of concern by the agencies involved, including being the subject of a child protection plan. The most common characteristics of the incidents were physical abuse or long-term neglect.