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  • The Troubling History of Serious Case Reviews

    David N Jones

    Social Work History Network

    24 November 2015

    People Need People Consulting Realising the potential in human services

  • Source material

    Serious Case Reviews in Child Protection: Historical Reflections David N Jones (2015) ADCS Virtual Staff College http://www.virtualstaffcollege.co.uk/wp-

    content/uploads/historical_reflections_publish.pdf

    People Need People Consulting Realising the potential in human services

    http://www.virtualstaffcollege.co.uk/wp-content/uploads/historical_reflections_publish.pdfhttp://www.virtualstaffcollege.co.uk/wp-content/uploads/historical_reflections_publish.pdfhttp://www.virtualstaffcollege.co.uk/wp-content/uploads/historical_reflections_publish.pdfhttp://www.virtualstaffcollege.co.uk/wp-content/uploads/historical_reflections_publish.pdf

  • Possible questions What generates public concern in

    serious cases? Has all the energy devoted to Serious

    Case Reviews had any impact on policy and practice?

    Does the history of SCRs throw light on service development and improvement?

    How do SCRs fit alongside developments relating to risk management in other fields?

  • What pushes a serous case into the public domain?

    People Need People Consulting Realising the potential in human services

    Scandals do not just happen. They are made.

    They are constructed out of such everyday tragedies as

    the small carelessnesses and institutional brutality of the long stay hospital,

    the abuse of children or the violent deaths of innocent bystanders

    (Butler and Drakeford, 2005).

  • Victorian scandals, inquiries and reform

    Haydock Lodge scandal (1846-1852) involved the

    transport around the country of large number of paupers with mental illnesses and learning disabilities

    Timothy Daly (1864) St Bartholomews death by exhaustion from bed sores & fever Florence Nightingale workhouse reform Lancet Commission, etc

    Mary Ellen (1874) - New York - NSPCC (1895)

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  • Reviews since 1945

    Children Act 1948 Dennis ONeill Monkton inquiry 7 weeks Curtis Ctte

    Children Act 1975 - Maria Colwell Children and Young Persons Act 2008

    Victoria Climbi Laming 2003 Every Child Matters 2003

    From 1973 increasing use of public inquiries

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  • Enquiries 1973 Graham Bagnall 1973 David Lee Naseby 1973 Maria Colwell 1974 Max Piazzani 1975 Auckland family 1975 Richard Clark 1975 Lisa Godfrey 1975 Stephen Meurs 1976 Neil Howlett 1977 Wayne Brewer 1977 H family 1978 Paul and L. Brown 1978 Stephen Menheniott 1978 Simon Peacock 1979 Lester Chapman 1979 Darryn James Clarke 1980 Paul Stephen Brown 1980 Claire Haddon 1980 Carly Taylor 1981 Maria Mehmedagi 1981 Malcolm Page

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  • 1981 Christopher Pinder/Daniel Frankland 1982 Jason Ceasar 1982 Lucy Gates 1984 Shirley Woodcock 1984 Heidi Koseda 1985 Jasmine Beckford 1985 Reuben Carthy 1987 Tyra Henry 1987 Cleveland - 121 children

    1990 Orkney 2000 North Wales (Waterhouse) 2001 Caleb Ness 2003 Victoria Climbi 2006 Michael McGarrity 2007 Baby Peter 2009 J children - Edlington 2010 Khyra Ishaq 2012 Edlington case Carlile 2013 Daniel Pelka 2013 Hamzah Khan 2013 Operation Pallial (North Wales)

    People Need People Consulting Realising the potential in human services

    Enquiries

  • 2013 Operation Yewtree 2013 Rochdale CSE 2013 HMICs review into (police handling of) allegations and

    intelligence material concerning Jimmy Savile 2014 Rotherham 1997-2013 2015 Oxfordshire 2015 Independent oversight of investigations into matters

    relating to Jimmy Saville at schools and childrens homes: 2015 Themes and lessons learnt from NHS investigations into

    matters relating to Jimmy Saville Inquiry into non-recent abuse

    People Need People Consulting Realising the potential in human services

    Enquiries

  • People Need People Consulting Realising the potential in human services

    Concern increased through 1980s cost and public relations impact

    Search for a credible, robust and cost effective inquiry system, which would convince politicians, the media and judges that there was a robust system of review and therefore that public inquiries were not necessary.

    Resulted in Part 8 duty on LSCBs to undertake formal inquiries into serious cases.

    Government guidance

  • People Need People Consulting Realising the potential in human services

    Government guidance 1970 Battered babies DHSS 1980 Child abuse: central register systems DHSS 1986 Working together: arrangements for

    interagency co-operation for child protection DHSS 1991 Working together 1999 Working together 2006 Working together 2010 Working together 2013 Working together 2015 Working together

  • People Need People Consulting Realising the potential in human services

  • Other sectors

    1997 A New NHS: Modern; Dependable DH 2000 An organisation with a memory: report of an expert group on learning from adverse events in the NHS (DH) 2001 National Patient Safety Agency (DH) 2003 Keeping Children Safe (DH) - CDOPs Aviation International experience

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  • A new direction?

    Munro articles (19962008) systems approach New government Climbi impact Ofsted reviews Munro reports (2010-2011) Publication or not? Revised guidance National Audit Office (2016)? An industry or a service?

    People Need People Consulting Realising the potential in human services

  • Factors shaping SCR impact

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    The type of case (severity and death do not

    always lead to public outcry). The response of the local agencies - how they

    handle the case in public. How the response is perceived by the public -

    whether this is credible or defensive - increasingly whether there is a sufficiently sincere apology.

    Other news on the day of publication (impact of social media?).

    Whether local politicians see scope for political advantage.

    Whether national politicians or media see political advantage or Ministerial exposure to risk

  • Observations

    People Need People Consulting Realising the potential in human services

    UK experience consistent with other English

    speaking countries learning or blame? Serious case reviews have had a major impact on

    social policy and development of childrens services

    Research and evidence has also had an impact but serious cases have shaped perceptions more than anything else

    SCRs have not addressed the organisational context system which is perhaps why learning appears less effective repeating the same behaviours (cf aviation) increased focus on learning

    Understanding of human behaviour still partial

  • Observations

    People Need People Consulting Realising the potential in human services

    England is not unique in grappling with these challenges. Indeed it is arguable that our structured and formal systems, which have called forth considerable professional and academic enquiry and energy, are more robust, effective and consistent than those of many (even most) other countries. Despite this, there is professional, political and public frustration with the outcomes of many reviews and therefore a clear need to explore more effective ways to understand the dynamics within organisations and between individuals, including family members and children themselves, and why these sometimes result in tragedy but much more frequently provide positive support to people in profound and difficult circumstances. Serious Case Reviews in Child Protection: Historical Reflections David N Jones (2015)

  • Observations

    People Need People Consulting Realising the potential in human services

    Why did this happen? is inevitably a legitimate question and one which demands a credible answer through the Serious Case Review or whatever alternative process is used. Scandals do not just happen. They are made. (Butler and Drakeford, 2005)

  • References

    People Need People Consulting Realising the potential in human services

    Butler, I. and M. Drakeford, (2005) Scandal, social policy and social welfare, Bristol Policy Press

    Butler, I. and M. Drakeford (2012) Social work on trial: the Colwell inquiry and the state of welfare, Bristol, Policy Press

    Jones, D. N. (2015) Serious Case Reviews in child protection - historical reflections, ADCS Virtual Staff College. http://www.virtualstaffcollege.co.uk/wp-content/uploads/historical_reflections_publish.pdf (Accessed on 30 October 2015)

    Virtual Staff College on behalf of partners (2015) The role of serious case reviews in improving the child protection system. Nottingham, ADCS Virtual Staff College. http://www.virtualstaffcollege.co.uk/wp-content/uploads/Role_Serious_Case_Studies_final_2.3.pdf (Accessed on 2 December 2015)

    http://www.virtualstaffcollege.co.uk/wp-content/uploads/historical_reflections_publish.pdfhttp://www.virtualstaffcollege.co.uk/wp-content/uploads/historical_reflections_publish.pdfhttp://www.virtualstaffcollege.co.uk/wp-content/uploads/Role_Serious_Case_Studies_final_2.3.pdfhttp://www.virtualstaffcollege.co.uk

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