Our long-awaited triennial review of Serious Case Reviews has now been published by the Department for Education and is available, along with a number of other resources, on the Research in Practice SCR website.
Over the past year Professor Marian Brandon from University of East Anglia and I have been working with a small team of researchers to review all 293 Serious Case Reviews undertaken by Local Safeguarding Children Boards between 2011 and 2014.
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A Serious Case Review is a local enquiry carried out where a child has died or been seriously harmed and abuse or neglect are known or suspected, and there is cause for concern about professional working together. This study is the fifth consecutive analysis of Serious Case Reviews in England undertaken by our research teams dating back to reviews from 2003-2005, and represents one of the largest national analyses of serious and fatal child abuse and neglect anywhere in the world.
I have been really inspired by this research which I feel gives us some extremely helpful insights into the nature of severe child maltreatment and what we – as professionals and as a society can do to help prevent it and to intervene where appropriate to protect children and support families.
No increase in child maltreatment fatalities in spite of huge increases in child protection activity
The data demonstrate that there has been an increase in the number of Serious Case Reviews carried out since 2012. However, this does not reflect any increase in actual numbers of fatal cases and is set against a backdrop of a steady year-on-year increase in child protection activity. There has been no change in the number of child deaths linked directly to maltreatment and a reduction in the fatality rates for all but the older adolescent age group.
Serious case reviews 2005-14:
fatal and non-fatal cases by year
The research found an average of 66 deaths per year 
in all age groups, compared to 73 deaths per year in the previous study from 2009-2011. Fatality rates had fallen from 4.67 to 3.78 per 100,000 in infants, but had risen from 0.31 to 0.65 per 100,000 in those aged 16-17. In the same time period, the numbers of referrals to children’s services in this country had risen from 609,000 per year to 619,000 per year.
Children falling below the threshold
As we explored these data in detail, it became clear that only a small proportion of those children suffering severe or fatal abuse and neglect were subject to child protection plans at the time of their death or serious injury (just 12%). However, over two thirds were or had been known to children’s social care at some point prior to the incident. These findings, along with our detailed qualitative analysis, suggest that once children cross the threshold for child protection services, they tend to be well protected, and that we have good child protection systems in place for managing some of these complex cases. However, there are large numbers of children and families who simply do not meet those thresholds, yet nevertheless are vulnerable.
“Throughout our review, we encountered examples of creative and effective child safeguarding. Examples of poor practice were also identified, involving failure to follow guidelines; an absence of safeguarding systems; barriers to effective co-working; or failure to recognise or act upon safeguarding opportunities. These apparent failures, however, need to be seen in the light of the effective safeguarding work that takes place across the country on a daily basis.
For many of these children, the harms they suffered occurred not because of, but in spite of, all the work that professionals were doing to support and protect them.”
Characteristics of the children and families
In keeping with previous research, we found that most, but not all, serious and fatal child maltreatment takes place within the family with children living at home or with relatives.
Babies and young children are inherently vulnerable and dependent, and features which mark them out as especially fragile place them at higher risk of abuse and neglect. However, there is a second peak in adolescence. By adolescence the impact of long-standing abuse or neglect may present in behaviours which place the young person at increased risk of harm. Almost two thirds of the young people aged 11-15, and 88% of the older adolescents, had mental health problems. Some young people responded to adversity by engaging in risk-taking behaviour including drug and alcohol misuse and offending. Others are placed at risk through sexual exploitation.
“We found that the vulnerability of adolescents was often overlooked because they were considered to be already adult or thought to be resilient, when taking time to listen to them or to understand their behaviour would have revealed the extent of their difficulties. This was often the case with the young people who were sexually exploited and also with many of the young people who took their own lives”
Cumulative risk of harm
One of the most important findings in our research has been the cumulative risk of harm to a child when different parental and environmental risk factors are present in combination or over periods of time. This particularly relates to domestic abuse, parental mental ill-health, and alcohol or substance misuse, but it also includes other risks such as adverse experiences in the parents’ own childhoods, a history of violent crime, a pattern of multiple consecutive partners, acrimonious separation, and social isolation.
Cumulative risk of harm:
the number of families experiencing multiple problems
Implications for practitioners
The primary aim of a Serious Case Review is to learn lessons in order to improve inter-agency working to protect children. In this research, we were able to identify a wide range of lessons for practitioners in different agencies, for managers and policy makers, and for our wider society. A lot of these revolve around learning to listen: to children and to families, and to other practitioners. The research has emphasised the importance of safe and trusting environments for children to be seen individually, speak freely, and be listened to; of treating parents with openness and respect; and for moving from incident or episodic service provision to a culture of long-term and continuous support, recognising that many of these situations are complex and ongoing.
“Adolescents may struggle to express their needs or feelings, or to engage effectively with services, and there are dangers of older adolescents falling between child and adult services. Importantly, children and young people may demonstrate ‘silent’ ways of telling about abuse and neglect through verbal and non-verbal emotional and behavioural changes and outbursts.”
We have, in conjunction with Research in Practice, produced a series of practitioner briefings for different professional groups, including health professionals, education, social services and police.
These are available, along with an introductory video, the full report, and a number of other resources on the Research in Practice Serious Case Reviews website:
http://seriouscasereviews.rip.org.uk/
Marian Brandon and I will be discussing some of the key findings of the research in a webinar this Thursday from 12.00-13.00. To register for the webinar, click here. Places are limited, so book early.
Over the next few weeks, I will be posting more blogs highlighting some of the different findings from our research. To keep up to date with these, and with my other blogs, click on the link below: ‘notify me of new posts by email’.
