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Analysis: Patchy access to case reviews hampers learning from Baby P cases

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Kicked into the long grass: learning from tragic cases are hampered by a lack of transparency. Image via Shutterstock

The Baby P photo is an unhappily iconic image: a blond toddler in a vivid blue sweater that matches his eyes, his bare feet just visible on the black and white floor tiles, reaching up towards the camera. His left cheek is oddly swollen.

Shortly after the photo was taken, Peter Connelly was found dead in his cot on August 3 2007. An autopsy found the 17-month-old had over 50 injuries, including a broken spine, broken ribs and a missing finger tip. His mother, her boyfriend and her boyfriend’s brother were convicted of causing or allowing the death of a child.

The case appalled the nation – particularly as a succession of social workers and doctors had failed to prevent the brutal and sustained abuse. Then-prime minister Gordon Brown swore to do ‘everything in his power’ to prevent such a case happening again.

They always talk about learning the lessons, but if you can’t get hold of the review, how can you learn from it?’
- Nushra Mansuri, British Association of Social Workers 

But such a case had happened before – in the very same borough, Haringey. In 2000, Victoria Climbié, an eight-year-old from the Ivory Coast, died in a London hospital of malnutrition and hypothermia. A pathologist found her body scarred with 128 injuries. Social workers, police and doctors had raised concerns about her welfare, but nothing had happened.

Haringey Council’s child protection department was hauled over the coals for failing to learn from its mistakes. Yet five years after Baby P’s death, one of the key tools for learning from tragic cases such as Peter’s and Victoria’s is dogged by a lack of transparency.

Serious case reviews are in-depth investigations, carried out every time a child dies and where neglect or abuse are believed to be the cause. They can also be carried out when children have been seriously harmed – for example, after a paedophile ring was found to be operating in a Plymouth nursery.

The Department for Education, which oversees children’s services, says the purpose of a serious case review is ‘to establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children’.

New guidelines introduced by the Coalition mean councils should usually publish the detailed report rather than a summary.  This came after David Cameron said in opposition that only publishing summaries gave the ‘impression of an establishment stitch-up’.

Every two years, experts comb through the reports. The latest biennial review, which looked at 184 reports, said case reviews offered insights into the ‘traps that professionals can find themselves in’. This report found that 10% of children who died were in a child protection plan at the time of their death.

‘What these reports show is that large numbers of children who are subject to serious case reviews have been neglected, and that many of them were not receiving support at the time,’ said Shaun Kelly, head of safeguarding at Action for Children.

Reading the full reviews is illuminating, and it’s easy to see how a social worker who has read about a mother who gave unrealistic explanations for a child’s bruises might be less readily similarly fobbed off, for example.

But to learn the detailed lessons, social workers must be able to access the reports that are most relevant to them.

Out of reach
‘At the moment it’s often hard for professionals to access serious case reviews – they always talk about learning the lessons, but if you can’t get hold of the review, how can you learn from it?’ asks Nushra Mansuri of the British Association of Social Workers.

There is no specific guidance for the 148 safeguarding children boards as to how serious case reviews should be published; they are sometimes available only on request due to confidentiality concerns, or removed from the board’s website after being up there for a while.

To request a serious case review, first you must know it exists. There is no centralised, complete register that professionals or the public can turn to. This means that unless an incident has received widespread press coverage, a social worker in Crewe could easily miss the chance to learn from a case that took place in Colchester.

This week the Mirror and the NSPCC released research showing around 100 further toddlers have been killed since 2007, for which the charity combed through serious case reviews. ‘We have concerns that lessons from serious case reviews are not changing frontline practice because the same issues keep cropping up,’ said an NSPCC spokesman.

‘There are many good, highly motivated professionals doing an extremely difficult job but they need to be supported by a system that allows a co-ordinated approach to child protection. Only then can we start to plug the gaps which sometimes leave children exposed to serious harm.’

A Department for Education spokeswoman said new guidance means more reviews will be available in future. ‘We have made it clear that serious case review reports should be written from the outset with publication in mind and give as full an account as possible about the things which went wrong in a case and why. This is a fundamental requirement in the new guidance.’

The government is now consulting on new rules that she said would eliminate ‘the need for redaction of reports, so when it comes into force there should no longer be concerns about Local Safeguarding Children Boards holding back information.’

Last year the Munro Review of child protection recommended that serious case reviews should include good practice as well as awful cases, and should focus on processes rather than assigning blame.

But Professor Munro did not touch on the issue of transparency, or on the access that professionals have to such reports.

The NSPCC’s research this week is a reminder that only a fraction of child deaths achieve the notoriety of Baby P’s; only a handful end up with a haunting photo that gets plastered over the papers. Serious child abuse is impossible to eradicate entirely – but unless social workers, doctors, teachers and other professionals can easily learn what went wrong, such cases are harder than ever to prevent.