Office for Standards in Education (Ofsted)
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Learning lessons from serious case reviews 2009-2010

Illustrated with detailed case studies, Ofsted’s latest serious case review report, ‘Learning lessons from serious case reviews 2009-2010’  is published today.  The report looks at 147 serious case reviews (SCRs) evaluated by Ofsted between 1 April 2009 and 31 March 2010. SCRs are local enquiries into the death or serious injury of a child where abuse or neglect is known or suspected to be a factor.

Overall, the quality of the reviews themselves continues a strong trend of improvement, with 42% judged good, 42% adequate and 16% 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.

Each SCR may involve more than one child. In this year’s report, incidents involving 194 children were subject to a review. Of these, 90 related to cases where children had died and 104 to serious incidents. The most common characteristics of the incidents were physical abuse or long-term neglect.

The report found that of the 194 children involved, 119 children were known to children’s social care services at the time of the incident; 90 children were receiving services as children in need, of which 49 were the subject of child protection plans. Thirty one of the children who had died were receiving children in need services.

Christine Gilbert, Her Majesty’s Chief Inspector, said:

“There is a positive trend in how serious case reviews are being conducted and it is encouraging to see that more reviews are being judged good with fewer reviews inadequate. The case studies highlight the complexities of the situations which social workers and others are responding to. In undertaking these reviews, agencies have been able to reflect on what happened and learn from their experience. They have identified gaps in their approach and most important, have agreed actions to improve the protection of children and so reduce the chances of such serious incidents from happening again.”

A consistent finding from the reviews was that there had been a failure to implement and ensure good practice even though established frameworks and guidance were available.

One SCR, following the death of a three-week-old baby, illustrates the lessons which were subsequently learnt by one Local Safeguarding Children’s Board (LSCB) when established procedures were not implemented. The mother was well-known to children’s social services. A child of the father by a previous partner was the subject of care proceedings. Despite this, there had been no pre-birth assessment and the baby, who was the subject of the review, was not known to children’s social care. The child’s grandparents had raised some concerns but this information had not been acted upon by the mother’s social worker or by the health visitor. One of the multi-agency learning points for the LSCB was that the system for identifying vulnerable children had not been followed.

The report also found most of the reviews identified sources of information that could have contributed to a better understanding of children and their families. For example, some parents within these reviews were receiving support from adult social care, adult mental health, substance misuse, housing and probation. However, too often agencies involved did not share this information early enough.

Evaluation of the reviews also found that there was insufficient consideration of the child’s individual views and needs, and statements received from parents or other family members were not sufficiently challenged. In some cases this led to poor assessments by the agencies involved.

The voice of the child is not always being heard. One case concerned a 12-year-old girl whose mother had a long history of drug abuse and was known to social services. The girl suffered a serious sexual attack by an adult male known to her mother. The review found that there was only one occasion during their involvement when the girl’s views had been sought. Even though her views ‘shouted out so clearly’ from this one intervention, the review concluded that she was left in circumstances where she was vulnerable to the sexual attack.

Editor's notes:

1.       The report, Learning lessons from serious case reviews 2009-2010, can be found on the Ofsted website

2.       The report is the fourth report by Ofsted of serious case reviews evaluated between 1 April 2009 and 31 March 2010.

3.       The Office for Standards in Education, Children's Services and Skills (Ofsted) regulates and inspects to achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children's social care, and inspects the Children and Family Court Advisory Support Service (Cafcass), schools, colleges, initial teacher training, work-based learning and skills training, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for looked after children, safeguarding and child protection.

4.       Media can contact the Ofsted Press Office through 020 7421 6617 or via Ofsted's enquiry line 0300 1231231 between 8.30am - 6.30pm Monday - Friday. Out of these hours, during evenings and weekends, the duty press officer can be reached on 07919 057359