Office for Standards in Education (Ofsted)
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The voice of the child: learning lessons from serious case reviews

Yesterday Ofsted publishes ’The voice of the child: learning lessons from serious case reviews’. This is Ofsted’s fifth report evaluating serious case reviews (SCRs) and considers 67 carried out between 1 April and 30 September 2010. The cases involved 93 children, 39 of whom died.

The report has a single theme: the importance of hearing the voice of the child. It provides an in-depth exploration of this key issue. It draws out practical implications and lessons for practitioners and Local Safeguarding Children Boards.

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

'It is shocking to see that too often children in vulnerable situations are not heard by those who should be looking out for their interests. That is why this report’s focus on listening to children is so important. The report shares valuable lessons that can help protect children and prevent such tragic incidents.

'I hope all involved in the protection of children will read the report and take stock of the importance of observing and listening to children, using different approaches to encourage children to speak openly and taking account of those who speak on their behalf.'

The report also looks at the roles of adults who are in a position to speak on behalf of children. It highlights where the concerns raised by fathers, grandparents, neighbours and even members of the public could have helped to protect children had they been taken seriously. For example, in four of the cases in this report, grandparents reported their concerns about the care of their grandchildren but this did not lead to effective action to prevent the serious incident.

Being alert to parents and carers who prevent access to the child is also a lesson that needs to be taken on board. Analysis of reviews found that practitioners often failed to make the connection between the difficulties that they themselves experienced when trying to see the child, and the likelihood that children in the family were experiencing stressful and abusive behaviour.

Another finding from the report was that children’s needs were overlooked because practitioners had focused too much on the parents, especially when the parents were themselves vulnerable. A focus on parents’ need for support can lose the focus on a child’s right to protection. In one case where this occurred, a young baby suffered skull fractures. The family was known to agencies due to the mother’s misuse of alcohol. The review found that staff in adult-focused health services should have established and assessed the impact of the mother’s drinking and depression on her childcare responsibilities.

Throughout, the report uses case examples from published serious care review executive summaries to highlight the importance and the complexity of some of these issues. It looks, for example, at how the experiences and feelings of babies can be better understood. It also identifies circumstances where children’s views were given a determining weight when they should have been balanced with other considerations.

The report has identified five key issues in these SCRs which ran through many of the cases considered:

  • the child was not seen frequently enough by the professionals involved, or was not asked about their views and feelings
  • agencies did not listen to adults who tried to speak on behalf of the child and who had important information to contribute
  • professionals were prevented from seeing and listening to children by parents and carers
  • practitioners focused too much on the needs of parents, especially vulnerable parents, and overlooked the implications for the child
  • agencies did not interpret their findings well enough to protect the child.

Notes for Editors

1. The voice of the child: learning lesson from serious case reviews can be found on the Ofsted website at

This report covers the evaluation of 67 serious case reviews carried out between 1 April and 30 September 2010. Sixty five cases focused on children and their families and two on adult perpetrators. This report examines the 65 cases which involved 93 children. Of these, 39 children died and 54 were involved in serious incidents.

The reviews under consideration here, and the evaluations, were conducted in accordance with the current statutory guidance set out in Chapter 8 of Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children.

Annex A of the report sets out the circumstances in which a Local Safeguarding Children Board must consider conducting a serious case review.

The review of child protection by Professor Eileen Munro is considering possible changes to the serious case review process, and Professor Munro has recommended in her interim report that in due course Ofsted should cease to have responsibility for the evaluation of serious case reviews.

Ofsted’s work in the evaluation of serious case reviews has had a positive impact in improving their quality but we have agreed that these should now end and have been suggesting this ourselves for some time. Ofsted supports the Review’s proposals for how SCRs are likely to be approached in the future to maximise learning and improve practice.

2. 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.

3. Media can contact the Ofsted Press Office through 020 7421 6574 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.

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