Best Practice

Serious case reviews: Safeguarding trends and crucial lessons for schools

Pastoral issues Behaviour Safeguarding Pupil wellbeing Mental health Attendance
An analysis of serious case reviews offers vital insights into safeguarding trends as well as key lessons learnt that all safeguarding professionals should be aware of. Elizabeth Rose explains


The report Learning for the future: Final analysis of serious case reviews 2017 to 2019 was published in December and is the last document in a 21-year series of reports examining serious case reviews (SCR) into incidents where children have suffered non-fatal serious harm or died (DfE, 2022).

This final analysis looked at case reviews published between 2017 and 2019. It is the final report of this kind because SCR processes have now been replaced by a new system of rapid reviews, national reviews, and local child safeguarding practice reviews.

This final document, like the nine reports before it, shares findings and trends that are useful for anyone working with children to understand, as well as points for learning, consideration and development.


Background

The purpose of this report is to establish commonalities between SCRs and to understand the challenges faced within child protection practice in order to draw down learning. The report looked at 235 cases that proceeded to a SCR, following serious harm or the death of a child or children. Some overarching findings included:

  • Domestic violence was reported in 55% of SCRs.
  • Mental ill-health, particularly for the mother, featured in 55% of SCRs.
  • Parental alcohol or substance misuse were each noted in 34% of the SCRs.
  • Mental health problems were reported for 69% of the young people aged 11 and over.
  • Alcohol misuse was reported for nearly 30% of the over-11s, and drug misuse for more than 40%.
  • A quarter of the children in the SCRs were reported to have a disability prior to the incident.
  • Neglect featured in three-quarters of the reports and poverty in nearly half.

A further point which is important to stress in staff training: most serious or fatal maltreatment occurs within the family home, involving parents or other close family members.


Characteristics of children

The review also considers the characteristics of children involved in the SCRs. This analysis found that a total of 131 SCRs (57%) involved boys and 103 (43%) girls, as well as the following:

  • 57% of the children had current involvement with children’s social care, 19% were previously known but their case was currently closed and 23% had never been known to social care.
  • A total of 86 children (37%) were aged under one year. This continues to be the age group most commonly featured in SCRs.
  • Children over the age of 16 make up nearly a fifth of the cases, which makes this cohort the fastest growing group represented in SCRs.
  • Sudden unexpected deaths of infants (SUDI) and suicide are again the largest causes of death.
  • In terms of background, 73% of the children were white British, 10% were black/black British, and 9% were from mixed racial backgrounds.


Characteristics of families

We often talk about “vulnerabilities” in safeguarding training and practice, and those working in schools have ever increasing knowledge and expertise about wider issues that may have an impact on a child’s wellbeing or safety.

The analysis found that domestic abuse and violence, parental mental health issues and parental alcohol and drug misuse feature heavily in SCRs (see statistics above), as well as poverty, parental separation, transient lifestyles, multiple partners, and social isolation.

You may be familiar with the term “trio of vulnerabilities”, referring to domestic violence and abuse, parental mental health issues, and parental substance misuse – it has long been known that these three factors increase the risks to a child and this review once again found this to be the case.

When assessing risks to children, these findings once again highlight the importance of understanding a child’s lived experience while considering wider factors within their life to ensure that they (as well as their families) are receiving adequate, appropriate, and effective support.


The issue of neglect

This report focuses on three main areas – neglect, challenges in practice, and listening to the voice of the child – because these are themes that have been persistent throughout the 21 years that these deep dives into SCRs have been in place.

It is particularly important to note that neglect featured in three quarters of the reports, and the issues and findings around this are discussed in detail in the document. The report finds that there are several problems with the identification and response to the issue of neglect, including:

  • Low expectations of parents because of poverty and deprivation. In some cases, families were not challenged because neglect was “normalised” or chronic and those working with families in poverty do not always challenge because of a family’s circumstances, where they would in other contexts.
  • A lack of willingness, time, or ability to identify the indicators of neglect.
  • Poverty was found to “inhibit” professionals from assertively interacting with children and responding to clear risks and, in some cases, those working with families felt powerless to do anything about poverty.
  • Understanding that neglect is often accompanied by physical, emotional or sexual abuse/exploitation.
  • Professionals focusing on practical tasks to “solve” the problem – such as sourcing baby equipment or addressing housing issues – rather than responding robustly to neglectful parenting or issues such as domestic abuse.


Points for our own practice

The analysis is extensive and looks at child protection practice as a whole. As such there aren’t specific recommendations for schools. However, key learning and points to revisit can be extrapolated from the findings to further strengthen our approaches in school. In order to respond to these findings in your school you could:

  • Consider staff training, particularly around the issue of neglect. This should start with the designated safeguarding lead – how confident is the DSL in identifying neglect, maintaining high expectations of families even with significant social or economic issues, and can they challenge other professionals when expectations are not high enough? Staff should also be trained to be able to identify signs and symptoms and know what to do if they are concerned.
  • Build in reflective practice to consider if expectations remain high for all children.
  • Analyse your safeguarding data and look at trends or patterns – particularly in relation to neglect.
  • Ensure that the safeguarding team has enough time and space to work effectively, including time to attend multi-agency meetings, develop robust plans for support and challenge with other professionals and discuss children and families in enough detail.
  • Review your understanding of children’s daily lives (lived experience) regularly. Have you given children regular space to talk about what their lives are like outside of school? Do you revisit this with vulnerable children regularly?
  • Consider all angles when working with a child. If a child has poor attendance, could this be an indicator of neglect or abuse rather than a compliance issue? If a child is displaying challenging behaviour, is this because they are communicating something about their lived experience? Taking a “safeguarding first” approach means that we can create spaces that may make it possible to intervene early if a child is being harmed.


Final thoughts

This analysis looks at cases where children have been seriously harmed or have died. Your local authority will also have locally published safeguarding practice reviews that may assist in developing your knowledge and it is likely that there will be resources accompanying these that can be used for staff training.

In addition, there will be many children who you have worked with and who have been protected and supported and it is important to take learning from these cases as well.

Having space to reflect on your own working – thinking about what went well and why – is extremely valuable and helps, alongside looking at what can go wrong, to build effective strategies and ensure that children are better protected going forwards.


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