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Are we learning anything?


A discussion on Serious Case Reviews, Keanu Williams and Professor Ray Jones.


Tragically, Serious Case Reviews seem to be piling up at the moment. We have just had Daniel Pelka’s, Keanu Williams’ came out last week. No doubt we will have one soon on Hamza Khan and I have already read today of another mother charged with the death of one child and neglect of another three. As we know from recent articles, most social workers don’t manage to find time to read them, and anyone who does read them finds the same themes continuining to crop up.


The Keanu Williams one is here



{This one actually identifies really early on that Keanu’s death could not have been PREDICTED, but that he ought to have been identified as a child who was at risk of significant harm. We actually know from reading the Serious Case Review that his social worker took the case to Child Protection Conference, with a report identifying why Keanu was at risk of significant harm and why he should be placed on the register and have a child protection plan – the Conference took a different view and decided Keanu was a child in need, instead


“A well-argued social work report, stating the risks and concerns that had been assessed for Keanu, formed the basis for the Child Protection Conference. However, the Conference concluded that Keanu did not require a Child Protection Plan but was a Child in Need requiring a family support service such as the nursery place as the focus of the meeting changed.



The outcome of the Child Protection Conference led to a loss of focus on Keanu, because the Child in need services moved the attention towards practical matters such as the lack of settled accommodation and provision of the nursery place.


Paradoxically the services failed to consider precisely what the impact was on Keanu’s development and welfare of being moved around and cared for by many different people.” }


But what also interested me was Professor Jones take on Serious Case Reviews, as reported in the Daily Telegraph



(A brave thing to say, since the gut instinct when reading “we have no more learning left to be done” is  to retort – then why are these cock-ups continuing to happen?)


I can sort of see where Professor Jones is coming from. With every child death of this kind there is a clamour for ‘lessons to be learned’ and ‘we must ensure that no other child has to go through this again’  and of course the media clamour that someone in authority must have bungled and they should be identified and sacked. That’s backed very often by central government (at least some element in David Cameron’s rise to power was on his tough handling of Baby P) and their demand that all Serious Case Reviews should be made available to the media and public.


The media of course, take a long and dense document, and strip out the bits that show that “Professionals had X chances to save baby Morris” , because that’s what makes the good story. Never mind that any of those chances would only have been a real chance if (a) the professionals could see into the future or (b) were so risk averse that they were removing children with similar histories left,right and centre, most of whom would have been okay at home. 

I will defend professionals from unfair criticisms that they didn’t accurately predict the unpredictable, but mistakes do get made in child protection and where those mistakes are due to sloppy practice or laziness then those responsible ought to be dealt with. If a child died because professionals didn’t make referrals, or the referrals got ignored or visits weren’t made (or you were a paediatrician that can’t spot a broken back), then yes, those involved ought to be rethinking their career – I just don’t believe that having failed to identify that of your thirty kids with bruises and low-level neglect THIS was the one where it was going to go awfully wrong is that sort of mistake.


{On the same basis, given how many times serial killers are described as ‘quiet blokes who wouldn’t harm a fly and was nice to his mum’ we could be cutting down serial killing by imprisoning in advance every person like that… Or blaming the police for every such bloke who goes on to commit murder, on the basis that it was obvious that he would turn into a serial killer one day}



And of course all of those Serious Case Reviews start with the known fact that the child died, and works backwards from that foundation, which allows them to in part discount the very thing that makes social work hard – the tension between family preservation and child rescue.


If the child has died, then we KNOW that the child ought to have been removed from home before then and that the family ought not to have been preserved. So the Serious Case Review can just look for any opportunities professionals had to break up that family unit and rescue the child.


Here are the things that a Serious Case Review CAN potentially do


(a)  Handwringing  (lessons have to be learned)

(b)  Finger-pointing/witch-hunting

(c)  Identifying whether there were flaws in local procedures, or in following those procedures

(d)  If there have been serious and genuine bad practice or negligence, taking action as a result

(e)  Extracting lessons of general principle to be learned in other cases


I think that our current system is pretty good at (a), not bad but not great at (b),  pretty poor at (d), okay at (c)  and it THINKS that it is very good at (e) but actually isn’t.


So I agree with Professor Jones that most of the ‘lessons to be learned’ are already well-established and well known. We know in advance that common themes from an investigation into a child death will include


(i)            That information held by different agencies was never really shared properly and that had one person known all of it, different decisions could have been made

(ii)          That a rule of optimism was applied

(iii)         That a history of low level neglect or bruising continued over time and nobody took it seriously enough

(iv)         That the voice of the child was overlooked or the child simply wasn’t seen enough

(v)          That too much of professional attention was focussed on the adult



And that having report after report say that, really doesn’t help.


I don’t think that the Keanu Williams one is particularly bad, it is fairly typical of these reports (and is to my mind, a better one than Daniel Pelka’s, for example)


So do Serious Case Reviews tell us anything at all? Or are they just handwringing and witch-hunting?


[I would disagree with Professor Jones on two categories of inquiries  – I think that the Victoria Climbie inquiry did genuinely tell us new and important things about the dangers of walking on eggshells around respecting differences in culture and losing sight of child protection, and I think that all of the inquiries relating to situations where ‘child rescue’ went too far – Rochdale, Cleveland, Orkney Islands, tell us a great deal of significance about what happens not in an individual case where a judgment call went wrong but when there is a systematic failure to properly balance evidence, risk and the desire to keep families together]



I would myself like to see Serious Case Reviews focussing on whether what had happened in the case throws up issues of poor practice amongst the professionals involved (not that they failed to predict the future correctly, but whether they weren’t alive to the possibility that their prediction might be wrong) or where local procedures need to be improved, and shy away from the ‘broad lessons to be learned’ unless it is a case like Victoria Climbie which genuinely has something new and important to say.


Frankly, the only real way to tell whether it was bad luck or bad social work in a Serious Case Review is to run them blind – the board are given information on two cases with children of similar ages and length of professional involvement. One is the child death in question and one is a child who remains at home unharmed.  If child deaths are caused by bungling professionals missing the obvious, then the Serious Case Review ought to have no problem at all in identifying the bad social work that led up to the child death, without knowing which case is which.


About suesspiciousminds

Law geek, local authority care hack, fascinated by words and quirky information; deeply committed to cheesecake and beer.

20 responses

  1. I agree with Professor Jones that SCR’s have become formulaic, and as you rightly work backwards from the catastrophe for the child, when it became known to the authorities. SCR’s tell us WHAT happened, they furnish us with a chronology of events with professionals already involved……but not WHY and HOW, and that process must involve collecting the evidence of all those frontline professionals involved, and asked leading questions as to what options were explored at the time.

    Mr Timpson has just asked for this information in an addendum to the SCR. We might find out if there were resource implications in the decisions NOT to act at certain points in the chronology.

    I worked in social work for nearly 40 years and came across a rough cross section of the characteristics of social workers….some good…some not so good…..some with more learning to do with good support and supervision …..and some extremely defective individuals who should never have come into social work in the first place. Unfortunately a large number of these defectives quickly apply for management posts where their capacity to damage the core task of the organisation is that much greater.

    I do not believe that any frontline social worker has any autonomy left at all, and that includes Cafcass. Everything must be run past a manager and my rule of thumb is one good manager who possess the necessary domain knowledge and who doesn’t fall back on oppressive practices if a subordinate questions decisions, to 4 poor ones. When climbing further up the greasy pole the number of poor to good increases, and this failure of leadership deeply colours the culture of organisations, and infects service delivery.

    When dramatic increases in caseloads with less resources are introduced as they have been throughout our child protection system, on top of the failure of leadership it gives birth to a condition called systemic dysfunction. If one joined up the dots and included all deaths, abuses and scandals involving children who are known to social services, as I have done over several years, it becomes difficult to say with any confidence that these are isolated incidents.

    We know how damaging negative cultures can be if allowed free reign, but the growing evidence points towards service failure and organisation dysfunction in Child Protection as it does in the NHS scandals after all it is a self evidential truth that in a fully functional organisation if lessons are to be learned they would be learned. They would become a priority, but I will tell you now that in my nearly 40 years of practice not one manager has brought nor disseminated the findings of a SCR to me and my colleagues and a number of my managers attended the Local Safeguarding Children’s Boards. Good social workers read what they could through their own research and interest.

    Sorry for running on at length but more handwringing and scapegoating just will not do, and we await further SCR’s including the one on the Philpott family which is also due.

  2. I need to add one detail, in that the additional information required by Mr Timpson is in relation to Daniel Pelka’s death. If he is brave enough he will add this requirement to all future SCR’s

  3. One think that jumps out of the page about the Keanu Williams page is that she was bailed and he was remanded in custody – although in due course she was convicted of murder and got life and he was convicted of less serious offences and got a suspended sentence. Of course I don’t know how the evidence looked at that stage but I would like to know what line the CPS took on bail. Sexist prejudicial stereotyping at work?

    • Yes, it does seem odd in retrospect. I don’t know enough about the bail hearing, she may have been less of a flight risk or less of a risk of interfering with witnesses I suppose, but it certainly gives a perception that there was a gender bias that it ‘must have been the bloke who did it’

  4. Front line staff must do as they`re told – called working together in partnership in the best interests of the child or other such waffle. If front line staff don`t do that, they will lose their jobs. See the list of whistleblowers who lost their jobs. It did not work that way twenty years ago when social workers were more involved with their clients and respected. Since MANAGERS have moved in it has become a living nightmare for everybody – but most of all a disaster for children. Don`t quote disasters, just look at the figures and the poor babies and distraught children who will never know their families.They`re increasing and with no good outcomes.

  5. In the area that I live it was found there was a serious management problem. Nothing so far has been done. The same managers who hand pick certain front line staff who will work to the orders of the bad management.
    What happens next is that numerous innocent parents are losing their children in order to protect the LA image.
    While at the top of the tree was a Director who had a special interest in drug rehabilitation which meant drug abusers were in the main allowed to keep their children and receive vast assistance, including free holidays from the social services departments.
    This obviously proved upsetting to the many innocent and decent parents who may have rung the social services department themselves for assistance with a problem only to have the social services go on to make many false reports and lose them their children.
    Sir James Munby has the first and most important answer. Open up the family courts and make them transparent and accountable. Get rid of cases that have obviously gone in the wrong direction taking up vast resources away from those children who are without doubt at risk of serious harm. Let the public have a say in where its going wrong. After all we are the neighbours and within the community of where these child murderers live. Build a social services network where social services are trusted, not hated. (That alone will take some doing given their history)

  6. As for the rest, I totally agree with Boxerdog. Too many bad apples handpicked by bad managers in order to protect NOT the children but the image of the LA. Just read the outcry from social services and their protective army when Sir James Munby made his comments.
    Picked up from every internet site and social work community was. Ooh dont look behind our curtains, dont blame us. There are reasons you know why we think family courts should remain closed etc. This is a typical reaction of the guilty.
    Sir James Munby got it right and was also courageous in voicing his opinions. He obviously has the interests of children above that of anyones ‘image’.
    And in the long run by being courageous, Sir James Munby will spearhead the trust in families that was long ago lost and the trust in a social services that has fallen into the most hated ‘profession’ by increasing numbers of the general public.
    Secondly, it would not go amiss, to cross reference previous cases, not just the SCRs. This alone will show serious flaws where so many innocent families have lost their children and where the others slipped through. Look for these main factors. perjury, contempt of court, failure in duty of care, LAs bringing an onslaught of so called other professionals into the case.

  7. When that is done, go back to the SCR cases. Look for drug abuse, look for people who manipulate, look for cases where numerous calls to that address have not resulted in access to the child areas. Perhaps, as in too many SCRs the people were not whistleblown on by neighbours, perhaps the neighbours were too frigtened to, or just did not want social workers on their doorstep. (Too many innocent families losing their children once a social worker gets through the door.)
    Yes, trust is a very important word and has a very important meaning. And LAs have certainly blown that one.
    When I read this post back before its posted, one word sticks out. Manipulation. Read the SCRs, read and cross reference cases where manipulation against innocent parents is obvious. Read posts from those who whistleblow on the system or certain social workers. Manipulation rings out. From managers, from LAs, from protectors of ‘image’ from certain media who report and picture over and over again a child death, seriously important the child death is it does nothing but give the manipulators the excuse to destroy more innocent families while at the same time NOT protect the children where it is needed.

  8. And what did the SCRs find out, the people who murdered their children (and children have also been murdered by foster carers, carers and adopted parents) that those responsible were clever manipulators, just as those who destroy innocent families, And what comes with people who manipulate, power and fear.
    Hence no-one trusts the social services and children will always be murdered.

    The only hope for ALL children is Sir James Munby. The only one with the courage to force the changes that are needed.

  9. Common factors, fact finding and history.

    SCRs and Traffic lights. How to keep out of the red. A new blueprint for child protection. (If I dare be so bold)
    1/ State care. Most children who have experienced care have already suffered loss which often reflects in the inability to form long term or positive relationships.
    It would be naive to believe that these children/young people have not faced forms of abuse within the care system.
    Leaving care – All care leavers should have a key worker until the age of 25yrs who is a source of emotional and practical support.
    2/ As part of their leaving care package and during the last stage before rehabilitation to either family or accomodation, every young person should be given a parenting course, anger management course and a course based on the same principles as that given by the courts for minor offences. The later course show and teach the consequences of offending behaviour, drug and alchohol abuse and impact of crime.

  10. SCRs and traffic lights – How to stay out of the red.
    Common factors, fact finding and history.

    Drug and alcohol addictions. (Not to be confused with malicious allegations)
    1/ Any parent who has proven (multi agency fact finding) drug or alcohol addictions regardless of whether it is GP treated i.e. with substitutes should have the children living in respite (not through family courts) until such time that they are CLEAR of drugs or alcohol addiction. Regular supervised contact should be arranged for the children with age appropiate explanations as to their alternative arrangements.
    2/ Any person who has also experienced care should have counselling and the same packages as for the leaving care on the near completion of their rehap.

  11. History not known – How to stay out of the red.

    No child brought into the country should have a ‘relative’ or ‘friend of family’ care for them without being tested for a fostering role. (Multi agency finding of facts)

  12. NOTE Out of the thousands of ex care leavers rehabilitating back into the community every year only a few become child murderers or abusers. No more than the general population, including those that are foster carers, carers or adopted parents. But a high number do leave for another institution, being prison.
    A high number of care leavers also end up with drug and alcohol problems.

    So wouldnt it be a good idea if :-

    Only children were put in state care because they would be better off than with their own birth families.
    At the moment it is clearly NOT the case for many.
    That social work became the front line work it should be preventing abusive situations and family crisis and giving helpful and practical intervention where needed. Ultimately firing up the trust so needed between social work and communites.

  13. Pingback: Are we learning anything? | Children In Law | S...

  14. Keanu :- How to prevent a child murder.
    The mother.
    Having read this tragic and heartbreaking death, it forced me to understand the life of the mother. A life in or in and out of care, since a young child. No doubt a knowledge that any children she may have will be under the scunity of the social services.
    Of course it would be helpful to read all of her case notes from foster carers etc. To have cross referenced all the family court statements and social worker reports. To understand the dynamics of the extended family.
    But one thing is obvious, few survive the care system too well. It does not teach stability, parenting or deal with all the emotions and feelings of abuse within it or out of it.
    Nor does it teach to love, the importance of respect and it criminalises not only the parents (rightly or wrongly) it also criminalises the child. It also brings shame.
    So with all that on her shoulders, where does she go. Back to the family, who may or may not ave abused her, back to negative relationships, having children because she wants to find

    or give something she never had. Men treat her bad, she has no self respect or self esteem. She becomes an angry person, unable to break a cycle of abuse, neither to herself or to her children.
    So, perhaps there should be 2 SCRs. One on the mother and one on her dead son. As the first could have prevented the second. But who cares when the child is no longer a child. Someone has to if there is any chance of preventing another tragic case of murder.
    I can only applaud those who leave care and are strong enough to not only deal with their past but do everything in their power to move on, be good parents and manage a stable relationship. But then, some of those are broken up too by a incomp

  15. cont. incompetent social services departments only too ready to criminalise.
    I would like to see a massive shakeup of not only opening family courts but making sure that ALL children who HAVE to be looked after by LAs, have social workers that can ensure that the care of children in LA care exceeds that which can be given by the birth parents or family.
    So far, this has often NOT been the case. And as stated before it should also include everything writen above. That children in care have a standard of learning that would be expected in a family home. One day they will become parents themselves.
    And for this to happen, there has to be CLEAR legislation that demands this. And to make sure of it, remove ALL carers, social workers and foster carers immunity to prosecution.
    Harsh, but what is a murdered child’s life worth…

  16. £3.500 per week, a private children’s home. What does the child get from that and how much of it goes to the owners bank account.
    Example. Child has a bedroom, second hand and old funiture, worn out bedding, few clothes. Continuous rotation of various carers, all writing daily notes about the young person. Little interaction. Child gets treat on Fridays, takeaway or McDonalds. Education exists of a few hours a couple of days a week because its registered to supply the education.
    On top of that they give a few hours a week with each child in the house. This is to ‘prepare’ them for leaving care. They are shown how to choose a fitted kitchen or how to furnish a house. Meals are provided but most are not allowed in the kitchen. (Some units even insist on plastic cultery)
    But look again. What would you teach a child. Gardening, job seeking, financial, how to care for other children, babies, seeking GPs for health issues, registering with dentists, how to cook and care for yourself, how to deal with housing problems, how to save money on a budget, making time to follow interests, extra education and where and how to obtain it. Showing care and respect for elderly relatives, Making sure you are careful in your friendships or choosing friends carefully, birth control and the list is endless. What does the inspector inspect when looking at children placed in children’s homes etc. Where are the flaws? £3,500 per week per child,

  17. Foster care. Some private agencies claim up to £1000 per week per child. LAs quite a lot less. Every label put on the child is an increase in payment.
    What does the child get for this?
    A room, sometimes shared, sometimes other foster children. In total a foster carer can be receiving more than a £1000 per week for 1-3 children. The child will get a small amount of pocket money. Again may be treated to a takeaway or McDonalds. But some will be given only the basic of meals. Perks for foster carers, respite care for the children giving them breaks whenever its needed.
    Holidays, some children will go on holiday with their foster carers, at the same time there will be holidays where the children are excluded to give the foster parents time out, while the children go to respite care. Unsettling for children as if you add up the respite care, children can be forced to live with hundreds of ‘strangers’ as well as be moved many times in their time in care.
    These children often do not even own a suitcase, often packed off at short notice, with their belongings in a black plastic sack. Often they do not even get all their belongings.
    They lose out on education. They are prevented from many activities of their interest, due to health and safety reasons. Some are not allowed pets, and if they are, any lack of interest, no matter how short and the pet is taken away.
    Financially what do they get. Are savings made to help them in the future. Are the children taught everything they would be in their own home concerning finances.

  18. Look at a foster carers home. Have they had extensions built since fostering, are they taking more holidays than before, have they upgraded their car to a more expensive one.
    Private children’s homes, are they buying more properties, what sort of lifestyle do they have and how many holidays per year are being taken.

    Adoptions, there are now more incentives than ever for adoption, even when its forced. This is the patch to fix a broken child protection industry where money abounds.
    Great for children if there is SERIOUS harm.

    So before we all jump on the bandwaggon on screaming for justice for murdered children, just spare a thought for all the children in care who have no need to be there and where they would have been better of at home even if that meant giving support. And by that I mean in the old fashioned sense where its a package of practical assistance, not ticking boxes. Where front line non manipulating staff and the whistleblower type can get on with real social care and the protection of children where needed.

  19. As for decent parents who have lost their children into care, a child death hurts more than most. They also know it is another excuse to hoodwink the public into believing that social workers should take no chances and remove even more children from their birth famiies, And most of the people who believe that, have NO experience of life in care OR understand the huge flaws in the social service departments.

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