Serious Case Review


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Two serious case reviews relating to the circumstances of the death of Peter Connelly (also known as ‘Baby P) were published for the first time yesterday.  I read through the second one (pdf) this morning but to be honest, gained no new information from it. I don’t know how different the first one was so I’ll rely on newspaper reports to inform me.

Interestingly, the second report was demanded by the Department of Children, Schools and Families when the first one was seen to be inadequate. I know for the interests of further knowledge I should read both but honestly, my heart isn’t in it.

I instead refer to Patrick Butler’s comment piece on the Guardian website which teases apart the issues of the two serious case reviews and the politicking that allowed a tragic situation where mistakes were made without any shadow of doubt, into a pillorying of social workers and social services nationally with the explicit agreement of Ed Balls and his government.

What did I learn from the second report? That the case was mismanaged and mishandled by numerous agencies, including social workers, doctors, the police etc.

This shouldn’t absolve social workers from their responsibility of course and there is absolutely no pleasure or pride in saying ‘look, they did it too.. it wasn’t just us’.

The difficulty is that joint-working seems like a far-sighted dreamland where people of with different professional and personal backgrounds come together to battle through their own assumptions and ‘walls of knowledge’ to share openly.

The fact that information sharing and multi-disciplinary working and the problems with it tends to come up with alarming frequency at reviews into deaths of children in care as well as adults who require the same protection, is an obvious result that greater information, better interdisciplinary working and just easier and more open systems will lead to better outcomes.

This is not a work of genius or anything new. The consideration is why hasn’t this been done and what is the best way for it?

IT solutions have proved to be clunky and unpopular.

I go down an old-fashioned but possibly (and this is where the problem comes in) more time-consuming route of both physically working more closely together across agencies but more importantly or perhaps more practically, getting to know who the people are in different agencies and build up those relationships of trust and routes of conversation that allow people to admit difficulties and cut down some of the bureaucracy.

I am of the mind that if police officers responsible for safeguarding came into our offices informally and regularly so we have names to contact and likewise if social workers had the time to meet with the GPs to discuss – and this is the important bit – not just individual cases as they arise but ways of working and getting to know each other as people, it would shore up the ease of the flow of information.

The difficulty is that this takes time and there is little value and even less measureable data on the quality of inter-professional working relationships.

In a world of measured outcomes and performance targets, we shouldn’t forget the human relationships, the informal conversations – the knowledge of where someone stands – when Mr X means ‘serious’ you drop absolutely everything and run but that Mr Y says ‘serious’ to mean anything out of his own personal comfort zone and Mr Z’s use of ‘serious’ is his baseline ‘normal’.

Greater trust and understanding of different systems is crucial. One of the things I did pick up from the SCR that I read relates to poor communication and a lack of understanding between the agencies, perhaps most notably between children’s services in Haringey and the health services.

In my opinion, the best way of tightening links formally is to tighten links informally. Professionals owe it to the public to work well together and they.. we.. work better with people who can relate to and whom we know personally. Systems set up for particular failures can often be weak because they might plug one gap  but miss another than comes out in a SCR the following year.

What needs to be fixed is the underlying distrust and professional silos across individuals who work in health and social care and then the information deficit and knowledge gap can be plugged both informally by Dr Y calling Mrs P who she met on a training course and sometimes chats to when she has some concerns that she isn’t quite sure about and by Mrs P sending a quick email to Dr Y asking to just pay closer attention to child X because she has a few gut feelings or is concerned about the relationship between child X and their foster carer.

It’s hard to quantify how it might happen in practice. That’s why I am no policy writer and just a humble practitioner. What won’t work is developing reams of policy documents in response to every mistake that is made.

We need to work on the structural failures rather than the failures of specific individuals and note that poor practice is sometimes just poor practice.

That isn’t saying we should be complacent, of course we shouldn’t – but sometimes the answers are just very straightforward.

More staff, better management and supervision and more trust and respect between professionals.

2 thoughts on “Serious Case Review

  1. Ian, is it safe to assume that at a child development clinic a full physical exam would be done. Where I work, that is certainly not the case. The doctor at the child development clinic would look at developmental issues such as gross and fine motor skills, cognitive development, speech development. If she had reason to suspect abuse, it would be referred to an ER doctor, particularly one knowledgeable in child abuse and non-accidental trauma. You may be underestimating the power of specialization here. (Of course, I have only had access to the one report you linked to).

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