Learning from significant case reviews – March 2015 to April 2018

A report on 25 significant case reviews has highlighted that some agencies in Scotland did not always recognise or respond adequately or quickly enough in some of the most serious child protection cases.

The findings from the Care Inspectorate are published today in a report on significant case reviews carried out between April 2015 and March 2018.

A significant case review is a multi-agency process initiated by child protection committees. They are intended to establish the facts of, and lessons from, a situation where a child has died or been significantly harmed. Significant case reviews should focus on learning and reflect on day-to-day practices and systems within which those practices operate.

In today’s report, inspectors said: “The importance of well-managed, interagency collaborative working was evident in supporting planning and decision making alongside timely and appropriate sharing of information. In 12 of the reports we reviewed, there was a need to strengthen processes for effective development and review of the child’s plan with multi-agency input.

Inspectors also noted: “A further recurring theme was that of children remaining unnoticed in neglectful or harmful situations until a threshold for child protection was reached. This was a factor in just over half of the SCRs we reviewed.

“As in our previous review of SCRs 2012-2015, neglect had not been sufficiently recognised or adequately responded to before risks escalated and children were seriously or fatally harmed. In almost all these cases, families were already known to services and were being supported on a non-statutory basis by a range of universal and statutory services.”

Inspectors also highlighted the importance of children’s service staff being well supported to be confident and competent in their assessments and making good use of chronologies.

They added: “Linked to this was the importance of seeing and listening to the child. This has been a recurring theme and in this review, nine of the 25 reports found a lack of focus on the child’s or young person’s experiences and perspective in considering their wellbeing and safety.”

Inspectors also found some reports were overly descriptive with too much of a focus on what happened and not keeping the child as the focus of the review and they added: “The more analytical reviews provided deeper insight, reflection and consideration of what went wrong and why, made effective use of research and presented clear findings.”

Peter Macleod chief executive of the Care Inspectorate said: “It’s everyone’s job to help ensure that every child in Scotland is kept safe, nurtured and supported to reach their full potential.

“We know that social workers and others across Scotland successfully care for and protect many children and young people every day, despite often challenging circumstances.

“We also know that it is very difficult to eliminate all risk.

“In the small number of cases where a child has come to harm, it is crucial that all agencies involved are fully committed to reviewing actions and decisions in each case, to learn any and all lessons that need to be learned.

“This report contains important insights that we expect partners to consider.”

The report is available here