The journey started by accident, not in Wales but in Cambridgeshire in 2003. I had 26 assorted professionals in a room for a whole day to reflect on a situation of child neglect and exploring an enabling way to work with their parents which had not initially been possible. These professionals had all worked with the family in some way or another and my task was to facilitate their process of learning and reflection. It did not quite meet the criteria for a Serious Case Review but the ACPC (Area Child Protection Committee) thought there was something to learn because of the complexity of the situation. What I learnt was that bringing people together in a safe space to think about systems and practice was a powerful, immediate and in-depth way of developing thinking, increasing understanding and generating ideas for the future.
Up to this point, my experience of Serious Case Reviews had been of sometimes remote paper exercises that had little impact on wider systems and services. They tended to focus on who got what wrong, thus generating anxiety and defensiveness. SCR reports were lengthy, concentrating on what happened in such detail that they became more akin to an investigation with little analysis or clear learning points. For some, a long report was reassuring as they saw it as tangible evidence that the review process had been thorough and all encompassing. Reports often concluded with long lists of recommendation full of ‘shoulds’ and ‘oughts’ leading to a flurry of training and policy reformulation.
When the Welsh Government posed the question ‘how can we make learning from practice fundamental to the day to day activity of front-line practitioners?’ and I became part of the development group, it was that experience in Cambridgeshire which provided a basis for exploring and expanding the model into a feasible framework.
One of the main tasks at the beginning of this journey was to change the culture around reviews and to convince people that this process was rigorous even if the outcome was not the 100 page report and lengthy lists of recommendations that they had been used to.
Setting out the underpinning principles of the new framework was the first step in its construction. These principles emphasised the requirement of a positive shared learning culture, highlighted the need for organisational cultures to be experienced as fair and just and stressed the importance of professionals being given the support they needed to undertake the complex work of protecting children.
The learning event for practitioners and first line managers was the one aspect of this model that was very different from traditional approaches to reviews. At first I saw this learning event as the main feature of the model and the main source of learning. However, increasingly I realised that it was one part of the ‘collective endeavour’ that included Panel meetings and engagement with family members. These latter two elements strengthen the systems thinking which is at the heart of the framework.
In the last few reviews I have undertaken, we have introduced a learning event for senior managers to enhance the strategic perspective of the review. This has worked well and contributed to learning across the system.
I have come to realise that the reviewer’s role is not one of expert but rather to identify and co-ordinate all the sources of learning and weave them into a coherent whole. The experience of the learning events has also highlighted that reviewers need sound facilitation skills to both manage and shape the event and to encourage active participation. Some of the most effective events have been the ones that succeeded in creating a safe environment, where trust was built between participants, who were thus supported to open up and move towards appropriate and constructive challenge.
Another difference between this model and more traditional approaches has been with regard to background information - specifically the use of time lines, and brief analysis reports rather than weighty Internal Management Reports (IMRs). Would this mean there was not enough information on which to conduct the review? I found the very opposite. As a reviewer, I understood more from the studying of a well-constructed time line than ploughing through a pile of IMRs.
There were a few things we did not get quite right in the beginning. I don't think the differentiation between Concise and Extended Reviews is particularly helpful and has led to some wrongly describing it as a tiered model, with the assumption that extended reviews are more important than concise reviews. The Welsh Framework was not designed to be a tiered one; all reviews are equally important and it is within the terms of reference that the scope of a review can be set out.
For the final report, a template was developed to ensure consistency. However, adapting the framework for use in England has led me to see the original template as being a little too brief. In reviews in England and Scotland, therefore, I have produced a more free narrative style of report, albeit not too long and with an emphasis on the main learning, linking this with recommendations for action.
Having undertaken somewhere in the region of 20 reviews using this framework, I now recognise that, perhaps without initially being conscious of it, we had built in flexibility and adaptability. Each review has, quite rightly, been somewhat different and it has been possible to tailor the process to the situation under review in order to both maximise learning and to make it accessible but without losing sight of the underpinning principles of collective endeavour, creating the right conditions for learning throughout the review and using a systems approach lens.
In Scotland, a Significant Case Review (SCR) is a multi-agency process for establishing the facts of a situation where a child has died or been significantly harmed, within a child protection context, in order to learn lessons on how to better protect children and young people and provide best support to the wider family and professionals involved.
CELCIS is a member of the Case Review Oversight Group, which works towards progressing a set of recommendations specific to case reviews. The recommendations were formulated by the Child Protection Systems Review and were fully adopted by the Scottish Government’s Child Protection Improvement Programme in 2017. CELCIS has been asked to support the exploration of a tiered approach to reviews and the production of national guidance setting out the skills and competencies required by reviewers.
The views expressed in this blog post are those of the author/s and may not represent the views or opinions of CELCIS or our funders.
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