Building on the learning from serious case reviews: a two year analysis of child protection database notifications 2007-2009

Abstract

Serious case reviews (SCRs) are local enquiries into the death or serious injury of a child where abuse or neglect are known or suspected.They are carried out under the auspices of Local Safeguarding Children Boards (LSCBs) so that lessons can be learnt locally.Every two years an overview analysis of these reviews throughout England has been commissioned to draw out themes and trends so that lessons learnt from these cases can inform both policy and practice.This is the 5 th such biennial analysis of serious case reviews, and relates to incidents which occurred during the period April 2007 -March 2009, and complements the two earlier biennial reports undertaken by the same authors.This report is written in separate chapters and most chapters can, potentially, be used as "stand alone" learning materials for different audiences and different interests. FindingsIn the two year period there were 675 notifications of incidents to Ofsted, of which 268 progressed to serious case review.In 152 (57%) of these cases the child or young person died, and in 116 cases (43%) children and young people were seriously injured or harmed.The number of serious case reviews covered by this biennial report is higher than in either of the previous two years (there were 189 reviews in the 2005-07 report and 161 in the 2003-05 report).This amounts to a 43% increase in the number of deaths, and a 111% rise in the number of serious harm cases which were the subject of a serious case review between 2003-05 and 2007-09.The characteristics of the children, and their families, are very similar to those found in the earlier biennial reviews; there was, for example, a similar proportion of children with child protection plans, and a similar age range.Approximately half of all serious case reviews are in relation to babies under one year of age, underlining the importance of effective universal services provision for young children, for example health visitors and early-years services such as Sure Start Children"s Centres.A quarter of the reviews concerned older young people who are likely to pose a risk to themselves and/or others, and whose needs are not always recognised, or met.Little difference was noted between those notifications for serious injury which became a serious case review and those which did not (based on the information available to the researchers).While more than three quarters of the children were killed or harmed at home, just over one in five incidents (21%) took place in a "community context".The incident that prompts a serious case review is not always preceded by practice failings.* Gender unknown in one case involving an unborn child ** Information on the child"s ethnicity was missing for 54 of the children and young people

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