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Audit and Analysis of Initial and Significant Case Reviews


Executive Summary

This report presents the findings from an audit and analysis of 56 Significant Case Reviews (SCRs) and 43 Initial Case Reviews (ICRs) conducted in Scotland since 2007.


National guidance for undertaking SCRs was introduced in Scotland in 2007 - 'Protecting Children and Young People: Interim Guidance for Child Protection Committees for Conducting a Significant case Review'. There was a commitment within the national guidance to promote national, as well as local, learning. However, in contrast to England and Wales where national analyses of case reviews are commissioned bi-annually, until now the findings from SCRs have not been collated at national level in Scotland and accessible data on the number of SCRs that have been undertaken has not been readily available. As a result, the value of learning in SCRs to date has been limited, with lessons insufficiently shared beyond local boundaries. The Scottish Government commissioned an independent short life working group of key multi-agency professionals in 2009 to consider the SCR process in the light of recent research and practice. The group made 10 specific recommendations to the Scottish Government to improve the SCR process in Scotland. This included a recommendation that they should commission an audit and analysis of all SCRs undertaken since 2007 to provide a baseline and an understanding of the relevant issues for practice. This report presents the findings of this audit and analysis.


A content analysis approach was used to undertake the review which involved elements of a case study approach so analysis could be undertaken on a case by case and cross case basis. This enabled the findings to be pulled together across the reports but also allowed the complexities of individual cases to be examined in greater depth. Such an approach permitted in-depth analysis of the interaction of child, family, environmental and agency factors and exploration of the different causal pathways to death or harm.

The study was carried out in a number of phases. The number of SCRs that had been undertaken in the 30 CPCs in Scotland since 2007 was not known prior to this study. Phase 1 was, therefore, a mapping and collation exercise to identify how many ICRs and SCRs had been undertaken since the national guidance was issued. Phase 2 of the research involved the reading/rereading of the reports, and coding and analysis of data. A template was devised to capture anonymised information about the SCR process, as well as more detailed, qualitative information about the type of case, factors relating to the children, the characteristics of the family and their involvement with agencies, as well as factors relating to professional practice. Final analysis occurred on a case by case and cross case basis and considered:

  • Recurrent themes and features
  • What common features could be identified to inform practitioners and agencies about risk and serious harm
  • How findings in Scotland compare with findings elsewhere in the UK, and whether there are any Scotland specific findings which have not been found in other parts of the UK
  • What national policy and practice issues arose from the reports.

Findings: the SCR process

The findings of this study suggest that CPCs are following the general principles of the SCR process as specified in the national guidance but there is a lack of consistency in the way in which ICRs and SCRs are being undertaken across Scotland. There is a need for more standardisation across CPCs and for closer adherence to some parts of the national guidance:

  • There needs to be more consistency in the way in which ICRs are undertaken and recorded, and there is a particular need for better recording of the reason why ICRs do or do not proceed to SCR.
  • There should be closer adherence to the guidance in terms of what constitutes a SCR and in relation to production of chronologies and Executive Summaries.
  • There should be more discussion of how findings and recommendations will be taken forward including the ways in which they will be disseminated to staff and where appropriate, to families.
  • There should be discussion of whether or not children and families were included and if not, why not; where families are included the SCR report should provide details of how they were involved and how their views were represented in the report.
  • The members of the review team should be listed, information about timescales should be provided and there should be some discussion of the methodology which was used including whether or not the review included interviews with staff.

Findings: type of case and child and family characteristics

Children died in half of the SCRs included in this study. A small proportion died at the hands of their parents; some died as a direct result of their own risk taking behaviour. Others died from accidents or natural causes, not as a result of abuse or neglect. In some accidental deaths, however, parents' lifestyles probably played some part in the child's death.

The other half of SCRs related to non-fatal physical injury, ingestion of substances, neglect and sexual abuse. These cases were more likely to involve abuse or neglect on the part of parents or carers, but did not necessarily involve intent.

Criminal proceedings had been instigated in half of all SCRs.

In terms of child characteristics the main findings were as follows:

  • There was a slightly higher proportion of boys than girls
  • A third of children were under a year old; a third were eleven or over
  • Ethnicity could not be established in the large majority of cases
  • Almost a quarter of SCRs involved families with four or more children
  • None of the children had disabilities but a small number had health problems and almost a fifth had been born with neonatal abstinence syndrome.

The main findings in relation to parents were:

  • Parents' ages were not always recorded but where age was recorded parents did not appear to be particularly young; a significant proportion were in their thirties or forties
  • More than a third of parents were noted to have had troubled childhoods
  • There was a high prevalence of parental substance misuse (almost two thirds of SCRs)
  • Domestic abuse featured in over half of cases
  • Children were affected by parental mental health in 43% of SCRs
  • Well over half of families had criminal records for serious offences relating to violence or drugs
  • Families were only noted to have financial problems in a small number of SCRs but this is likely to be an under estimate; there was a high prevalence of housing problems including frequent moves, overcrowding, poor conditions and intimidation from neighbours
  • A high proportion of families had support from their wider extended family. In some cases this was a protective influence for the child but family members sometimes contributed to the levels of stress families experienced. A small number of families, particularly those who had moved to Scotland from another country, were socially isolated.

A very high proportion of families (93%) whose circumstances formed the subject of SCRs were known to social work services, with just 7% of families known only to universal services. This suggests that concerns had been identified in these families and had been correctly passed on to statutory services as specified in national child protection guidance. 14% of children were on the child protection register and a fifth were looked after.

Findings: agency factors

While this study identified some excellent practice, in common with previous studies it also identified that intervention is not always as child centred as it might be. All agencies, including adult services, must maintain a focus on the potential risks to the child as a consequence of their parent's lifestyle. A reflective, questioning practice culture should be adopted in which practitioners feel confident to challenge parents as well as each other. Managers must listen to frontline staff, acknowledge the difficulties they face in working with troubled families and provide appropriate supervision, training and support.

Despite considerable efforts in recent years, through the implementation of GIRFEC, and the child protection guidance and other national policies, to ensure that children and families get the help they need when they need it, the findings of this study suggest that thresholds have not necessarily been broken down and remain a concern. All professionals in child and adult services must heed Lord Laming's comment that child protection does not come labelled as such. There should be no distinction between those children who are considered to be at risk of harm and those that are not. All children may be at risk at any time and decision making for all children, including those outside the child protection system, must always be based on an assessment of cumulative risk and harm as well as need. A significant amount of progress has been made in recent years to ensure that all agencies acknowledge they have a responsibility for child protection and this is evidenced in the numerous examples of good safeguarding practice in universal and adult services identified in these SCRs. However, the reports demonstrated that there was some confusion in relation to responsibilities in individual cases and there needs to be a shared understanding of roles across agencies.

Findings: understanding risk

Children and young people die or experience harm for a range of different reasons. While there are a number of common risk factors, the way in which the various child, family and agency factors interact and result in the different types of death or harm will be unique in each case. Risks change as children get older and it is, therefore, important for professionals working with children and families to have a good understanding of child development. Parental risk factors will be important for younger children, but teenagers usually die or are injured as a result of their own risk taking behaviours.

The following risk factors were identified for cases involving infants:

Child factors Parent factors Agency factors
Neonatal abstinence Syndrome (NAS)
Failure to thrive
Attendance at Accident and Emergency for injuries
Substance misuse
Domestic abuse
Mental health problems
Troubled childhoods characterised by lack of attachment and lack of positive parental role models
Criminal record especially for violence or drugs
Social isolation/lack of family/ community support
Housing issues - frequent moves, anti social behaviour, problems with neighbours
Non engagement, lack of cooperation, changing patterns of engagement
Missed health appointments, failure to obtain medical care
Frequent appearances at Accident and Emergency
Focus on the parents as opposed to the children
Child not seen
Risks not assessed, accumulating information not analysed to allow assessment of increasing risk, or case not considered to be 'child protection'

The following risk factors were identified for children in the middle years or in families with several children including one or more of school age:

Child factors Family/environmental factors Agency factors
Low attendance/lateness at school/nursery
Behavioural problems at school
Presenting as dirty at school/nursery
Health problems including weight problems
Large families
Substance misuse
Domestic abuse
Mental health problems
Troubled childhoods characterised by lack of attachment and lack of positive parental role models
Criminal record especially for violence or drugs
Social isolation/ lack of family/ community support
Housing issues - frequent moves, anti social behaviour, problems with neighbours, overcrowding/poor conditions
Non engagement, lack of cooperation, changing patterns of engagement
Missed health appointments, failure to obtain medical care
Frequent appearances at Accident and Emergency
Failure to speak to the child and/or to analyse their behaviour
Risks not assessed, accumulating information not analysed to allow assessment of increasing risk, or case not considered to be 'child protection'
Long involvement with universal and statutory services with few signs of improvement
Sexual abuse not identified

Risk factors for teenagers included the following:

Child factors Family/environmental factors Agency factors
Mental health problems
Risk taking behaviour - self harm; substance misuse; offending etc
Long term involvement with social work and SCRA
Looked after with multiple placement moves
Non engagement/lack of cooperation with services
Previous abuse/neglect
Social isolation/lack of family/ community support
Known to associate with peers/family involved in risk taking behaviour
Lack of resources to meet young person's needs
Risks presented by transition to adult services
Professional powerlessness
Mental health needs not met
Housing needs not met

National policy implications and recommendations

The findings of this study raise a number of important national policy issues. A particularly significant finding is the high number of SCRs which relate to the care and protection of children living in families whose lives are dominated by drug use and the associated issues this brings, including criminality and neighbourhood problems. In most cases the child's needs had been identified and an extensive support package had been put in place, but this did not prevent these children from dying or experiencing harm. This inevitably raises issues about leaving children, particularly infants, in the care of parents involved in substance misuse, particularly when both parents and sometimes the wider extended family, have a long history of substance misuse and no one is able to provide a protective influence. It also raises issues around the threshold for intervention in respect of levels of drug dealing and intimidation known to police and other agencies such as housing.

Another challenging finding is the lack of suitable resources for the placement and support of troubled and troublesome teenagers and the impact this has on staff in a number of agencies, particularly social work, housing and mental health agencies. As these SCRs demonstrated this can lead to situations of professional powerlessness, where professionals do not know how to support these young people, resulting in them being left in dangerous situations where they are placed at significant risk of engaging in risk taking behaviour which can sadly lead to death through suicide or misadventure.

Lastly the findings demonstrate that we should not lose sight of school age children. Policies often prioritise pre-school children or adolescents but there were a number of concerning SCRs involving long term neglect and sexual abuse of school age children who had been known to statutory services for many years. These families had been correctly identified as being in need and intensive packages of support had been put in place to meet their needs but the 'rule of optimism' resulted in cases being allowed to drift. Cumulative risk had not been identified because children had not been spoken to and the reasons for their challenging behaviour had not been considered. These particular children had finally come to the attention of agencies because a particularly serious incident had resulted in them being the subject of a SCR or the accumulation of concerns had finally been picked up. In the majority of these cases children did not die but they had experienced serious abuse or neglect. They were normally removed from their parents' care as a result of the incident or catalogue of incidents that led to the SCR but retrospective analysis suggests that some of these children should have been removed much sooner.


1 The SCR process and separate process for review of the deaths of LAC should be better aligned

2 There needs to be more standardisation in the way in which ICRs are undertaken and reported across Scotland. CPCs should follow the national guidance, use the template and keep a register of cases. The template should be revised to include a section where CPCs can record the reason for their decision

3 The 2010 National Child Protection Guidance replaced 'Protecting Children - A Shared Responsibility: Guidance for Inter-Agency Co-operation' and the categories of abuse and neglect have changed. The national guidance should be revised to take account of this.

4 All reviews that are multi-agency and meet the criteria for a SCR as set out in the national guidance should be termed SCRs to avoid confusion

5 The national guidance should be updated to include information about the process of undertaking cross border SCRs

6 As specified in the national guidance SCRs should be undertaken by a mixed team not by a single reviewer and reports should include a list of contributors to the review

7 SCR reports should include a separate chronology or take a chronological approach

8 SCR reports should include a separate executive summary as specified in the national guidance

9 It may be appropriate for CPCs to produce separate action plans rather than including them in the SCR report but reports should provide some discussion of how the findings will be disseminated and how the recommendations will be taken forward

10 In line with the national guidance SCR reports should include information about whether or not children and families were informed and involved. If they were not involved reports should record why they were not involved. If they were involved reports should record the nature of this involvement and document how their views have been represented. Diversity issues should be considered and adequate support should be provided to ensure that family members are able to participate.

11 The national guidance states that 'A review should not be escalated beyond what is proportionate taking account of the severity and complexity of the case.' The SG should look at new review arrangements in Wales which include a continuum of review (multi agency professional forums; concise reviews; extended reviews) (see Appendix 2) and consider the appropriateness of updating the national guidance to include different levels of review

12 The decision not to interview staff may be appropriate but where staff views have not been sought SCR reports should include information about whether there was any consideration about involving them and why the decision was made not to involve them. All SCR reports should document how the findings of the review will be fed back to frontline staff

13 All SCR reports should reflect upon good practice as well as on what needs to change

14 SCR reports should record the length of time it took to undertake the review and set out any reasons for delay

15 Authorities are subject to the public sector equality duty. They should consider the relevance of protected characteristics such as age, disability, race, religion, sex and sexual orientation and ensure appropriate monitoring. Any associated cultural issues should also be considered and documented.

16 Some of the deaths of babies are accidental but preventable. Mothers and fathers of vulnerable children should be given ongoing information about safe sleep as well as at the time of their baby's birth. The Scottish Government is currently updating its Getting our Priorities Right (GOPR) Guidance and should consider including advice for professionals to warn mothers with a substance misuse problem who breastfeed to make sure they return their baby straight to his or her cot after feeding as they may be more inclined to fall asleep

17 SCRs should include information about the family's economic situation

18 SCR should record the level of involvement with SCRA

19 All staff and students in social work, social care, education, health and the police should receive training on issues that have arisen from this and other studies of SCRs

20 All staff working with children and families and students training to work with children and families in Scotland should have regular training in working with difficult to engage and hostile parents and young people