Upload
vucong
View
226
Download
0
Embed Size (px)
Citation preview
The Troubling History of Serious Case Reviews
David N Jones
Social Work History Network
24 November 2015
People Need People Consulting Realising the potential in human services
Source material
Serious Case Reviews in Child Protection: Historical Reflections David N Jones (2015) ADCS Virtual Staff College http://www.virtualstaffcollege.co.uk/wp-
content/uploads/historical_reflections_publish.pdf
People Need People Consulting Realising the potential in human services
Possible questions What generates public concern in
‘serious cases’? Has all the energy devoted to Serious
Case Reviews had any impact on policy and practice?
Does the history of SCRs throw light on service development and improvement?
How do SCRs fit alongside developments relating to risk management in other fields?
What pushes a ‘serous case’ into the public domain?
People Need People Consulting Realising the potential in human services
“Scandals do not just happen. They are made.
They are constructed out of such everyday tragedies as
the small carelessnesses and institutional brutality of the long stay hospital,
the abuse of children or the violent deaths of innocent bystanders”
(Butler and Drakeford, 2005).
Victorian scandals, inquiries and reform
Haydock Lodge scandal (1846-1852) involved the
transport around the country of large number of ‘paupers’ with mental illnesses and learning disabilities
Timothy Daly (1864) – St Bartholomew’s – death by exhaustion from bed sores & fever – Florence Nightingale – workhouse reform – Lancet Commission, etc
Mary Ellen (1874) - New York - NSPCC (1895)
People Need People Consulting Realising the potential in human services
Reviews since 1945
Children Act 1948 – Dennis O’Neill – Monkton inquiry 7 weeks – Curtis Ctte
Children Act 1975 - Maria Colwell Children and Young Persons Act 2008 –
Victoria Climbié – Laming 2003 – Every Child Matters 2003
From 1973 increasing use of public inquiries
People Need People Consulting Realising the potential in human services
Enquiries 1973 Graham Bagnall 1973 David Lee Naseby 1973 Maria Colwell 1974 Max Piazzani 1975 Auckland family 1975 Richard Clark 1975 Lisa Godfrey 1975 Stephen Meurs 1976 Neil Howlett 1977 Wayne Brewer 1977 H family 1978 Paul and L. Brown 1978 Stephen Menheniott 1978 Simon Peacock 1979 Lester Chapman 1979 Darryn James Clarke 1980 Paul Stephen Brown 1980 Claire Haddon 1980 Carly Taylor 1981 Maria Mehmedagi 1981 Malcolm Page
People Need People Consulting Realising the potential in human services
1981 Christopher Pinder/Daniel Frankland 1982 Jason Ceasar 1982 Lucy Gates 1984 Shirley Woodcock 1984 Heidi Koseda 1985 Jasmine Beckford 1985 Reuben Carthy 1987 Tyra Henry 1987 Cleveland - 121 children
1990 Orkney 2000 North Wales (Waterhouse) 2001 Caleb Ness 2003 Victoria Climbié 2006 Michael McGarrity 2007 Baby Peter 2009 ‘J’ children - ‘Edlington’ 2010 Khyra Ishaq 2012 Edlington case Carlile 2013 Daniel Pelka 2013 Hamzah Khan 2013 Operation Pallial (North Wales)
People Need People Consulting Realising the potential in human services
Enquiries
2013 Operation Yewtree 2013 Rochdale CSE 2013 HMIC’s review into (police handling of) allegations and
intelligence material concerning Jimmy Savile 2014 Rotherham 1997-2013 2015 Oxfordshire 2015 Independent oversight of investigations into matters
relating to Jimmy Saville at schools and children’s homes: 2015 Themes and lessons learnt from NHS investigations into
matters relating to Jimmy Saville Inquiry into non-recent abuse
People Need People Consulting Realising the potential in human services
Enquiries
People Need People Consulting Realising the potential in human services
Concern increased through 1980s – cost and public relations impact
Search for a credible, robust and cost effective inquiry system, which would convince politicians, the media and judges that there was a robust system of review and therefore that public inquiries were not necessary.
Resulted in Part 8 duty on LSCBs to undertake formal inquiries into serious cases.
Government guidance
People Need People Consulting Realising the potential in human services
Government guidance 1970 Battered babies DHSS 1980 Child abuse: central register systems DHSS 1986 Working together: arrangements for
interagency co-operation for child protection DHSS 1991 Working together 1999 Working together 2006 Working together 2010 Working together 2013 Working together 2015 Working together
Other sectors
1997 A New NHS: Modern; Dependable DH 2000 An organisation with a memory: report of an expert group on learning from adverse events in the NHS (DH) 2001 National Patient Safety Agency (DH) 2003 Keeping Children Safe (DH) - CDOPs Aviation International experience
People Need People Consulting Realising the potential in human services
A new direction?
Munro articles (1996–2008) – systems approach New government – Climbié impact Ofsted reviews Munro reports (2010-2011) Publication or not? Revised guidance National Audit Office (2016)? An industry or a service?
People Need People Consulting Realising the potential in human services
Factors shaping SCR impact
People Need People Consulting Realising the potential in human services
The type of case (severity and death do not
always lead to public outcry). The ‘response’ of the local agencies - how they
handle the case in public. How the response is perceived by ‘the public’ -
whether this is credible or ‘defensive’ - increasingly whether there is a sufficiently sincere apology.
Other news on the day of publication (impact of social media?).
Whether local politicians see scope for political advantage.
Whether national politicians or media see political advantage or Ministerial exposure to risk
Observations
People Need People Consulting Realising the potential in human services
UK experience consistent with other English
speaking countries – ‘learning’ or ‘blame’? Serious case reviews have had a major impact on
social policy and development of children’s services
Research and evidence has also had an impact but serious cases have shaped perceptions more than anything else
SCRs have not addressed the organisational context – system – which is perhaps why learning appears less effective – ‘repeating the same behaviours’ (cf aviation) – increased focus on ‘learning’
Understanding of human behaviour still partial
Observations
People Need People Consulting Realising the potential in human services
‘England is not unique in grappling with these challenges. Indeed it is arguable that our structured and formal systems, which have called forth considerable professional and academic enquiry and energy, are more robust, effective and consistent than those of many (even most) other countries. Despite this, there is professional, political and public frustration with the outcomes of many reviews and therefore a clear need to explore more effective ways to understand the dynamics within organisations and between individuals, including family members and children themselves, and why these sometimes result in tragedy but much more frequently provide positive support to people in profound and difficult circumstances.’ Serious Case Reviews in Child Protection: Historical Reflections’ David N Jones (2015)
Observations
People Need People Consulting Realising the potential in human services
‘Why did this happen?’ is inevitably a legitimate question and one which demands a credible answer through the Serious Case Review or whatever alternative process is used. “Scandals do not just happen. They are made.” (Butler and Drakeford, 2005)
References
People Need People Consulting Realising the potential in human services
Butler, I. and M. Drakeford, (2005) Scandal, social policy and social welfare, Bristol Policy Press
Butler, I. and M. Drakeford (2012) Social work on trial: the Colwell inquiry and the state of welfare, Bristol, Policy Press
Jones, D. N. (2015) Serious Case Reviews in child protection - historical reflections, ADCS Virtual Staff College. http://www.virtualstaffcollege.co.uk/wp-content/uploads/historical_reflections_publish.pdf (Accessed on 30 October 2015)
Virtual Staff College on behalf of partners (2015) The role of serious case reviews in improving the child protection system. Nottingham, ADCS Virtual Staff College. http://www.virtualstaffcollege.co.uk/wp-content/uploads/Role_Serious_Case_Studies_final_2.3.pdf (Accessed on 2 December 2015)
Thank you
[email protected] @JonesDavidN
SWHN – 24 November 2015
People Need People Consulting Realising the potential in human services
The Troubling History of Serious Case Reviews