The 2nd Serious Case Review (SCR)report, published by the HaringeyLocal Safeguarding Children Board in

May, is another view of the events leading upto the death of Baby Peter in August 2007. Itwas published the same day as the sentenceswere passed on those found to be responsiblefor his death. The accompanying public andmedia dissatisfaction with the sentencesmeted out to those responsible, appears tohave minimised the extent to which itspublication enabled critics to heap yet moreblame on individual practitioners andmanagers.

The second SCR report is notable for itslength and detail, and one can only wonder atwhat has been left out of the full overviewreport to produce its Executive Summary. Thelevel of detail is certainly illuminating. Forinstance, it refutes the claim in the originalSCR Executive Summary that, ‘There weremany factors that contributed to the inabilityof the agencies to understand what washappening to Child A. With the possibleexception of the paediatric assessment of01.08.07, none on their own were likely tohave enabled further responses that mighthave prevented the tragic outcome’.

LeadershipThe report is also useful in identifying theimportance of leadership, although onceagain this appears to follow the corporatemodel, which suggests that all leadershipcomes from on high. It really is time that,where welfare services are concerned,leadership is recognised as coming equallyfrom the practitioner-user interaction.

I would argue that a key factor in achievingthis recognition is in promoting the role ofsupervision. The second report does make arecommendation that social workers andtheir managers are trained, supervised andsupported to fulfil their statutory role but thebody of the report appears to disregard theimportance of supervision when it states:‘Even if the supervision had taken place, it isunlikely that it would have illuminated thedeficiencies in the practice as in this instancethe team managers were familiar with thecase and themselves had insufficient concernsdespite the frequency of injuries to Peter.’

Yet if supervision was working properlythen surely it would have acted to counterwhat the report describes as ‘the biggestfailure of the intervention with Ms A…[which] was not to find out how deeply sheloved her children or how far she would goout of her way to care for them properly’.Aside from whether it really is possible tohave a tool or scale for measuring ‘depth oflove’, what supervision does offer is anopportunity for what the Social Care Institute

for Excellence (SCIE) Guide 1 (ManagingPractice) calls ‘line-manager attention to thequality of work, including issues of accounta-bility and formal decision making, and timeand focus for the individual worker’.

Of course, we don’t really know whetherthe second SCR report is any more anaccurate reflection of what happened than thefirst report. The first report was judged‘inadequate’ by Ofsted but it is worthconsidering that a judgement has yet to bemade on the second report. Equally, onequestion that must arise but isn’t addressedby the second report is the effect of the OfstedJoint Area Review (JAR) judgement ofHaringey in October 2006 on seniormanagement decisions about resource

allocation across children’s services, a reportthat indicated Ofsted’s own difficulties inpinpointing failures in the authority beforeBaby Peter’s death. This stated: ‘Childprotection work is generally of a satisfactorystandard; most performance indicators arenow in line with those in comparatorauthorities. This reflects good and sustainedimprovements in practice and managementsince 2001 when practice was poor.’

The second SCR report goes on to tacklethe thorny question of funding, suggestingthat finances weren’t a major factor in whyevents unfolded so tragically in Haringeyduring 2007. ‘Within the scope of this reviewit is difficult to determine whether or not thatquantum of resource should have been

PROFESSIONALSOCIAL WORK10

Feature July 2009

www.basw.co.uk

David Barnes considers the findings, both useful and less so, of thesecond Serious Case Review into the death of Baby Peter in Haringeyand considers how best social work can take the lessons from thistragedy and move forward by developing stronger practice

A serious casefor change

A teddy bear left in Haringey as a tribute to Baby Peter

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deployed differently,’ the report states.‘However, what is clear from the detailedconsideration of workload and deployment offrontline staff is that further resources inthemselves would not have impacted on theoutcome of this case.’

Nevertheless the report makes arecommendation that the local authorityshould secure an external audit of resourcesmade available to children’s services between2005 and 2008, to satisfy itself that itsexpenditure was sufficient to meet the needsof those services and with a view toestablishing the appropriate resources formeeting the needs of the JAR Action Plan.

ExpertPerhaps the most encouraging part of thesecond report is the recognition of the role of‘expert practitioners’ in ensuring effectivepractice. This offers a welcome recognition ofthe need to consider the views of well-informed frontline practitioners whose viewsmay very well differ from those of seniormanagement. The report recommends thatconsideration should be given to the creationof an ‘expert pool’ from the four protectingagencies. ‘This pool, both virtual and real, willbe trained to ensure authoritative knowledgeof assessment and intervention. It will be asource of learning, advice and support toensure effective multi-agency working.’Crucially, for a much undermined andmaligned profession, it would also offer asource of practice leadership, with social workfirmly embedded in that group.

The death of Peter and of other children insimilarly tragic circumstances must be givendue regard through proper reflection, policyand practice. Now that some of the initial

‘moral panic’ has subsided, it is time thatsafeguarding children does properly becomeeveryone’s business, with neighbours andcommunities co-operating with serviceproviders to best look after the interests ofchildren. Whether the plethora of initiativesand reports we have seen in recent monthswill help achieve this is, of course, anothermatter. For example, Ofsted has published anew framework for inspections. Based on thisframework it will shortly commence annualunannounced inspections of contact, referraland assessment arrangements for childrenand young people in need, as well as childrenand young people who may be in need ofprotection. Ofsted says that it will not use theannual unannounced inspection as a proxyfor inspecting wider safeguarding matters butit does intend to continue with theimplementation of what it calls ‘limitingjudgements’, so that if any aspect ofsafeguarding is considered inadequate thenthe overall judgement cannot be adequate.

Meanwhile SCIE is actively promoting theuse of its Guide 24, Learning Together toSafeguard Children: Developing a Multi-Agency Systems Approach for Case Reviews(see box above). This approach, if employedwidely, holds out the very real prospect ofmoving from a blame response to tragedies toone of proper accountability throughout theentire child protection system.

Elsewhere, writing in the Journal of MentalHealth Law (Spring 2009 Edition No. 18)Gillian Downham and Richard Lingham’sarticle, Learning Lessons: Using Inquiries forChange, proposed an approach that diversifiesthe learning across serious case reviews,domestic homicide reviews and mental healthhomicide investigations, so that there ‘is a

systemised approach to implementation ofrecommendations’. It is just this sort ofreflection on practice that is so vitallyimportant because social work (and court)decision-making is particularly susceptible topolicy changes and to public outcry. Forinstance, CAFCASS recently publishedstatistics showing how applications to courtshave risen. It produced a graph showing theprobable impact of the Public Law Outline inreducing applications to the court (with thethreshold for interventions having beenraised) during 2008/09. After October 2008the rapid increase in numbers seems certainto be the result of a lowering of thresholds inresponse to the Baby Peter convictions.

ImprovementIn recent years there has been a greatimprovement in the use of evidence-basedpractice but more needs to be done so thatsocial work provides a robust and sensitiveservice to people in vulnerable circumstances.BASW has a long tradition of providingsupport to individual social workers throughits excellent Advice & Representation Servicebut increasingly we need to also providesupport to the profession as a whole, tosupport the delivery of vital social workservices. A recent initiative in BASW has seenthe establishment of a Serious Case ReviewProject Group. If you are interested in gettinginvolved in the work of this group thencontact the BASW England office[england@basw.co.uk]. There is no bettertime for us to be taking this forward with theimpending revision of the Working Togetherguidance on serious case reviews, set to bepublished soon by the Department forChildren Schools and Families.

We also need to connect our reflectionswith wider considerations. The current Radio4 Reith Lectures, given by Michael Sandel onthe topic of ‘A New Citizenship’, offer anexcellent way of doing that. He describeseconomics as “a spurious science in so far as itis used to tell us what we ought to do becausequestions of what we ought to do in politicsor as a society are unavoidably moral andpolitical, not merely economic questions, andso they require democratic debate aboutfundamental values”.

For ‘economics’ I would substitute‘performance management’ – the sentimentwould apply equally well.

www.basw.co.uk PROFESSIONALSOCIAL WORK 11

July 2009 Feature

David Barnes is a BASWEngland ProfessionalOfficer who also works fora safeguarding childrenboard in the north west ofEngland.

The basics:The goal of a systems case review is not limited to understanding why specific cases developed inthe way they did, for better or for worse. Instead, a case is made to act ‘as a “window” on thesystem’. It provides the opportunity to study the whole system, learning not just of flaws but alsoabout what is working well.

The cornerstone of the approach is that individuals are not totally free to choose between goodand problematic practice. The standard of their performance is influenced by the nature of:• the tasks they perform • the available tools designed to support them • the environment in which they operate. The approach, therefore, looks at why particular routines of thought and action take root in multi-agency professional practice. It does this by taking account of the many factors that interact andinfluence individual worker’s practice.

Ideas can then be generated about ways of re-designing the system at all levels to make itsafer. The aim is to ‘make it harder for people to do something wrong and easier to do it right’.

www.scie.org.uk/publications/guides/guide24/introduction/learning.asp

Learning together to safeguard children: developing amulti-agency systems approach for case reviewsSCIE Guide 24

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