The Scottish Government

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Nick Axford and Roger Bullock, Dartington Social Research Unit
ISSN 1478-6788 (Print)
ISSN 1478-6796 (Online)

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Welcome to Insight

Insight is a publication of the research group within Information and Analytical Services Division, which is responsible for providing analytical services within the Scottish Executive Education Department ( SEED). Their work is part of a multidisciplinary unit (consisting of researchers, economists and statistics staff) and the staff undertakes and funds economic analysis and social research in the fields of: school education; children, young people and social work: architecture; and tourism, culture and sport.

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Insight aims to present the essence of research projects in a format that will be useful and informative for practitioners, policy makers, parents, academics, and anyone else who has an interest in economic and social research in these areas.

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Introduction

This research report provides an international comparison of child death and significant case reviews, an issue of interest to the Scottish Executive seeking clarity on how reviews should best be conducted. This concern emanates from a continuing review of child protection in Scotland and a desire to explore the strengths and weaknesses of procedures in other countries following child deaths and other significant events, methods of ensuring accountability and specific approaches that may usefully inform policy and practice.

Methods

The study is based on a survey across 16 ¹ countries of arrangements for conducting reviews. Information has been gathered from several sources, including a literature search, a substantial structured questionnaire to experts in child protection in the respective countries and consultations with agencies and individuals elsewhere. While there is a large body of research on child abuse and neglect and on child death rates generally, there is very little published material on the case review process and even less on its effectiveness. Most available evidence comes from England.

Findings

Initially, it is important to understand the context in which child death and significant case reviews are conducted. All of the countries studied had strengthened their child protection policies in recent years and sought to enhance children's rights. But the extent and nature of children's needs differ across countries, as do the professional structures designed to meet them. Models cannot easily be transferred across international borders. It is more useful therefore to concentrate on the conditions necessary to achieve effective reviews and apply these to particular countries.

All of the countries surveyed had a system for reviewing child deaths and significant cases where abuse and neglect were contributory factors. However, the approaches varied considerably. The main differences were:

• in the likelihood of a review taking place,
• the existence of a standing group to commission and undertake it,
• whether the driving force behind the inquiry was the fact of death or an attempt to understand the abuse that caused it,
• the criteria for cases to be investigated,
• whether the mandate was legal or professional,
• the roles of the coroner and police in commissioning inquiries,
• the scope of the inquiry,
• the relationship of abuse and neglect investigations to monitoring arrangements of other causes of harm to children,
• the quality of the information systems that reviews feed into,
• the costs of inquiries, and
• the arrangements for publication, dissemination and handling the media.

An analysis was undertaken to construct a typology of approaches, setting out the various mechanisms, structures and procedures invoked when a child death or significant case is brought to the attention of the authorities. In order to do this, the system in each country was coded according to five variables:

1. Whether or not reviews routinely take place;
2. Whether such reviews are mandated by law or discretionary;
3. Who orders the reviews to happen;
4. Whether the reviews are typically investigative/forensic or focused more on lessons for practice learning;
5. Whether or not the service for reviewing child deaths/injuries in the case of suspected/actual abuse/neglect is integrated with the system for reviewing all unnatural child deaths.

The analysis based on the five variables identified above indicated three groups of countries with similar approaches to reviews.

Group 1 comprised those countries with a review system in place, a group of people qualified to undertake inquiries, a process for doing so and an intention to improve policy and practice. Seven countries fell into this category: England, Wales, Northern Ireland, Canada, US, Australia and New Zealand. The US and Australia were slightly different from the other three, however, because their systems were often more legalistic in that they took place in the context of mandatory reporting to a child protection service.

In Group 2, the countries had no permanent system for reviewing child deaths but were able to assemble an appropriate group to do so, should the need arise. The impetus sometimes came from legal officials or the police but the final product and its effects were much the same as for countries in Group One. This situation pertained in Germany, Switzerland, Scotland, Norway and Ireland.

In the remaining four countries (Group 3), there was a system in place but the approach was limited in that it was largely legalistic and forensic and limited in scope with few desired effects beyond clarifying the nature and cause of an incident and improving matters locally. Jordan, Belgium, Israel and South Africa fell into this category. The table below summarises these features.

SUMMARY OF THE KEY FEATURES OF SYSTEMS OPERATING IN THE DIFFERENT COUNTRIES (BASED ON QUESTIONNAIRES)

* Aus= New South Wales, Australia; Belg= Flanders, Belgium; Eng= England, Wales and Northern Ireland; US=Los Angeles County, California.

Features Codes
[1] 'Routine system' concerns whether reviews routinely take place in the event of a child death and/or serious injury/neglect (=Yes) or not (=No).
[2] 'Criteria' concerns whether such reviews are mandated (=M) by law or discretionary (=D), that is dependent on the situation or people involved.
[3] 'Who orders' concerns who orders the reviews to happen, divided here between legal/police (=L) and professional (=P) bodies.
[4] 'Purpose/style' concerns whether the reviews are typically investigative/forensic (=F), that is mainly concerned with finding out what happened and where responsibility lies for the death/injury, or focused more on drawing out lessons from the case in order to improved practice learning (= PL).
[5] 'Integrated' refers to whether the service for reviewing child deaths/injuries in the case of suspected/actual abuse/neglect is integrated with the system for reviewing unnatural deaths generally (=Yes) or not (=No) .

1. Do reviews routinely take place in the event of a child death and/or serious injury/neglect?

All countries review child deaths and serious injuries but not all have a process for doing so. The research found variations centred around whether there is a predictable routine for assessing the circumstances surrounding the death of child or adolescent and whether there is a specific group or team to do this. Some countries, for example those where child deaths are rare, simply convene a group for each case ² .

Effective systems for undertaking reviews of child deaths and serious injuries

On the basis of all the evidence from the literature review and the expert survey, an attempt was made to identify the features of a 'good' review system. These features are described in the remainder of this Insight summary.

Background considerations

It is important initially to stress that what is deemed a 'good' review of an individual case might not be good for children's services generally. Recommendations can create cumbersome and expensive procedures and reinforce an adversarial and forensic approach that is not helpful for the majority of child protection work. Child deaths are relatively rare and the majority of children at risk of harm present relatively low levels of abuse and neglect and are protected while living at home by means of family support services.

Reviews will encounter a variety of situations with some aspects in common but much that is case specific. It is necessary to combine general knowledge, for example about risk factors and process dynamics, with an analysis of the circumstances peculiar to each situation. This is a difficult process as the former seeks to apply generalities to the specific, while the latter seeks generalisations from individual incidents.

It is necessary to be sensible about predictions. Retrospective analysis of cases usually indicates strong links between background and outcome but these are rarely borne out by 'blind prospective' forecasts where known risk factors are present but the future is unknown. Trying to predict what will happen in such situations, especially for something as rare as a murder or manslaughter, is very difficult. Indeed, for child abuse generally, there will probably be some 20 wrong predictions for every correct one, even in situations even when the risks are high. These incorrect forecasts are termed in research parlance 'false positives'. On the other hand, it is equally important to stress that the factors that increase the likelihood of harm are known and should be reiterated and included in the assessment procedures for all children in need. Research which clarifies these factors should be supported.

Early decisions and organisation

2. What are the criteria for including a case in the existing procedures for conducting reviews?

There has to be a method of deciding when to undertake an inquiry and the criteria for doing so. Is it all child deaths where abuse and neglect are known or thought to be contributory factors? Do adolescents running away or living in chaotic circumstances qualify? What level of serious injury reaches the threshold? The factors to be considered may be varied - public interest, media coverage, professional shortcomings, system failure etc. - but the criteria should be clear.

In the study, the main variation in the criteria for including cases in existing procedures concerned the motivation for the inquiry - whether it was the death or the abuse that caused it - and the extent of professional discretion on whether and how to proceed.

3. Who, or which type of organisation, orders reviews or enquiries and with what authority?

In some countries the inquiry is ordered as part of legal proceedings, whereas in others it is professionals who decide that an inquiry would be a helpful complement to other police inquiries and legal formalities. In more legalistic systems, the role of the coroner or some other legal functionary is often central.

It is helpful to have a standing group to make decisions to undertake an inquiry and a core of people who can be drawn on to undertake it. Most countries have such a system but the weakness is maintaining the expertise and accumulating knowledge. Staff turnover is often high and professionals can be exhausted by the exercise, so some person or a stable group should be encouraged to gather and analyse the information from successive reviews to build up a knowledge base. This does not seem to be done locally or regionally and only patchily at a national level.

4. Who undertakes the enquiries and who else is involved in the process?

Significant here is the varying role of the police in different countries. Where the reporting of all child abuse is mandatory, the police are likely to be automatically involved from the start. Most countries have a standing or ad hoc review team and in some the police are members rather than managers. Most of those involved have professional qualifications but not necessarily training in child protection.

The role of the police in reviews must be clear. They have a specific area of responsibility that can conflict with welfare considerations. Their role in the review process must be agreed at the outset if criminal investigations are not to undermine other ambitions and if collaboration is not to be perceived as collusion.

5. Are enquiries subject to any regular or periodical overview?

Whether or not enquiries are subject to regular overviews varies considerably. In some countries, a report on child deaths is published annually whereas in others there is no system or attempt to collate the information produced.

Those countries with an office providing an overview of all child welfare, such as a Children's Commissioner, allow independent scrutiny of reviews, opportunities to link the recommendations to other initiatives for children and families, external pressure to complete reviews satisfactorily and a direct line to senior policy makers and politicians if there is dissatisfaction with any part of the process.

6. What are the arrangements for conducting and funding an enquiry?

The costs of inquiries are universally borne by state and government agencies with other agencies and professionals hired as necessary. Most teams and almost all members do this as part or as an extension of their other work. Yet to be effective, each review needs one person as the official or understood leader. A team coordinator is essential and larger teams can pay for such a service.

There must be an accurate estimate of the likely costs of the review in terms of staff time, expenditure and agreement about who pays. A sudden need to consult an outside expert, for instance, can radically affect budgets and lead to acrimonious disputes. It should be recognised that some reviews will need to be very expensive, others less so. Agreed cost estimates should be related to the aims and desired effects of the review.

It is important that the review has adequate political and professional 'clout'. It must be supported by top management and local politicians and have the power to demand participation and information. It should be recognised as a major event in developing services for children and families.

The scope and nature of reviews

7. What are the purpose, scope and style of the enquiries?

In some countries there is a fairly clear protocol regarding how the reviews are best conducted, including an understanding of what data are examined and in what order. Elsewhere, the process is much more flexible and ad hoc.

It is important that a review has a clear focus. What is it seeking to do? How does it complement and add to coroners' inquests and police criminal investigation? In Scotland, unlike some of the other countries studied, these will be separate and their respective functions need to be agreed.

The role of reviews in children's services development needs to be clear. Is their function to highlight gaps in services, make sure scandals never happen again, identify practice shortcomings or something more radical?

The inquiry process must be predictable and understood by all those participating and likely to be affected. It must be clear who will be involved, that participation is compulsory and what the outcomes and effects of the process are likely to be, independent of the specific findings.

8. Does the process seek to be inquisitorial or more focused on practice learning and service development?

The guidance in England, Working Together, allows considerable scope for deciding to undertake a review. In Scotland, there is no single system of notification, no agreed criteria for inclusion and national system of review. Nearly all reviews examine agency practice and most assess the personal, environmental or social circumstances of the child. Most of the official literature produced by countries and professional associations, such as ISPCAN (International Society for Prevention of Child Abuse and Neglect), emphasises the need to use information from inquiries to improve the welfare of children. All of the countries participating in the study appear to be moving towards the features described in the template laid out in Chapter Eight of the Working Together guidance for England and Wales.

Whatever else it considers, the inquiry should look closely at the agreed components of good child protection work to see how these have affected the case in question. These have been identified by respondents as the quality of: inter-agency work, the collection and interpretation of information, decision making and relationships between professionals and the families and children involved.

To achieve their aims, reviews have to be sensitive to the context of each country, its size, population distribution, the needs of all its children and the professional structures in place. For example, the co-existence of Schools Policy and Children's Services Policy in the Scottish Executive Education Department increases the possibility of policy liaison between schools and social services in a way that is more difficult in countries where these departments are separate.

Other groups in Scotland may be monitoring harm to children, for example from air pollution, disability, genetic and infectious diseases or road accidents, and it is important that findings about child deaths from abuse and neglect are linked to this other information as poverty is known to be an underlying factor in the deaths of and injuries to children to children, however caused.

Activity after the completion of reviews

Recommendations made in reports need to be realistic, understood and helpful to front-line practitioners as well as to children and families. They should not detract or draw resources from other children's services work and should be sensible about the extent to which abuse and neglect can be prevented. If there is bad practice it should be highlighted as such but for some cases it may be more a question of bad luck or an 'out of the blue' or chance incident.

Recommendations need to be related to other child protection work and Government initiatives for children and families. For example, it is important to minimise potential conflict with government plans concerning reductions in child poverty, computerised tracking of children in need, the provision of children's centres in local communities, initiatives such as Sure Start, extended schools and strategies to deal with alcohol and drug abuse.

9. How are the results of the reviews disseminated?

Most countries welcome publication of the findings but the timing and nature and content of publications vary considerably. With increased sophistication of publishing methods, different versions are usually prepared for different audiences, the content being judged in terms of public interest and confidentiality. Also, those disseminating the reports are given advice on handling the media at launches, radio and TV discussions and public meetings. However, it must be accepted that some reviews, or parts of reviews, might not reach the public domain, and the dissemination of review findings needs to be carefully timed to avoid leaks and prejudgement.

The implications and effects of review recommendations on legislation, guidance, procedures and professional practice should be made clear in the dissemination.

Annual reports and internal evaluations from around the world claim improved practice and better protection for children at risk of harm. However, it is hard to decide how influential child death inquiries are as agents of change. The experience of the countries studied suggests that they do produce immediate and long-term effects but because of the dearth of robust evidence it is less clear whether these better protect all children at risk of harm.

While the policy implications drawn from the survey will not completely eliminate child deaths from abuse and neglect, it is reasonable to say that reviews conducted under these conditions are likely to be more effective in achieving their aims and to lead to policy and practice initiatives that will reduce tragedies as far as is possible.

Conclusion: The function of reviews in modern children's services

All of the countries that participated in the survey are seeking to develop effective responses to problems intrinsic to economically developed or rapidly changing societies. Obviously, there are issues peculiar to each country but there is also much in common driven by challenging social situations and public expectation regarding solutions.

Although the professional context and extent and nature of presenting problems differ across countries, the general response is similar - to modernise children and family services. The essential features of such an approach can be summarised as a service that:

• Is needs-led and is therefore consistent and equitable
• Is evidence-based
• Has clear thresholds for services
• Offers provision that matches the needs of children and families
• Has a single process that leads to a continuum of interventions for all children in need
• Supports an integrated team approach and a correct balance between investigation and help for children at risk of harm
• Has a proper balance between prevention, early intervention, treatment and social prevention.

This service has to be supported by effective:

• Knowledge about the extent of need in local communities, based on accurate epidemiological data
• Identification of all children in need and those so defined who are at risk of harm or other impairments to health and development
• Assessment of the needs of each child and family identified and the prevailing risk and protective factors
• Ranges of multi-agency services for children and families that are logically related to their presenting needs and to current knowledge about what interventions are likely to produce optimal outcomes
• Systems and methodologies for aggregating data, evaluating effectiveness and using this information for enhance further service development and delivery plans
• Research programmes that seeks to identify and quantify risk and protective factors for children at risk of harm, produce actuarial information on them and logically link needs, services and outcomes.

This has to be further underpinned by:

• An understanding of child development and the role of risk and protective factors within it.
• A common language that employs concepts acceptable and meaningful to all professionals responsible for children. This should be based on the concepts of need, service, outcome, risk and protective factors and threshold and not on broad concepts such as 'vulnerable' or 'disturbed' as these have too many different meanings to be useful. Neither should it rely on technical terms specific to particular professions, such as 'failure to thrive' or 'conduct disordered' which tend to be misused when applied more widely across agencies.
• A system of recording information that is acceptable and useful to all professions, is accurate and up to date, serves clinical, management and research functions, signposts immediately key developmental data, social histories and other service involvement and comprises a single information set or file that follows the child, and which is kept by the child and family.

If such a system is in place, there should be fewer deaths and serious injuries to children who are known to services. This is because the various components of children's services are linked more effectively. One of the weaknesses found in numerous research studies and enquiries is that while individual service contributions can be impressive, they do not add up to a satisfactory whole and outcomes for children and families remain poor. Thus, the Victoria Climbié situation that occurred in England whereby a young girl at obvious risk of harm was seen by a plethora of agencies and professionals but without subsequent action to ensure her safety, leading to her death at the hands of her carers, should not arise using such a system. Those children who are killed or seriously injured in 'unpredictable' incidents will also be better protected as many of them are likely to be identified as children in need for other reasons.

A problem remains for those killed or injured who have never been identified as being in need. For them the service is obviously inadequate and something more radical, but as yet unfashioned let alone tried and tested, will have to be developed. However, the possibility of better protecting such children is more likely to be achieved in this service context as the post-incident review takes place in a culture of analysis, evaluation and change rather than as a separate inquisition. Thus, all children at risk of harm should benefit from the type of children and family services described because the conclusions of child death and serious injury reviews are more likely to be sober and practical and to be heard and acted on as they feed a process of continuing service evaluation and development.

The report concludes that while a review might be deemed 'good' as an isolated exercise, it may be less effective at contributing to service development. If reviews are to achieve their aims of improving prevention and meeting the needs of children at risk of harm, they are best viewed as making a specialist contribution to a continuing programme of needs analysis, service design and evaluation of outcomes of interventions with children and families.

Nick Axford and Roger Bullock, Child Death And Significant Case Reviews:International Approaches, Dartington Social Research Unit, 2005
It is available on the websites of the Scottish Executive ( www.scotland.gsi.gov.uk/insight) and the Warren House Group at Dartington ( www.whg.org.uk)

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1 These are: Australia, Belgium, Canada, England, Germany, Ireland, Israel, Jordan, New Zealand, NorthernIreland, Norway,Scotland, South Africa, Switzerland, US and Wales
2 This study has faced a difficulty intrinsic to all international comparisons of trying to generalise aboutcountries that have different traditions and policies within them. For instance, the legislation of each USstate is unique and 22 of the 50 states review child deaths from all causes and 6 of them only deaths due tomaltreatment. Similarly,thereis no uniform system of child death reviews across states in Australia.