Serious Case Reviews – Are they effective?

The serious case review (SCR) into the death of Noah Serra-Morrison aged 13 months has been published in the last few days. Noah, like many children before him died as a result of multiple injuries sustained over a prolonged period, inflicted within his immediate family environment by his mother’s violent partner.
It is no surprise to those of us who have dealt with many similar cases that the SCR found deficiencies in the workings of those professionals who were tasked with the keeping Noah safe. Like many previous SCRs, the same issues were identified. The family had lived in London and were known to Children’s Services but moved to an area outside London without full information about the family being passed on, as it should have been. The mother’s partner was known to be violent and was on bail for assault on a vulnerable individual at the time of Noah’s death. Somehow he was able to move into the family home without the knowledge of the authorities. Both parents were drug users.
The review identified (amongst other things) that social workers had heavy caseloads, there was a large turnover of staff and the safeguarding department experienced poor management.
Currently the purpose of a SCR is not to apportion blame to individuals but to recognise deficiencies and put in place improvement plans to try and prevent similar tragedies from reoccurring.
However, time and time again these same issues and deficiencies are highlighted. Local Authorities always state that they have or will put preventative measures in place. Meanwhile, the tragedies continue unabated and young children continue to die unnecessarily at the hands of those supposed to be exhibiting parental care.
Earlier this month the government published annual data relating to child death reviews. In the year to March 2017, of the 3555 reviews that were carried out, 3% involved the completion of a SCR – approximately 106 cases. Of this number 63% – approximately 67 cases were deemed to have modifiable factors (whether a death was preventable or potentially preventable).
Is it not time to look carefully at the value of SCRs? Unless proper procedures are put in place to ensure professionals are held to account for their actions then things will never change. As members of a civilised society should we not all be asking why we allow this situation to continue?

Colin Welsh

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