5. Developing a Learning Culture
Learning from Significant and Initial Case Reviews
5.1. Working with children who are at risk of significant harm and their families is incredibly complex and challenging. It is imperative that all professionals in local front-line roles, operational management, strategic and national roles are committed to a continuous learning approach. Understanding professional practice in this context requires 'a common theoretical framework that helps individuals and organisations move beyond apportioning blame to learning together about what is helping and what is hindering efforts to help children, young people and families' (Munro, 2011:63).
5.2. From the 1990s, there has generally been a shift from an inquisitional perspective when a child dies or suffers significant harm, to a learning perspective with a greater focus on contextualising professional practice in an ecological system. However, there continues to be a high level of political and public scrutiny that can impact on an open, reflective, learning culture and result in defensive practice. As Axford and Bullock (2005:55) argue in their international review, 'there is little point searching for a 'perfect' universal model', instead we need 'to avoid perceiving child death reviews as something isolated from other developments and practices and to view their function in the light of the wider child protection process and, indeed, the whole range of services for all children at risk of impairment to their health and development'.
5.3. Drawing on a public health approach, there should be a greater emphasis on prevention strategies in relation to child deaths and significant harm. Whilst there is a wealth of research evidence on child abuse and neglect, there has been far less attention on child fatalities and how the examination of these tragedies may allow development of effective prevention initiatives (Vincent, 2013; see also, Brandon et al., 2012). The Review Group considers that learning from Significant Case Reviews to prevent deaths might be more successfully framed from a public health perspective and could be linked to the National Child Death Review System that is currently under development. It aims to ensure that information is collected in relation to all child deaths and learning shared to try to prevent future child deaths or contribute to child health and wellbeing (Scottish Government, 2016b). For example, in Australia, child death reviews are conducted on themes from which public awareness campaigns are developed.
5.4. Scottish Ministers asked the Care Inspectorate to become the central collation point and undertake qualitative evaluation on all Significant Case Reviews from 1 st April 2012. The Care Inspectorate is required to report publicly on these findings to provide independent public assurance on the quality of care for children and young people; to share any learning and signpost good practice; and to support improvements to child protection practices and policy across Scotland (see Care Inspectorate, 2015b; Care Inspectorate, 2016).
5.5. As part of the inspection process with a focus on child protection arrangements, issues were identified about the decision-making processes and quality of Significant Case Reviews (Care Inspectorate, 2014a). In March 2015, the Care Inspectorate published a Code of Practice for the Review of Significant Case Reviews for children and young people in Scotland. The Code states that as part of a commitment to further improvement, the Care Inspectorate will:
(a) seek information about all Initial Case Reviews ( ICRs) carried out by Child Protection Committees ( CPCs) to understand the rationale for proceeding or not proceeding to an SCR;
(b) act as a central collation point for all SCRs completed across Scotland at the point at which they are concluded;
(c) review the effectiveness of the processes for conducting each SCR and reporting informally to individual COGs and CPCs on good practice and areas of improvement;
(d) conduct a biennial review of all SCRs completed in Scotland, and, reporting nationally on the key learning points for the benefit of relevant services across Scotland and the Scottish Government (Care Inspectorate, 2015b).
5.6. The Review Group were of the view that to ensure access to learning across professionals involved in child protection, all Initial Case Reviews should be submitted to the Care Inspectorate for analysis and review, as well as any Significant Case Reviews; the Care Inspectorate should hold an annual learning event to disseminate findings from ICRs and SCRs at a national level; and Care Inspectorate reports should provide anonymised case studies to emphasise the learning points.
5.7. The Care Inspectorate (2016) reported on different methodological approaches for conducting SCRs and ICRs and shared concerns over the quality of analysis and consistency. A range of terminology was being used for different reviews and this was considered to be unhelpful. In the review period, four SCRs had used the Social Care Institute for Excellence ( SCIE) Learning Together model and a further two used various aspects (Care Inspectorate, 2016). A number of local areas have stated a commitment to using this model for Significant Case Reviews in the future. The Social Care Institute for Excellence ( SCIE) Learning Together model uses systems thinking to gain a deeper understanding of current local practice and cultivate an open, learning culture ( SCIE, 2012). There was caution in proposing one methodological approach; however, there was agreement that the essential elements of a SCR and ICR should be set out in the Terms of Reference. The triennial review found that SCRs were not always clear on what needed to improve and how this would be monitored by Child Protection Committees (Care Inspectorate, 2016).
5.8. There was concern about the range of timescales for SCRs that did not always correspond to the complexity of the review or the methodological approach. For example, timescales in conducting SCRs varied from 5 months to 37 months (Care Inspectorate, 2016). Twelve SCRs were conducted by a single external reviewer (out of twenty) (ibid.). There was also discussion within the Review Group about there being little evidence based information around whether or not there were varying thresholds with regard to conducting ICRs and SCRs around the country. There was a perception that some conclusions of reviews were known with 48 hours of an incident, yet the process was much longer and often found what was expected. There was a particular interest in the multi-agency professional forum approach used in Wales that could be appropriate for these cases (for more information see, Appendix F & Welsh Government, 2012).
5.9. There was mixed evidence on the national and local learning following a SCR and ICR. At a national level, there are limited learning opportunities arising from Initial Case Reviews. The Review Group considered this to be a missed opportunity as ICRs could provide a valuable understanding of child protection practice. Given the relatively small number of SCRs in Scotland and limited review of ICRs, themes could be identified from SCR and ICRs collectively. There was a concern that front-line staff are not fully involved in the dissemination and future action plans. There were some reflections that the cultural environment played a significant role in how the learning from SCRs and ICRs was considered and taken forward. The learning from SCRs and ICRs should not be considered in isolation. Although it is understandable that they are seen as a critical lens for protecting children and young people, they should only be one part of a wider improvement agenda for protecting children and young people. Local and national improvement programmes could consider sharing with the public and media system reviews where there has been learning of how children have been successfully protected when previously identified as being at risk of significant harm.
5.10. There were a range of views and experiences about the full or partial publication of SCRs. There is not a central accessible repository for all SCRs conducted to enable the sharing of information and learning across all professionals involved in child protection work. Routine publication of all SCRs could be highly sensitive for families, front-line practitioners and local areas. There was often media interest in the publication of the findings of SCRs. Examples were given where the level of redaction required to comply with data protection principles in SCRs not only delayed any publication of a summary of findings, but could severely limit learning opportunities. The Review Group considers that there could be an anonymised central repository held by the Care Inspectorate which could be accessed for research and learning (subject to appropriate research ethics procedures).
5.11. Given the issues raised regarding local and national learning, variability and timescales, the Review Group recommends that the Scottish Government should explore a new three-tiered approach to Initial Case Reviews and Significant Case Reviews, based on the ' Multi-Agency Child Practice Reviews' used in Wales (Welsh Government, 2012; see Appendix F for more information). This would involve establishing: multi-agency professional forums, concise reviews and extended reviews. In certain circumstances, reviews should focus on the previous 12 months rather than covering an extended period. It is anticipated that this approach would provide a more streamlined, flexible and proportionate approach to reviewing and learning from what are inevitably complex cases. This should ensure reviews are timely, proportionate and part of an on-going learning culture.
5.12. The Scottish Government and public service providers are committed to delivering public service reform as recommended by the Christie Commission. The Commission proposed an asset-based approach, where services are developed with people, rather than for people.
'We recommend that, in developing new patterns of service provision, public service organisations should increasingly develop and adopt positive approaches which build services around people and communities, their needs, aspirations, capacities and skills, and work to build up their autonomy and resilience' (Christie Commission, 2011:27).
At the heart of the Christie Commission reforms are preventative approaches and early intervention to tackle inequalities across Scotland. This commitment is pertinent to the provision of child protection services and greater recognition of the role that children, young people, families and communities can play. There is an opportunity for community initiatives which protect, support and promote the wellbeing of all children and young people.
5.13. As set out in the National Child Protection in Scotland Guidance (2014:40), the core functions of Child Protection Committees include public information and communication, alongside continuous improvement and strategic planning. This requires raising public awareness and involving children, young people and families. Public awareness may be focused on how a member of the public can notify appropriate services if they have concerns about a child. There may be particular areas identified (for example, raising awareness about online safety of children). There are also opportunities to consider the messages for families who are in need of support. In an English study with 42 families, the importance of publicising positive outcomes in child protection work was emphasised by one parent:
'People think they (social workers) are there to take your kids away, but they're not. They are there to help you. I think they need to …. make people understand that' (Ghaffer et al., 2012: 900).
5.14. Community knowledge about child protection is likely to be principally known through media reporting of high-profile cases where a child or young person has died and/or experienced abuse and neglect. It was observed that the media often focussed on any comment in a SCR on past practice that could have been better; without clarifying that the practice was not directly linked to the harm occurring. National development of positive news stories about professionals protecting children and franker explanations of the complexities and challenges experienced by professionals who were seeking to prevent harm was considered by the Review Group to be likely to encourage better understanding of the issues and raise public engagement.
5.15. Elected members play a pivotal role in championing the work of Child Protection Committees and making strong links to Community Planning Partnerships and other strategic planning groups. Elected members can share concerns facing local communities in regards to protecting children in a CPC planning forum. They can provide insight and support on public awareness of child protection issues. Responsibility for local accountability in the allocation of resources also lies with elected members. Improved understanding of some of the complexity in working with children and young people at risk of significant harm and the value of early intervention for local authority decision-making would be valuable.
Improving Analytical use of Data and Evidence
5.16. The ability to analyse complex data is critical to developing services to protect children and young people at a local and a national level. Part 3 (Children's Services Planning) of the Children and Young People (Scotland) Act 2014, requires every local authority and its relevant health board to jointly prepare a Children's Services Plan for the area of the local authority, in respect of each three-year period. Part 3 aims to improve outcomes for all children and young people in Scotland by ensuring that local planning and delivery of services is integrated; focused on securing quality and value through preventative approaches; and dedicated to safeguarding, supporting and promoting child wellbeing. This demands that systems be put in place to regularly collect and analyse information relating to service performance and child wellbeing.
5.17. An understanding of national and international evidence on identification, referral, service provision and long-term outcomes for children and their families should be used to inform the work of Child Protection Committees. The Review Group considers that it would be valuable to examine the reasons behind apparent variations in patterns of child protection registration across the country. One area that has been identified as having a significant impact on child abuse and neglect, but where data is rarely analysed from this perspective, is the socio-economic circumstances of families (Bywaters, et al., 2016). For example, the Care Inspectorate's (2016) review of Significant Case Reviews found that economic circumstances of families were often not recorded; however, frequent housing problems suggested material hardships.
5.18. Such information should come from a range of sources, and include both quantitative and qualitative data. The views of children, young people and families, and front-line professionals will be particularly valuable in making assessments of progress (in respect of children and young people feeling safe). Moreover, useful information will already be stored in the information management systems of Children's Services Planning partners, and by service providers, offering detailed insight into how services are working for specific groups of children. Careful consideration must be given to how such information is collected, anonymised, collated and analysed, ensuring at all times that is done in appropriate, safe and proportionate ways, in line with current data protection legislation and guidance.
5.19. Scottish Government programmes, such as, Realigning Children's Services ( RCS) can assist local authorities and relevant health boards in the development of local assessment. The RCS team helps local areas to: (1) collect data on wellbeing directly from children and parents; (2) map children's services that are currently provided and how much they cost; and (3) deliver a development and facilitation programme for community planning partners. This may be a useful resource for some Child Protection Committees. Identification of patterns and trends in referrals where there are concerns about abuse and neglect at a local level from a range of sources can inform strategic planning forums. The use of Information Technology systems across organisations also provides an opportunity to explore sharing data sources over a number of interlinked areas - for example, educational attainment, school exclusion rates, household deprivation, neighbourhood crime, missed health appointments, Accident & Emergency admissions, and missing from home incidents which could all be used to establish a picture of what is impacting locally on children and allow for more effective planning of services. This provides a wealth of information for Child Protection Committees where there is analytical capacity.
5.20. The 14 health boards in Scotland, under the auspices of the three Regional Planning Groups, have developed three regional Managed Clinical Networks ( MCNs) for child protection, to support and facilitate the delivery of consistent, equitable, high quality services to meet the needs of children and young people who may have experienced abuse and their families. It was recognised that scant data existed across health boards to capture standardised information on all paediatric forensic activity, to provide the basis for robust governance, accountability and audit arrangements. The three regional MCNs have developed a standardised data collection tool with a minimum dataset which doctors who perform child protection assessments on children and young people will be expected to complete, from January 2017. The information collected will feed into and relate to other data collection systems to inform the work of Child Protection Committees. It could also enhance the ability to 'horizon scan' for future risks for children; for example, sexual exploitation of children via the internet will evolve further with future technological advances.
5.21. Building on the expertise of data linkage programmes used in other public services arenas, there is also an opportunity to develop better understanding of children and young people's wellbeing at an individual, as well as a macro level, through connecting health, education, social work and other relevant information sources to gain a holistic understanding of children's lives to develop services that will meet their individual needs.
5.22. Information which might provide an earlier holistic overview of all matters affecting a child, and potentially highlight emerging risk at a very early stage, is not available from any one central record. Separate records relevant to each child or young person are held by the organisations employing each professional working with the child or young person. Access to these records is not given to the professionals in other organisations. Criminal Justice social workers do have access to a national Information Technology ( IT) system which holds information from across all local authorities on the adults they are engaging with, but social workers working in child protection can only access the social work information held by their own local authority IT system. Records of adult social work engagement with adults in a family where there are children are also retained separately. The professionals in police, health and education cannot access each other's systems or social work records and there is no national IT facilitated access sharing of appropriate relevant information, while maintaining necessary constitutional independencies and data protection requirements, such as occurs between police, prosecutors, courts, criminal justice social workers and prisons. This is an area which would benefit from further consideration by the proposed National Child Protection Leadership Group.
Recommendations on Developing a Learning Culture
The Care Inspectorate should become the central repository for all Initial and Significant Case Reviews and should explore the development of a 'Community of Practice' portal on the Care Inspectorate website to enable secure access to all Reviews by child protection professionals in all relevant organisations.
The Scottish Government should explore a new tiered approach to and methodology for, Initial Case Reviews and Significant Case Reviews, based on the 'Child Practice Review' model used in Wales.
A set of National Standards should be developed setting out the skills and competences required of those reviewers undertaking Initial Case Reviews and Significant Case Reviews. Appropriate involvement of the child or young person and their family should be a key component of training for reviewers and a Good Practice Guidance Note should be developed on how to engage with children, young people and families involved in Child Protection processes. This should ensure all Reviews are timely, proportionate and contribute to an on-going learning culture.
The National Child Protection Leadership Group and Child Protection Committees Scotland should support local areas to deliver robust continuous improvement programmes. This should include working with relevant organisations to synthesise and share learning from different sources including inspection, research, reviews and local practice.
The Data and Evidence work stream of the Scottish Government Child Protection Improvement Programme should develop a strategic programme to deliver robust data sets to support child protection improvement. Scottish Government should develop a national resource for advice on using child protection data for local planning and service development.
Email: Judith Ainsley