Summary of themes emerging from the 2019 Triennial Analysis of Serious Case Reviews 2014-17, presenting key messages for child and family social care. The presentation includes links to related Research in Practice resources which will be useful for learning and development activities based on the findings of this report.

1. 2019 Triennial Analysis of Serious
Case Reviews
Messages for Social Care
Professionals
1

2. Workshop objectives
› Review main learning from the report in five
key areas:
− Neglect and poverty
− Relationship-based practice
− Care and court work
− Vulnerable adolescents
− Multi-agency working
› Identify implications for children’s social care
teams
› See https://seriouscasereviews.rip.org.uk/
for further information
2

3. Key themes
› Findings based on:
− Quantitative analysis of 368 SCRs notified to DfE 2014-2017
− Detailed analysis of 278 SCR reports that were available for review
− Qualitative analysis of a sample of 63 SCR reports.
› Complexity and challenge: complexity of the lives of children and
their families, and challenges faced by practitioners seeking to
support them.
› Service landscape: challenges of working with limited resources,
high caseloads, high levels of staff turnover and fragmented services.
› Poverty: the impact of poverty, which created additional complexity,
stress and anxiety in families.
› Child protection: once a child is known to be in need of protection
the system generally works well.
3

4. Complexity and challenge
1. Complexity of
children’s and families’
lives:
› Neglect in context of
poverty
› Cumulative harm
› Emerging extra-familial
threats in adolescence
› Better assessments for
children’s long-term care
and in court processes
2. Challenges facing
professionals:
› Lack of reflective
supervision
› Enabling discussion of
different views in multi-
agency working
› Using chronologies
effectively
› Fragmented working
4

5. 5
Neglect and poverty
› Neglect was the category of abuse in 75% of all SCRS
› Most children living in poverty do not experience neglect
› Poverty leads to additional complexity, stress and anxiety and can
heighten the risk of neglect
› Parents living in poverty may:
− Have fewer social, emotional and physical resources to call upon
− Feel shame and hopelessness, which may discourage them from
seeking and accepting help
› Recognition of poverty and its impact on parenting was often missing
› Professionals reluctant to name neglect because of fear it might be a
barrier to engagement
› Cumulative risk of harm in neglect cases: low-level concerns followed
by sudden escalation of risk

6. Adverse family circumstances in
cases of neglect
6
Table 1: Parental and family adversity in SCRs where neglect
was a feature (Rates are likely to be an underestimate as they
depend on whether a factor was recorded in the SCR report; in some
cases the question may not have been asked, in others the SCR
author may not have felt the factor was relevant.)

7. Learning points
› Addressing poverty alone does not automatically keep children safe.
Practitioners should seek to understand the pathways through which
socioeconomic issues interact with other factors to influence parenting
› Professionals who work in areas of high deprivation may no longer
notice the warning signs of poverty and neglect:
− Supervision/case management is crucial to support practitioners and help
them build effective chronologies
− It is important to use language that properly and explicitly depicts issues in
ways that do not dilute impact and harm, or the reality of life for the child
› There is a dearth of information about men in SCRs. Assessment and
support pre-birth and in infancy should include both parents/other
adults in the home
› Neighbours are often aware of the difficulties families are facing.
Concerns reported by neighbours or anonymously should be recorded,
taken seriously and triangulated with other sources of information
7

8. 8
Relationship-based practice
› Positive, consistent relationships can result in increased protection for
children
› Adults’ past experiences of trauma/negative experiences of statutory
services, may leave them fearful of engaging with services:
− Practitioners need to take time to build a trusting relationship and to
understand underlying issues preventing parents’ engagement
› Relationship-based work with families requires robust management
and support for practitioners, including reflective supervision:
− Practitioners need support to examine their own values and preconceptions
and how those contribute to their interpretation of events
− Selection of cases for discussion in supervision should not be left to
practitioners alone; cases should include those with persistent ongoing
concerns below the threshold for child protection
− Supervision should explore the impact of the work on the practitioner’s
wellbeing, including feelings of powerlessness, guilt and anxiety

9. 9
Care and Court Work
From a sample of of ten SCRs involving children in care or subject
to care proceedings, the report highlights the importance of:
› Ascertaining and applying knowledge about a child’s culture,
ethnicity, religion and background in assessment and planning
› Taking account of the child’s wishes: the impact of past trauma
and instability must not constrain assessment of what the child
is saying and doing
› The court’s timescales should not undermine the need for a
thorough assessment of all potential carers
› Ongoing support post-proceedings is important for kinship
carers
› There should be clear plans for monitoring a supervision order,
including a child protection plan where appropriate

10. Vulnerable adolescents
 One in three SCRs involved
children aged 11 or over
 There is increased potential for
extra-familial risk and harm
during adolescence
 Risk-taking/violent behaviour
by the young person and child
sexual exploitation (CSE) were
the most common causes of
serious harm in adolescent
cases
 After infancy, suicide was the
most common category of
death related to maltreatment
10
› Emerging threats outside the
home include:
− going missing
− criminal exploitation (eg,
moving drugs, violence
gangs, trafficking)
− sexual exploitation
− harmful sexual behaviour
− radicalisation
› Adolescents feeling lonely and
isolated or going missing may
become vulnerable to grooming
and criminal/sexual
exploitation or radicalisation

11. Complex and Contextual Safeguarding
(Firmin et al, 2019)
11
› Complex Safeguarding
− This encompasses a range of
safeguarding issues related to
criminal activity involving
vulnerable children or
adolescents, where there is
exploitation and/or a clear or
implied safeguarding concern.
− Includes child criminal
exploitation, county lines,
modern slavery including
trafficking and child sexual
exploitation (CSE).
› Contextual Safeguarding
− This is an approach to safeguarding
children and young people which
responds to their experience of
harm outside the home – for
example, online, in parks or at
school.
− It provides a framework for local
areas to develop an approach that
engages with the extra-familial
dynamics of risk in adolescence.

12. Learning points
› It is important to recognise the relationship between adolescents’
prior experiences and their risk of harm
› Children who have experienced trauma are not quickly made safe. It
needs:
− Prolonged and persistent engagement
− A balance of preventative work and crisis management
› An adolescent going missing is a powerful signal that all is not well.
− Local Authorities should offer a return home interview within 72hrs of child
being found after missing; if declined, be persistent
− Evidence from return home interview should be shared with other agencies
› Criminal exploitation is closely linked to school exclusion, going
missing, substance misuse, loss and separation
− Responses should recognise vulnerability, not just criminal processes
− Practitioners should find ways to understand and record patterns in
adolescent group and individual behaviour to capture a holistic picture of
potential harm
12

13. Learning points
› CSE: present in 1 in 10 SCRs
− Practitioners slow to recognise vulnerability, particularly for males
− Young people must be at the centre and should not be held responsible
− Responses need to be based on a wide range of evidence
− No one agency can address CSE in isolation; collaboration is essential
− Communities and families are valuable assets and need support
− Effective services require resilient and supported practitioners (Eaton and
Holmes, 2017)
› Harmful sexual behaviour (HSB)
− May have experienced poly-victimisation: a victim as well as a perpetrator
− Must always be a therapeutic and/or safeguarding response
13

14. 14
Multi-agency working
› Sharing information between agencies and across local
authorities was an issue:
− There is a need for clear multi-agency plans at child in need or
child protection level
− Assessment and planning tools must be designed to facilitate
communication of concerns across agencies
− The lead professional's role is important for maintaining contact for
the child or family; coordinating interventions; and ‘holding’ the full
picture of the child’s life
− Cross-service chronologies and consistent use of clear descriptive
language are important
− Opportunities for professional challenge should be supported-
practitioners should feel able to ask questions about each other’s
roles and decision-making

15. Reflective questions
› What effective tools do you use when working with
neglect? How do you identify hidden poverty?
› How are ongoing, low-level concerns monitored over
time (before they could escalate)?
› How might your practice be more inclusive of men?
› How does your supervision help you maintain
professional curiosity and challenge?
› What opportunities are there for you to provide
prolonged and persistent engagement to support
adolescents?
› How do you find out about a child’s background,
culture, religion and personal identity and use the
information in planning an assessment of their
needs?
15

16. Further reading
› Brandon M, Sidebotham P, et al (2019) Complexity
and Challenge: A Triennial Review of Serious Case
Reviews 2014-2017. London: Department for
Education.
› Children’s Commissioner (2019) Keeping kids safe:
Improving safeguarding responses to gang violence
and criminal exploitation. London: Office of the
Children’s Commissioner.
› Eaton J and Holmes D (2017) Working effectively to
address child sexual exploitation: An evidence scope.
Dartington: Research in Practice.
› Firmin C, Horan J, Holmes D and Hopper G (2019)
Safeguarding during adolescence – the relationship
between Contextual Safeguarding, Complex
Safeguarding and Transitional Safeguarding.
Dartington: Research in Practice.
16

17. Contact details
17
www.rip.org.uk
ask@rip.org.uk
@researchIP