Sequeli welcomes the First Annual Report of the National Panel of Independent Experts on Serious Case Reviews

Sequeli is a social enterprise not-for-profit limited company which provides training for chairs of mental health investigations, domestic homicide reviews, children’s Serious Case Reviews (SCRs) and adult safeguarding SCRs. The First Annual Report of the National Panel of Independent Experts on Serious Case Reviews was published last month. Here, Gillian Downham, Sequeli‘s founder and Director, addresses the issue of the effectiveness of SCRs (and the training associated with them) that is raised in the Report. (652 words)

As Director of Sequeli, I have worked hard for over a year developing courses, seminars and training materials for the Department for Education’s (DfE) ‘Improving the Quality of Serious Case Reviews’ training programme. It has been a pleasure to work with experienced colleagues, among them members of the Social Care Workforce Research Unit at King’s College London, as well as the NSPCC and Action for Children. I have been steeped in the subject. So not surprisingly I have a few comments on the Panel’s first Annual Report.

Firstly, this is a very welcome Report. It is good to see the Expert Panel have been so assertive on the initiation of children’s SCRs (suspecting that alternatives to SCRs are on many occasions ‘proposed as a way of evading publication’) and publication of SCR reports. The need for independence, thoroughness, openness and proportionality has been the bedrock of the Sequeli approach and at the centre of the DfE training. It is heartening to see these mentioned throughout the Annual Report.

It seems the DfE have been heading in the right direction with their training programme. Or have they?

Nothing can be taken for granted. And the Report recommends that the DfE ‘instigate in the next 12 months a review of SCRs produced under Working Together 2013 guidance’ and ‘it should consider whether the training for SCR authors which it funded has been effective’ (Paragraph 29 bullet point 1).

This is a good proposal, but what does ‘effective’ mean? The Report mentions the word on several occasions. Is the effectiveness of a SCR to be judged by the content of its report? Or the change brought about by a report? Or change resulting from the process of the SCR itself? How is change or improvement to be identified and measured? And how can it be determined whether training has been effective? Effective at producing what outcome? There are four key points to consider.

First, I suggest part of the effectiveness (or not) of the DfE training in producing quality SCR reports can be measured reasonably straightforwardly. The training materials contain a section called ‘Features of a good review report’ which were deliberately designed to be measurable. It would be relatively simple to establish whether a final report contained these features or, if it did not, seek an explanation from the reviewer for omissions.

Second, what about effectiveness of the training and the SCR at bringing about service improvement? The link is likely to be more tenuous. Though if it can be established there is a positive connection between training and recommendations and there is evidence the recommendations have been implemented, it might be possible to deduce that the training had a positive impact on the quality of services. But most people know that caution is needed in measuring the impact of training and training has many purposes.

Third, the effectiveness of any SCR at reducing future child death and serious injury is more difficult to ascertain and some would argue near impossible. Even if services in one part of the children’s sector have been improved by means of a SCR, there might still be weaknesses in services in another. Causal links will be difficult to establish. However, SCRs are in a strong position to make a difference. They are capable of identifying service and system problems and contributing towards raising of standards, which could make similar deaths or serious injury less likely.

Lastly, as many readers of this blog will know, some SCRs relate to events that took place some time ago and the SCR may have necessarily been delayed. Caution is needed when reading or criticising recently published SCRs as they may still have been commissioned under the ‘old’ Working Together approach.

Practitioners know that making unrealistic claims for the effectiveness of SCRs does not help anyone. Work on refining and improving SCRs needs to be as rigorous as the SCRs themselves should be.

Gillian Downham is Director of Sequeli and a barrister and member of 1 Garden Court Family Law Chambers, Temple, London.

A longer version of this post is available on Sequeli’s website.

Professor Jill Manthorpe and James Blewett of the Social Care Workforce Research Unit in the Policy Institute at King’s are associates at Sequeli. See Unit research on adult SCRs.