Investigation and Referrals

Procedures on Bruises in Pre-Mobile children

Notes from presentation ‘Procedures on Bruises in Pre-Mobile Children – why we need improved standards for policy making’ by Andy Bilson, Emeritus Professor of Social Work, University of Central Lancashire. 

AB requests that all local authorities review their policies and don’t make automatic section 47 referrals. Looking at bruising to a 4 week old baby. 2, 2cm bruises. What can have caused them? 

In this case, parent could offer no explanation. But these bruises were caused by baby suckling on his arm when hungry. Full child protection review, then baby was witnessed suckling his arm. This is not uncommon. 

Automatic investigation of any bruise under section 47, AB says is ‘not technically legal’. 

AB is going to

  • review the evidence base on accidental bruising,
  • review the procedures for pre-mobile children and
  • consider the impact of procedures. 

Impact on parent whose children was removed. Assumption that one bruise was good enough evidence to suggest child at risk of significant harm. ‘All I did was cry. I didn’t sleep’. 

Evidence base in RCPCH review – Pierce 2016. Under 6 months, 1.3% had a bruise (18/1395) – children seen at hospital. only one occasion of observation. Problems with research. Rates of bruising massively different between the 3 hospitals. 

Kemp 2015 – in Wales. Recruited people to report on weekly basis 1-12 weeks if their child had a bruise. Nurses visited to ensure accuracy.5.3% (7/133) had bruise. didn’t find any NA bruises. 

This was as high as 10.9% if baby rolling, 1.3% if not rolling. Longitudinal data. Over 7-8 weeks, 27% of babies had a non accidental bruise. Therefore 1 in 4 babies had a bruise over a period. 

Sugar 1999 – large study ‘children who don’t cruise, rarely bruise’. This has been disseminated widely. Pre-cruisers 2.2% (11/511). 0.6% ‘no upright ambulation’. Excluded abuse. African American children 3 times less likely to be bruised than white children. 

Carpenter 1999 – less than 6 months 4% 4/101. looked at a small number of children but over many occasions. Relies on parents reporting from local community. 

Challenge myths – accidental bruising in babies is NOT rare. Children can crawl from 4 months. ratio of accidental bruises to those leading to child protection plans is at least 1900 to 1. NO studies show bruising is ‘sentinel injury’. 

if ‘sentinel injury’ would expect Welsh study to show a higher number of children going on to be serious harmed. We orient to see bruises in a particular way. Expectation that parents will notice bruises. 

Causes in Welsh study – lying on dummy, children hit themselves in face with something. Toy dropped by sibling. 

Review of procedures – concern is that the wrong kind of policies and procedures will make parents more wary about seeking help. 

Since Dec 2010 AB has examined 147 Safeguarding Children Partnerships policies – 35 didn’t have ANY definition of ‘pre-mobile’. 12 treated rolling children as mobile, 25 did not! 74 included all children under 6 months. Big difference in Kemp study between rolling and not rolling. 

impact of getting this wrong in both directions is a problem – must avoid over and under reaction. 

Tendency to exaggerate – 20 LA procedures say any bruise is ‘highly predictive’ of child abuse. Almost all say that accidental bruises are ‘very rare’ – this is misunderstanding of statistics. 2% is not ‘rare’. 

Many procedures say ‘a small percentage of bruising in children not independently mobile will have innocent explanation or medical cause’ – they are trying not to miss anything but AB doesn’t think this is the right thing to do. 

18 LA ignore research and claim that infants do NOT bruise themselves by lying on dummy or banging themselves with rattles etc. and say that a self inflicted explanation should be rejected. 

Moving straight to section 47 investigation is therefore unlawful, as no reasonable cause. 

Almost all procedures require referral to CSC and a paediatrician. 27 LA required strategy meeting in all cases. That isn’t following national guidelines. 8 LA require immediate section 47 for bruises on any pre-mobile children. 

Bedford Borough – following 3 Serious Case Reviews, automatic section 47 for any child under 6 months who has any kind of physical injury. e.g. bruise, thermal injury, clinical or radiological evidence of fracture. 

Only challenge to section 47 is by judicial review and only one reported case – Judge commented on how significant a process this is 

A social worker wants to investigate how I am caring for my child

This is a post by Sarah Phillimore. 

What gives a social worker the power to investigate my family?

Children’s Services have two basic functions; to help and support families stay together but also to make application to the court to remove children from those families if they think there is a risk of serious harm. There is clearly a tension between these two different roles and the dividing line is not always clear between ‘support’  – which must be something you agree to have – and ‘removal’ – which is usually something forced on parents against their will.

However,as Lady Hale said in Williams v Hackney in 2018 when talking about children in section 20 accommodation, who might be there to provide their parents with some respite, or might be there because of worries about how safe they were at home:

In practice, the distinction between these categories is not always clear cut. Some accommodated children in need may also be at risk of harm if they are left at or returned home. In law, however, the distinction is clear. Compulsory intervention in the lives of children and their families requires the sanction of a court process. Providing them with a service does not.

Section 47 and sharing information

If the social workers at your local authority (LA) are given information that makes them worry your children are at risk, unless the situation is one of obvious and immediate danger (when the police should probably be called), the LA will need to carry out an investigation to decide if it should  make an application to the court or instead offer the family some support.

The important statutory provision here is section 47 of the Children Act 1989 which sets out the LAs duty to investigate:

Where a local authority—

(a) are informed that a child who lives, or is found, in their area—

(i) is the subject of an emergency protection order; or

(ii) is in police protection; . . .

(b) have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm,

the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.

When it goes wrong – AB and CD and the London Borough of Haringey

A case involving the LB of Haringey heard in November 2012 makes an interesting read.

There is a good blog post about it here if you want more detail.

Someone got in touch with the Haringey child protection team, making an anonymous allegation about two parents who happened to be child protection professionals. A social worker contacted the child’s GP and school for information before calling the parents. The mother reacted very angrily to the call, as no one had informed the parents before trying to get this information. Haringey was alarmed by her response and decided to carry out  a full child protection inquiry under section 47 of the Children Act 1989. No concerns were found; the original allegation was suspected to be malicious.

The parents then took legal action by way of judicial review and were awarded damages against Haringey.

What went wrong? The tension between support and investigation.

There will always be a tension between the role of the social worker in carrying out child protection investigations and assessing a family to offer help and support. Obviously, the more serious the worries about a child, the quicker they may have to act. But to act too quickly and on  limited information could also be very damaging.

Hilary Searing comments on this tension:

It strikes me that parents need to be very clear about whether there are actually grounds for a social worker to become involved. Social workers carry dual responsibilities – for welfare and protection. In the welfare role the focus is on the child’s development in the broadest sense and in providing appropriate services. Social work support is only provided with the voluntary agreement of parents, and parents have the right to decline the offer of an assessment.

However, in the child protection role the social worker has powers and duties defined by the 1989 Children Act which includes powers to investigate suspected abuse and neglect. When a sec 47 is carried out social workers are also permitted to obtain confidential information without consent.
 In ‘welfare’ situations there is an important principle of informed consent but I get the impression that social workers are too relaxed about this and tend to forget this principle.

It is worrying if some social workers do not understand the difference between ‘welfare concerns’ and ‘risk of significant harm’ and are incapable of explaining this to parents.

Hilary further explores this issue and the importance of understanding what is meant by ‘significant harm’ in this blog post. 

When can a social worker try to get information about your child?

The Data Protection Act sets out the limited circumstances in which it is permitted to share data:

  • If you agree
  • If the data has to be shared to enable someone to do what they are required to do by statute (‘the statutory gateway’)

Section 47 of the Children Act is a clear example of such a ‘statutory gateway’ to data sharing.

But in the case discussed above, Haringey had NOT started a section 47 investigation when they tried to get information from the child’s school or GP. The parents certainly hadn’t consented because they didn’t know. Therefore Haringey’s actions were unlawful.


But why is this a bad thing? Shouldn’t we be able to share any information we have in order to keep children safe?

Procedures matter and failure to follow them can have a number of serious consequences. Not only can this undermine the ability of the parents to work together with the LA, there are also legal implications if you fail to give sufficient protection to an individual’s right to privacy. In addition, as the court set out in the Haringey case, the consequences of a section 47 investigation can be very serious.

Section 47 enquiries are multi-agency in their scope and they will usually include such agencies as the child’s school, medical practitioner, social workers and the police. The police have an important role to play given the likelihood that in most cases where a child is suffering or is at risk of suffering significant harm, the perpetrator or perpetrators of that risk or that harm will have committed or will still be committing serious criminal offences whose victim is a child.

A section 47 enquiry involves an in-depth child-centred assessment of a child’s developmental needs, of the harm she is suffering or may suffer, of the capacity of the child’s parents or carers to respond to the child’s needs and of the family and environmental factors that are playing a role in the harm she is suffering or may suffer. This intrusive assessment should take account of the views of the different agencies involved with and the external influences on the child and it must also directly involve both the parents and the child unless this will endanger the child. The necessary fact-gathering should include sessions with the child without her parents or carers present and it should ascertain that child’s wishes and aspirations wherever possible. The assessment, known as a core assessment, must be concluded so that a holistic view may be taken of the child’s needs, of the significant harm that the child is being or is at risk of being subjected to and the steps that can be implemented for the eradication of negative influences on the child and the promotion of favourable ones on her.

A section 47 enquiry has in recent years become very damaging for the life, career and family relationships of many who are parenting or caring for the child being assessed. There are now extensive statutory checks that must be made about adults who are caring for or working with children or who are coming into contact with them in an educational, health, pastoral or care context. Thus, involvement in a section 47 enquiry may often result in the ending of a career involving contact with children. This will usually be for good reason but this is not always so and there will rarely be a means for those unfairly marked out by involvement in a section 47 enquiry to eradicate that stain on their professional and personal reputation.

A section 47 enquiry can of course prove to be very damaging for a child, for her parents and for their mutual relationships. In particular, the lives of parents can be badly affected if and when adverse conclusions are made about the harm that they have inflicted on their child. These can include criminal prosecution, the loss or their child, intrusive involvement in their family and private lives, loss of employment or being barred from working with children and an adverse entry on their records held by reporting authorities such as the police and various regulatory bodies. A particular trigger for any of these adverse effects is the fact that a section 47 enquiry was undertaken in relation to their child at all since its threshold is that significant harm has occurred or that there is a risk of it occurring. Thus, a section 47 enquiry, which will often be reportable by the parents concerned, can blight their lives irrespective of the nature and extent of the significant harm or of their involvement in it or of the reasonableness of the suspicion that generated the enquiry in the first place.

Social work perspective on this judicial view

Hilary Searing has concerns about the Judge’s perspective on section 47 investigations:

I strongly dispute the argument put forward in the Haringey case that ‘A section 47 enquiry has in recent years become very damaging for the life, career and family relationships of many who are parenting or caring for the child being assessed.’ Surely this is only the case following a police investigation into an alleged offence? It is completely different from a social work investigation in a Sec 47. You need to be aware that where concerns do not seem serious enough for police involvement there may still be sufficient concerns about the child’s safety to warrant a Sec 47 – sometimes there is a sole agency investigation by social services. Social workers are caring people and I cannot imagine a situation where a single home visit/interview would result in so much serious damage to individuals and relationships!

In 2012-3 only 41% of Sec 47s carried out in England resulted in the child being made the subject of a Child Protection Plan. In my experience, the investigation should focus on the cause for concern, such as a suspicious injury or an allegation, and gathering the facts around this in order to clarify the situation. In many cases the concerns do not merit further investigation but there may have been a family crisis (e.g. the concerns might be about a domestic incident where a child was present) and the social work role is to offer help in dealing with the underlying problems which have come to the surface. The family may have reached breaking point and is willing to co-operate with social workers on a voluntary basis.

While I understand you are bound to present the legal position from the perspective of parents you should be aware that from the social work perspective our view of a Sec 47 is that it serves an important function in identifying children who may be suffering cruelty and extreme neglect. It is sometimes a way for social workers to get into families who are on the borderline of ‘likelihood of significant harm’ and an opportunity to work with them in a structured, supportive way to prevent the need for care.

The need for balance

Even on this brief examination of different perspectives, we can see how important it is to continue to try to strike the right balance between the need to protect children and the need to intervene only when it is proportionate and appropriate.

The 2010 edition of ‘Working Together To Safeguard Children’  at para 5.3 discussed what should be done when working with children when there are concerns about their safety and welfare.

Achieving good outcomes for children requires all those with responsibility for assessment and the provision of services to work together according to an agreed plan of action. Effective collaboration requires organisations and people to be clear about:

  • their roles and responsibilities for safeguarding and promoting the welfare of children (see the Statutory guidance on making arrangements to safeguard and promote the welfare of children under section 11 of the Children Act 2004 (2007) and Chapter 2);
  • the purpose of their activity, the decisions required at each stage of the process and the planned outcomes for the child and family members;
  •  the legislative basis for the work;
  • the policies and procedures to be followed, including the way in which information will be shared across professional boundaries and within agencies, and recorded for each child;
  • which organisation, team or professional has lead responsibility and the precise roles of everyone else who is involved, including the way in which children and family members will be involved; and
  • any timescales set down in regulations or guidance which govern the completion of assessments, making of plans and timing of reviews.

This has been replaced by the 2013 edition which discusses sharing information in Chapter 1 at para 22.  The emphasis appears to have shifted from the earlier guidance about achieving good outcomes to a move to emphasising the importance of sharing information about children who could be at risk. However, there remains a clear need to have procedures in place to ensure that risk is properly identified and information appropriately shared.

The guidance was again updated in 2018.This appears to have expanded significantly upon the 2010 guidance and talks explicitly about data protection law and the need for practitioners to feel confident in how they apply its principles and exceptions. The relevant part now reads:

Effective sharing of information between practitioners and local organisations and agencies is essential for early identification of need, assessment and service provision to keep children safe. Serious case reviews (SCRs13) have highlighted that missed opportunities to record, understand the significance of and share information in a timely manner can have severe consequences for the safety and welfare of children.

The key points made are that practitioners should

  • be proactive in sharing information as early as possible
  • be alert to sharing information which may impact the child’s safety
  • recognise that Information sharing is also essential for the identification of patterns of behaviour
  • consider how to build positive relationships with other areas to ensure that relevant information is shared
  • have arrangements in place that set out clearly the processes and the principles for sharing information.
  • not assume that someone else will pass on information that they think may be critical to keeping a child safe
  • aim to gain consent to share information, but be mindful of situations where to do so would place a child at increased risk of harm.
  • have due regard to the relevant data protection principles which allow them to share personal information, as provided for in the Data Protection Act 2018 and the General Data Protection Regulation (GDPR).
  • be confident of the processing conditions under the Data Protection Act 2018 and the GDPR which allow them to store and share information for safeguarding purposes, including information which is sensitive and personal, and should be treated as ‘special category personal data’

Fears about sharing information must not be allowed to stand in the way of the need to promote the welfare, and protect the safety, of children, which must always be the paramount concern. To ensure effective safeguarding arrangements:

The parents in the Haringey case had a clear advantage over many other parents who might get such a phone call – they knew that Haringey was not following correct procedures. Not many parents could be expected to have their levels of knowledge about how the system worked.  This explains why it is clearly demanded of social workers that they help service users understand and exercise their rights.


Further reading

Assessing Children and Families  – an NSPCC factsheet November 2017

If you are not happy with the way an investigation has been carried out, see our post on making a complaint. 

You may also be interested in our post about how child protection issues get reported to Children’s Services.






The impact of investigation and the need for professionalism

We know that if the professionals in the child protection system are told that a child is being hurt or at risk of being hurt, they have to act. And that can sometimes mean an intrusive investigation into the family and some difficult questions. 

Here we set out some of the words of parents who have been investigated and no concerns were found – and how they found the experience. 

We hope that all who work in this field can recognise the potentially enormous impact of their interventions and will appreciate the importance of remaining professional in all their interactions. 


One mother’s story

This mother had to deal with an investigation following something her son said at school. Nothing came of the investigation but she is still dealing with its aftermath and her shock at the attitude of some of the investigating professionals. 

There were no concerns about my son until an unqualified student with no experience of autism turned an informal chat into a ‘therapy session’ in which she questioned him as to why he ‘looked sad’. This led him to become anxious and confused. A referral was made on the basis of what he said during this session.

We were not informed that a referral had been made and my son was sent home and was in great distress when he tried to explain what had happened.

I think I was so shocked at what had happened to us because I had spent 10 years putting everything I had into the children, particularly my son (with SN and who we had adopted) and my daughter who had died of cancer.

I remember thinking ‘what more do they expect of me? What more do I have to do to prove that my children are the most important thing in the world, that I would do anything to keep them safe?’

The thing that had kept me going after my daughter was the knowledge that I had done everything I could for her and I had felt proud that we had fought for our son. That he had been handed to us out of the blue because a relative couldn’t care for him and I had dropped everything to take him as one of our own.

But none of that seemed to mean anything and ever since I feel I have lost my credentials as a good mother. I have never been a brilliant or perfect or complacent mother but I knew that I did my best.

And all that seemed to have been snatched from me. For no good reason. Through the unprofessional behaviour of others. To those professionals it was a routine thing that was done and dusted and nothing came of it.

Not to me.

I have done the initial complaint and the response was rubbish. I am still working up to the second one. It is one of the very few times I have wished I was rich. Just so I could pay a solicitor to deal with it (even though its not a strictly legal matter).

The arrogance is breathtaking. I quoted paragraphs from the area guidelines and their own policy and the person dealing with my complaint just ignored the things he couldn’t justify!

I know I have to get on with it but ….GAH…I hate it.


Another experience

I think it shakes your confidence in your ability to keep your child safe to be honest,  and your trust in the health profession as well. Once my son was referred on every professional acknowledged that I was a knowledgeable and experienced parent who handled ds sensitively and that helped a great deal.
Five years after my son’s diagnosis I had my daughter and she restored my confidence, I escaped the pnd and puerperal psychosis, my daughter was a model baby and when she was diagnosed with autism at two it was so smoothly done (No one would have dared doubted me by then).
The anger has gone, I look back and just feel sad now and grateful in a way that it was autism because had it been something life threatening I’m in no doubt that my concerns wouldn’t have been listened to or acted upon until it was too late.
I’ve done the tribunal and judicial review to get my son into independent specialist school so you have my sympathy but I learned from my complaint to keep meticulous notes and they helped enormously.


My son was my fourth child, I was never neurotic, I had never expressed any concerns about the others, never needed any support and the others thrived. Suddenly that all counted for nothing, they totally dismissed that I knew what the average child should be able to do and my son was nothing like average.
I even said I thought it was autism (because my son presented as classical autism and I was looking for reasons why) but that was seen as being proof it was MBP. The psychiatrist himself asked for referral for assessment for autism because it was so obvious and yet the GPs thought they knew better than the psychiatrist and the SALT.


Their arrogance astounds me to this day.
The HV was forced to retire soon after my complaint when a baby nearly died because of her advice but the GPs are still there and it’s an open secret in this area that if a child enters school with developmental difficulties that haven’t been noticed or addressed the child is at that practise so my complaint counted for nothing in the end.
Hang in there,  go through every complaints procedure, it’s bloody frustrating but I got a little pleasure knowing I was giving them extra work and they were shit scared up before the health authority which pleased me no end.

You may also be interested in our post  – what if the doctors don’t believe my child is really ill?

How do child protection issues get reported?

From 2011 – 2012 over 600,000 children were referred to local authority children’s social care services because of concerns about their welfare.  This number decreased by 1.9% for the year end 31st March 2013. See the most recent statistics from the Department of Education. 

In this post we look at the routes of referral and what happens when a referral is made.


Structure of child protection in England

The Department of Education is the government department which is responsible for children’s welfare. It will consider what changes to the law and policy are needed and issue guidance for those agencies who deal with children such as schools and local authorities.

The Children Act 2004 set up Local Safeguarding Children Boards (LSCB) to ensure all the relevant agencies work together, such as local authorities, health authorities and the police. Each LSCB has to produce an annual report.

The key statutory agency involved in child protection is the local authority (LA). Each LA has a Director of Children’s Services (DCS) who has ultimate responsibility for the provision of local education and social services for children.   An elected local councillor with be the ‘lead member’ and the DCS, the lead member and the LSCB work together to produce and implement child protection procedures.

The main policy guidance is Working Together to Safeguard Children which first came out in 1999. The main statutes are Part IV of the Children Act 1989 and the Children and Families Act 2014


Who reports concerns about child protection?

The public

  • By calling the child protection team of their Local Authority; the emergency team can be called out of hours. The telephone numbers should be easily available; or
  • If it is an emergency, call the police; or
  • telephone the NSPCC on 0808 800 5000 or email [email protected].T

There is a useful article from the Guardian, discussing what members of the public can do if they witness something that makes them worried about a child. 

The police

The police have special powers to take a child into police protection for up to 72 hours without getting the court’s permission first. They should only exercise these powers in truly urgent and exceptional circumstances. They have the power to take a child to a place of safety – such as a hospital – or stop someone else trying to take the child away from a place of safety. You can find the police powers set out in section 46 of the Children Act 1989.

Schools and hospitals

All professionals who have regular contact with children ought to have clear procedures in place for how they will respond to any worries about a child they see. There should be someone who is clearly identified as the designated child protection teacher or nurse/doctor who will deal with the concern when it is first reported.

There is at the current time no legal requirement to report suspected child abuse. There are many who believe that this should change  – see for example the campaign following the death of Daniel Pelka.

Here is a useful article from the  website for doctors which discusses how to recognise abuse or a child at risk.

Risk assessments by Cafcass

Under section 16A of the Children Act 1989, if you are involved in ‘private law’ proceedings – i.e. you are asking the court to help resolve a dispute between parents about their children – an officer of Cafcass may have to carry out a risk assessment if he or she has cause to believe a child is at risk of harm and may have to then refer the matter on to Children’s Services.


What happens when the referral is made to the SW Team?

The team must decide quickly what action to take; they have one working day. If the team decides it needs more information to make a decision it will start a process of further assessment.

The initial assessment should be done within 10 working days of the referral. If this assessment indicates serious concerns then a strategy discussion takes place to decide whether or not to start an inquiry under section 47 of the Children Act 1989. Usually a ‘core assessment’ should take place to gather the relevant information from the parents, the child (if old enough) and other professionals. Core Assessments should be finished within 35 working days of the referral.

If the section 47 enquiry shows there are serious worries about the child, the LA then has decide what to do to protect the child. The more serious and urgent concerns should mean that  the LA make an application to the court for a care or supervision order. Other concerns may mean that the LA write out a ‘child protection plan’ so that everyone knows what they need to do to keep an eye on the situation or to take active steps to stop it getting any worse.

If the situation is VERY urgent, the LA can apply to the court for an Emergency Protection Order under section 44 of the Children Act which gives the LA permission to remove a child from home for up to 8 days. Another emergency option is to apply to the court under section 38A of the Children Act for an exclusion order to ban someone from remaining in or coming to the family home. Or the LA could ask the police for help, as the police could use their special powers to remove a child for 72 hours.

Have a look at this ‘map’ of the child protection system from the Children’s Legal Centre.



Child protection conferences and plans

If the outcome of the section 47 investigation confirms that the situation is worrying enough to need continued LA involvement,  then a child protection conference must be held within 15 working days of the last strategy discussion. The family, and all the relevant professionals will be invited to this meeting, as well as the child if he is old enough to understand what is going on.

Those at the conference will need to decide whether a child protection plan is needed.  These plans replaced the child protection register in April 2008, but the criteria for inclusion remains the same.

Plans should be agreed by everyone where possible and set out

  • the intended short and long term outcomes are for the child
  • how children’s services will monitor the child’s welfare
  • what needs to change to reduce the risk of harm to the child; and
  • what support will be offered to the family.

The child protection plan should be regularly reviewed; the first review should happen within 3 months and then at six monthly intervals after that. 


What happens if the situation doesn’t get better?

Then the LA will need to seriously think about asking the court to make a care or supervision order, which could mean that the child is taken away from the family. If the LA decide that things are so serious that they need to go to court, they should start the ‘Pre-Proceedings Procedure’ and they will explain to the parents in a letter why they are so concerned.

This information from the Government explains the pre-proceedings procedure and what parents need to do.

If the situation suddenly gets very bad then the LA may decide it needs to act very quickly and may apply for an Emergency Protection Order, as explained above.

See further our post about Care and Supervision orders and Interim Care orders.

‘Working Together’ – Serious Case Reviews and Local Safeguarding Children Boards

We are grateful to this contribution from Philiip Measures, a Social Worker. He is concerned about the current operation of Serious Case Reviews and the potentially damaging impact this may have on their integrity and focus. 

Serious Case Reviews are conducted when something has gone very badly wrong – for example a child has died. Here is an example of a Serious Case Review, carried out to investigate the death of Daniel Pelka when in the care of his mother and step father. 


Individual Management Reviews in Serious Case Reviews.

Under the new ‘Working Together to Safeguard Children (2013)’ multi-agency Guidance many people may be as surprised and amazed as I am to discover that the requirement for organisations to undertake Individual Management Reviews (IMR’s) in Serious Case Reviews (SCR’s) has been removed. IMR’s were the individual Agency Reports submitted to the SCR Independent Chair who could then pull them together and report from a, hopefully, informed and detailed basis and also seek further clarification on any matters arising.

See the summary of working together to safeguard children and

SO, how do we ascertain and have faith in the integrity, independence and correct focus of Serious Case Reviews if so much detailed information does not now have to be provided?

My starting point had to be the Guidance- so I saw at Paras. 37 and 38 that:

37) Each child who has been referred into local authority children’s social care

should have an individual assessment to respond to their needs and to

understand the impact of any parental behaviour on them as an individual.

Local authorities have to give due regard to a child’s age and understanding

when determining what (if any) services to provide under section 17 of the

Children Act 1989, and before making decisions about action to be taken to

protect individual children under section 47 of the Children Act 1989.


38) Every assessment must be informed by the views of the child as well as the

family. Children should, wherever possible, be seen alone and local authority

children’s social care has a duty to ascertain the child’s wishes and feelings

regarding the provision of services to be delivered.

It is important to  understand the resilience of the individual child when planning appropriate services.

Communication with the Department of Education

I sent 2 emails to the Department of Education of a more general nature and received their responses:

Dear Mr Measures
Thank you for your emails of 9 December and 23 December, regarding serious case reviews (SCRs) and local safeguarding children boards (LSCBs). I am providing a single response as there are areas which cross over between the two emails, and I trust this is acceptable. I also apologise for the delay in replying.The government is clear that professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. When things go wrong there needs to be a rigorous, objective and transparent analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children.Our statutory guidance, ‘Working Together to Safeguard Children’ (2013), is clear that the final decision on whether to conduct a SCR rests with the Chair of the LSCB, who should be independent from any local agency in order to hold them to account.Where a decision is made not to initiate a SCR, information should be provided to the national panel of independent experts on SCRs to enable them to scrutinise the decision. Where a SCR is initiated, the LSCB should appoint one or more suitable individuals to lead the SCR who are independent of the LSCB and the organisations involved in the case.’Working Together to Safeguard Children’ (2013) has removed the requirement for individual agencies to provide independent management reviews, and gives LSCBs increased freedom to use a range of learning models. This includes methodologies which are designed to get professionals thinking about the systems that they work within, and to challenge those systems and identify where weaknesses exist.

The involvement of front line professionals, and family members, in the review process is the key to drawing out clear understanding of how things seemed at that time and why decisions were made. Those who have taken part in this type of SCR are clear that the learning begins as the review unfolds, which is quite different to the historical method of conducting SCRs.(redacted)

LSCBs make a vital contribution to our safeguarding agenda, and play an important role in keeping children safe. ‘Working Together to Safeguard Children’ (2013) sets out the legislation which underpins LSCBs and their statutory objectives and functions. It makes it clear that each local authority (LA) is required to establish a LSCB for their area, and specifies the organisations and individuals that should be represented on LSCBs. It is also clear that LSCBs should be independent in order to provide effective scrutiny, and should not be subordinate to, nor subsumed within, other local structures. The accountability of LSCBs has been strengthened by requiring the Chief Executive of the LA to be responsible for the appointment of the Chair, rather than the Director of Children’s Services as was previously the case. The Chief Executive, drawing on other LSCB partners and, where appropriate, the Lead Member, will also hold the Chair to account for the effective working of the LSCB.

I can confirm that LSCBs are not public authorities for the purposes of the Freedom of Information Act 2000. LSCBs aremade up of many agencies and information requests should therefore be directed to the LA or relevant partner agency.

From November 2013, Ofsted has been carrying out reviews of LSCBs, alongside their inspection of services for children in need of help or protection, children looked after and care leavers. This is an important development and is the first time that there has been an evaluation of this kind. This will provide increased rigour to the knowledge and understanding of the strengths and weaknesses in the overall system.


Thank you again for writing and I hope this is helpful.


Well, it was informative and rather an eye-opener:

a) LSCB’s are no longer Public Bodies

b) Their Chairs are now appointed by Local Authority Chief Execs.

c) OFSTED inspect them.

I also asked about the Independent Panel and the Department of Education DoE) responded as follows:

 The Independent Panel

Dear Mr Measures
Thank you for your further email of 9 January, regarding the role of the serious case review (SCR) panel and individual agency reports.The government announced in ‘Working Together to Safeguard Children (2013)’ that a national panel of independent experts would be established to advise local safeguarding children boards (LSCBs) about the initiation and publication of SCRs. The panel has been fully operational since July 2013. Each panel member draws on their own area of expertise when considering the decisions made by LSCBs.Panel members are:

  • Peter Wanless, Chief Executive of the NSPCC
  • Nicholas Dann, Head of International Development at the Air Accidents Investigation Branch (AAIB)
  • Elizabeth Clarke, practicing barrister and specialist in family law
  • Jenni Russell, journalist

In addition to the panel, the department is funding the NSPCC to run training courses for independent authors of SCRs and LSCB chairs and members. The training concentrates on the need to keep asking ‘why’ when carrying out SCRs, in order to delve beneath the surface and establish what, if anything, went wrong within organisations. ‘Working Together to Safeguard Children (2013)’ states that, as part of the review process, LSCBs may decide to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. However, it is for LSCBs to decide whether such an approach is appropriate and proportionate to the scale and level of complexity of the issues being examined.

Thank you again for writing and I hope this is helpful.



Concerns about the nature of  the available expertise

Well, frankly, NO I didn’t find it helpful – informative, yes, but helpful? No. An Air Accident investigator and a journalist – as ‘experts’? – come on DoE, whose leg are you pulling? Where are the ‘experts’ from Health, Education and the Police? These are 3 of the main agencies involved in Child Protection.

So does this new methodology represent a positive way forward? I absolutely believe that it doesn’t for the simple reasons that without access to a clear, and forensically detailed Chronology, how can it be possible to really tell the child’s story?

We need to be able to make sense of the full family background

Unless we can clearly make sense of the full family background (Social History) and see that important / significant events have been properly evaluated and assessed how can it be possible to even question on any authoritative basis the Conclusions of SCR’s because absolutely vital information may be absent – either my omission or commission? Agencies may provide reports which, if open to more detailed scrutiny, may require further investigation.

Also, in order to learn lessons we need the fullest information:

a) What significant events took place?

b) Did any meet the Threshold Criteria for intervention by any of the agencies who were aware? (to include legal intervention,  calling a multi-disciplinary Child Protection Conference; referral to MARAC etc.)

c) What responses, if any, ensued? (to include further information gathering and sharing / clarification with other agencies)

d) Were those responses (either positive or negative) relevant, targeted; monitored / reviewed and re-evaluated?

e) Who was ‘holding’ / co-ordinating the Case?

f) Who had management oversight and was offering support?

g) Was there evidence of effective multi-agency involvement?

h)  Were there clearly defined Aims and Objectives and ‘markers’ as to how progress / levels of improved safety were to be judged as being achieved or not?

i) Also, was there evidence of appropriate training / learning from any previous SCR’s?


I would finally make a call for the routine involvement in SCR’s of experienced practitioners who are independent of the Case and the Local Authorities / agencies concerned and also for their inclusion of Overview / Expert Panels.

Unless and until it can be clearly demonstrated that SCR’s are completely open and truly independent there can neither be professional, and even more importantly, public confidence in their integrity.


Philip J Measures,

Registered Social Worker; C.Q.S.W; Cert. in Social Work (Probation & Child Care); Advanced Cert. in Working with Child Abuse; Graduate Award in Management & Leadership  in Social Care


Contact him

Philip Measures is happy to be contacted directly if you have any queries

[email protected]