A systemic failure to protect children

Sam Preston 26 January 2024 2 min read
A systemic failure to protect children feature image

In this article, Sam Preston reflects on serious case reviews and questions whether lessons can truly be learned.

Despite the promises made time and time again following serious case reviews, lessons haven’t been learnt and we have failed to stop repeating safeguarding failures.

Kenneth and Bronson Battersby

I say this as sadly we see the launch of yet another serious case review following the tragic death of Kenneth Battersby and his two-year-old son Bronson Battersby.

Both were found dead in their home, Mr Battersby having suffered a fatal heart attack, and it is thought that starvation was the cause of Bronson’s death.

There has been much speculation on the actions of the agencies involved, the family were known to Lincolnshire’s Social Care Services and police services and already questions about their practice have prompted allegations of missed safeguarding opportunities.

What are Serious Case Reviews?

Serious case reviews generate a lot of media coverage and as we have seen time and time again, this feeds the social media frenzy, where theories are speculated fuelling an uninformed blame culture which spirals exponentially. But this frenzied machine never really gets to the heart of why, when we are supposed to be informed by each case review’s outcomes, we continue to see safeguarding failures.

When do Serious Case Reviews take place?

Serious case reviews take place when something goes seriously wrong. They’re an in-depth, multi-agency review and are usually conducted following the death or serious injury of a child due to abuse or neglect or when there are concerns about how organisations or professionals worked together to protect a child.

These reviews are essential both to get an accurate picture of what happened and to identify areas to improve the child protection system to hopefully prevent similar incidents in the future. They are a learning process, where detailed information is gathered, analysed and findings reported. To be clear, I am not criticising the process, it is robust and most definitely necessary.

The problem with many Serious Case Reviews

The problem is that in many cases what these case reviews highlight are systemic problems, caused by both a failure to adequately fund them and equally as important strategically developing them to meet modern needs.

When systemic issues are identified in a serious case review, changes to policies and procedures within agencies and organisations may be necessary and these changes should be implemented promptly. However, there are some major overarching difficulties with this. For example, we know there are significant issues with the retention of social workers. More social workers are leaving children’s services in England, than are coming in to replace them. Government workforce statistics show that in the past year, 5,400 whole-time equivalent social workers left their jobs, an increase of 9% on the previous year, which directly impacts the caseload capacity of those in post. The Institute of Health Visiting’s State of Health Visiting Report has highlighted a national shortage of around 5,000 health visitors in England, with 79% of staff saying health visiting services lack the capacity to offer a package of support to all children with identified needs.

Individuals and organisations are accountable for any failings identified in a review, which may involve disciplinary actions or legal consequences where necessary, but as I’ve just described, there are major factors in the capacity for maintaining services, never mind improving them.

A worrying picture

Let’s be clear. This is a really worrying picture. A radical reworking of strategic multi-agency development and working practices is needed. Simply updating government multi-agency policy, such as Working together to safeguard children, is not enough. We need to be brave and bold and restructure our services, where multi-agency practice is shared and carried out in unity not in silos.

Learning from Serious Case Reviews

Learning from serious case reviews is a critical aspect of improving our child protection systems and preventing future harm to children. However, if we truly want to commit to statements like ‘this should never be allowed to happen again’ we need a strategic change in our core structures, recruitment and working practices. By retaining our current structure, we sadly will continue to see safeguarding tragedies due to systemic failure.

Sam Preston

SSS Learning Safeguarding Director