Serious Case Reviews – Baby Peter and beyond

I have been trying, ever since Baby Peter’s tragic case, to get the Serious Case Review published. A Serious Case Review (SCR) is produced after any such case by the agencies involved in that child’s care. It tells the chronological story of who did what and when. It is an invaluable document – but it is kept secret. An Executive Summary is published – but that really doesn’t tell anything like the whole story.

I have been battling to change this – so that SCR’s can be published. In Baby Peter’s case I have asked the Information Commissioner to publish the SCR for Baby Peter. I don’t believe that the ambition of that over-used phrase ‘lessons must be learned’ can ever be fully realised if the causes and actions are hidden.

The Information Commissioner came back to me to ask for more information as to why I thought it would be in the public interest for the SCR to be published. I sent him my reasons – which I paste below – and now the Information Commissioner is going back to Haringey Council for further information. This was my email to the Commissioner:

Having been Leader of the Opposition on Haringey Council when Victoria Climbie died and now MP in half of Haringey during the Baby P tragedy – I have come to the conclusion that a contributing factor to cases like these (and others) is the secrecy, the closing ranks culture and the lack of transparency.

The Serious Case Review (version 1) which I was allowed to read virtually under lock and key in the Department of Education (where I could not make notes or record any part of the document) was an eye opener to me. The executive summary of the same document which is published did not reflect the key problems, in my view, that were at least part-causal in the eventual tragedy.

The thing that struck me most was the litany of casualness with which people did their jobs (appointments missed, not followed up; files lost, handovers not done, meetings not attended). There was a litany of failures like these at every level, virtually by every person and every agency. I think that most people would expect that once a child is on the protection register and their case being brought to the Safeguarding Board – that there would be a rigour about all aspects connected with them.

This casualness and lack of care is only really demonstrated if you get to read the whole document. It does not come through in the summary and itself is cumulatively causal in my view.

Literally hundreds of professionals across the country emailed me about their knowledge and experience – as did the general public. I believe that the phrase which is dragged out ‘lessons will be learned’ won’t be fully possible if the facts of the case and the failures in the case are kept hidden. As I say, the Executive Summary, does not reveal the extent of the small, but cumulative failures – which I believe many professionals would recognise in their own fields and therefore be able to do something about. Therefore it must be in the public interest to be able to see the whole document.

Simply issuing another 150 Laming-like recommendations every time a tragedy happens simply adds procedures that take professionals away from their work without ever being able to see the why and wherefore of such recommendations – nor to judge or be able to critique the new ways from an informed position. The issues are kept between local authority, the other agencies and the Government – so keeping out those who would, could and should benefit from reading the whole story.

I am not an expert nor a professional – but unless and until we really open out all the issues around cases such as these – there will continue to be an air of defensiveness and self-protection which work against the safety and well-being of children at risk.

Social workers need to work in an atmosphere of support and good management – which can only come from opening up the real events, letting them stand there for all to see – and those in the professions taking those lessons away.

The argument Ed Balls makes to me against publishing the Serious Case Review (s) is that staff would not speak freely if they knew that what they said might be published. My view is that anyone working in any field where there is such an event has a duty to speak and say what happened. They would have to if the case goes to public inquiry or hearing. Names and personal information should be anonymized. It was anyway in the SCR I read and social workers were referred to as social worker 1 or social worker 2. It is also the case that quite a lot of time elapses between the event and the publication as the SCR is written immediately (usually) and the case and the trial and exposure comes much later.

OFSTED did an audit of Serious Case Reviews and found that nearly two thirds, I believe, were inadequate. So – additionally – this would not have come to light without OFSTED’s exposure. If they were published – these inadequate SCRs would have been exposed much earlier. So – whilst the Serious Case Review I am most concerned about is obviously the Haringey one – it is clear there is a wider issue too.

So – I believe it is totally in the public interest for the Serious Case Review to be published. Secrecy, lack of transparency and openess and closing ranks are at the heart of the problem in Haringey.

I hope you find in favour of publication.

Kind regards
Lynne Feathestone

0 thoughts on “Serious Case Reviews – Baby Peter and beyond

  1. Excellent as always on this case. Why they could even ask you for more information is an indication of how wrongheaded they can be on these matters. What possible reason could there be for not making it public? The agencies that represented the public in supposedly defending Baby Peter’s rights let the child and the public down. They alone stand to benefit from refusal to allow the material to enter the public domain

  2. With you on this one 100%, Lynne. Open public accountability is both liberal and democratic. Those wishing to keep reports and other information under wraps should be the ones justifying why it should not be in the public domain. The default position should be that if it is produced by public servants at taxpayers’ expense it should be freely available.

  3. Good work Lynne

    Looking closely at these very sad cases will surely tell us if changes in the law and monitoring of all children are genuinely needed to improve outcomes for our most vulnerable children or whether the current systems were simply not used to best effect.

  4. Elizabeth said “monitoring of all children”. My anti-liberal alarm went into overdrive. The state does not have a role to play in the day to day lives of families unless they have evidence of some form of criminal behaviour. I for one would not cooperate with any generalised monitoring that starts with the assumption that all adults are potential child abusers. Apart from the illiberality of such ideas, they are counter-productive, they create a state v people society, they waste resources looking at areas where there is no problem and they make it more likely that there will be incidents of abuse missed because the ‘monitors’ will monitor more families without abuse than with and so an expectation that the likely outcome of monitoring will be no abuse will develop.

    For the majority of children, their parents can be relied upon to do the best for them. We may have varying ideas as to what that best might be, how much telly and what they watch, what diet, what bedtime, what toys, etc? But that has always been the way and the majority of adults have survived to become functioning members of society. What we do not need is the state to try and impose some narrow, uniformity as to what is acceptable parenting, and that is what will happen in order to justify general monitoring of all children.